The 4 'Ts' — aiding prompt diagnosis of Type 1 diabetes in children
A quarter of children with Type 1 diabetes are already in diabetic ketoacidosis by the time they are diagnosed. Practice nurses can help by asking about the 4 Ts - Toilet, Thirsty, Tired and Thinner
Every year 2,000 children and young people in the UK are diagnosed with Type 1 diabetes and this number is going up — incidence is increasing by around 4% a year.1 It is vital that Type 1 diabetes is diagnosed quickly to avoid life threatening diabetic ketoacidosis (DKA) developing. About 500 children a year develop DKA before being diagnosed, but getting the right treatment at the right time could prevent this from happening.
DKA occurs when a severe lack of insulin upsets the body's normal chemical balance and causes it to produce ketones. Left unchecked, it will result in the child becoming acutely unwell and requiring hospital admission, sometimes paediatric intensive care. DKA is the leading cause of mortality and morbidity in children with Type 1 diabetes.2 The risk of death is small, but 10 children in the UK die from DKA every year, some at the point of diagnosis. The majority of these deaths are due to cerebral oedema, which is more common when DKA occurs at onset of diabetes.
Despite the rising incidence rate of Type 1 diabetes in children, the percentage rate for children not diagnosed until they are in DKA has remained unchanged for the past 20 years.3 This is why Diabetes UK is campaigning to improve the recognition of symptoms of diabetes in children to ensure more are diagnosed before they become seriously ill. There are about 29,000 children and young people with diabetes in the UK (one child in 450 in England has diabetes) and of these, 97% have Type 1. Other types of diabetes are rare in childhood, though with increasing rates of childhood obesity, Type 2 is becoming more common.4 Other rarer types of diabetes include: diabetes seen in patients with cystic fibrosis, neonatal diabetes, maturity onset diabetes of the young (MODY) and drug induced diabetes which can be caused by certain drugs, such as those used in chemotherapy5,6 and high dose steroids.
SYMPTOMS
Diabetes UK's 4 Ts campaign encourages parents and healthcare professionals to spot the signs of Type 1 diabetes as early as possible. The Ts stand for Toilet, Thirsty, Tired and Thinner because the most common symptoms of Type 1 diabetes in children and young people are frequent urination, bedwetting in a previously dry child or heavier nappies in babies; excessive thirst (and not being able to quench that thirst); feeling excessively tired; and losing weight or looking thinner than usual. The 4 Ts are the main symptoms to look out for, but other symptoms can include constipation (secondary to chronic dehydration, and a particularly important symptom in the under-5s) and oral or vulval thrush.
The early symptoms of Type 1 diabetes may be misdiagnosed as respiratory infection, simple candidiasis, gastroenteritis or urinary tract infection. The symptoms of DKA include vomiting, deep sighing respiration, abdominal pain and reduced conscious level. These symptoms may be misinterpreted as an acute abdomen, gastroenteritis, acute asthma or pneumonia.
Children do not necessarily display all symptoms at the same time, and symptoms may vary depending on the age of the child. While people with a family history of Type 1 diabetes are at an increased risk of developing diabetes, it is important to note there may be no family history of diabetes.
INCIDENCE
A large UK general practice can expect to see a child with newly diagnosed Type 1 diabetes approximately every two years. The UK currently has the world's fifth highest rate of Type 1 diagnosis in children up to 14.7 Finland has the highest incidence, at 64 per 100,000 population per year.8 The causes of Type 1 diabetes are complex, with environmental factors possibly contributing towards an autoimmune process against pancreatic beta cells in genetically susceptible people.
DIAGNOSIS
The peak age for diagnosis is 10-14, but it is the under-5s age group which has seen the steepest rise in recent years. While 25% of children are not diagnosed until they are in DKA, because the early symptoms of diabetes are unrecognised by parents or medical staff, this rises to 35% in the under-5s.
Any child with suspected Type 1 diabetes should have a capillary blood glucose level performed in the GP surgery immediately. Any child who has a high blood glucose level should have a same-day referral to paediatric diabetes services for confirmation of the diagnosis and immediate management of the condition. The diagnostic criteria for diabetes are the same in children as in adults — a random blood glucose level of greater than 11 mmol/l is diagnostic.
Do not wait for a urine test or a fasting blood glucose level. Any delay in diagnosis may result in the child progressing into DKA. DKA develops quickly, often appearing within 24 to 48 hours of the first symptoms appearing.3 The HbA1c test should also not be used to diagnose a child with suspected Type 1 diabetes.
QUESTIONS TO ASK PARENTS
1. Has your child recently been drinking more than usual?
2. Has your child been passing urine more or wetting the bed (strongly suggestive especially if the child was previously dry at night)?
3. Has your child been getting thinner?
4. In infants, have they been particularly unsettled and had heavier nappies than usual?
5. Has there been any nappy or oral thrush recently?
THINK AGAIN
1. Children cannot be 'too young' to have diabetes — they can get diabetes even within the first year of life.
2. Children can not be 'too well' to have diabetes — it is best to diagnose while they ARE well
3. Parents often don't realise their children are losing weight — they think they are growing. Ask if they are getting thinner instead or their clothes are getting looser.
4. Asthma or pneumonia do not cause deep sighing respiration — this is DKA until proved otherwise.
5. Children with an acute abdomen should have a blood glucose level check.
REFERENCES
1. Patterson CC et al Incidence trends for childhood type 1 diabetes in Europe during 1989-2008 and predicted new cases 2005-2020: a multicentre prospective registration study Lancet 2009; 373: 2027-33
2. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-1996 Arch Dis Child 1999; 81:318-23
3. Ali K, Wilson IV, Edge JA, Bingley PJ. Diabetic Ketoacidosis at diagnosis has not declined in children over the last 20 years: data from the Bart's — Oxford Study. Diabetic Medicine, 2009, 26 (Suppl 1), 34 SD18.
4. Haines L, Wan KC, Lynn R, et al. Rising incidence of type 2 diabetes in children in the UK. Diabetes Care. 2007;30(5):1097-101
5. Pui CH, Burghen GA, Bowman WP, et al. Risk factors for hyperglycaemia in children win leukaemia receiving L-asparginase and prednisolone. J Pediatr 1981; 99(1) 46-50
6. Drachenberg CB, Klassen DK, Weir MR, et al. Islet cell damage associated with tacrolimus and cyclosporine: morphological features in pancreas allograft biopsies and clinical correlation. Transplantation 1999; 68 (3): 396-402
7. The data on estimates for incidence of Type 1 diabetes in children aged 0 to 14 comes from the International Diabetes Federation's Diabetes Atlas, with the estimates being for 2011. It is online at www.idf.org/atlasmap/atlasmap. The league table only includes those countries where the rate of Type 1 incidence is known. There are a significant number of countries where this information is not available.
8. Harjutsalo V, Sjoberg L, Tuomilehto J. Time trends in the incidence of type 1 diabetes in Finnish children: a cohort study. Lancet 2008;371(9629): 1777-1782
