For over two decades, 45-50% of Queensland children with Type 1 diabetes haven’t been diagnosed until they develop a preventable, severe and life-threatening complication called diabetic ketoacidosis (DKA). 1,2
DKA is a metabolic emergency due to insulin deficiency and can lead to cerebral oedema, so these children require intensive care monitoring. DKA at the diagnosis of Type 1 diabetes is considered preventable if the early symptoms of high blood glucose are recognised by parents and early assessment is undertaken with a simple and inexpensive random finger prick blood glucose check.
Unfortunately, children are seen two to three times in primary care before being diagnosed with DKA.3,4,5
Primary health clinicians can urgently refer children with a random blood glucose level ≥ 11mmol/L to the closest Emergency Department.
Nurses working in primary care settings are well placed to improve parent’s health literacy and play an important role in the primary prevention and early identification of children with the 4T symptoms of high blood glucose.
The 4T symptoms are Thirsty, going to the Toilet frequently to urinate, Tired, losing weight and getting Thinner. If these symptoms exist, they may have Type 1 diabetes.
Early recognition of the 4T symptoms is the key to preventing DKA at the diagnosis of Type 1 diabetes.
In 2019, Clinical Excellence Queensland provided funds to the Statewide Diabetes Clinical Network to consult consumers and clinicians to prepare a well-informed implementation plan for a sustainable statewide campaign to reduce the rate of DKA at diagnosis in children under 16.
A campaign in Newcastle reduced rates to less than 25% for a short period.6 New Zealand has closely monitored rates and reduced and maintained a rate around 25%. Rates in Scandinavian countries with improved public health literacy have been 14% for many years.7,8
After extensive consumer and stakeholder consultation, an implementation plan was developed, and primary care nurses emerged as key clinicians who can play an important role in reducing DKA at diagnosis.
Primary care nurses are key to the early diagnosis of Type 1 diabetes, especially in children, to ensure prompt treatment, essential for preventing DKA. The outstanding work of nurses will be recognised by the International Diabetes Federation in this year’s theme for World Diabetes Day on 14 November 2020, Nurses: Make the Difference for Diabetes.
Continuous professional development on this topic has been made conveniently and freely available at the Nursing CPD Institute or on iLearn for Queensland Health nurses. Reflective questions for AHPRA CPD records are included at the end of this article.
New resources and strategies
A range of implementation strategies have been developed to become usual best practice.
Content on preventing DKA at diagnosis has been added to the Queensland Health Child & Youth Health Practice Manual.
The child health booklet in the personal health record has been updated with the 4T signs as a reason for parents to seek medical care.
Child Health Nurses working at 13Health Contact Centre have been provided with a factsheet for parents calling with subtle symptoms because high blood glucose often masquerades as other common childhood illnesses requiring medical review.
A new RACGP consensus guideline has been developed for the early recognition of hyperglycaemia in children under 16 in primary care. The guideline encourages GPs and nurses working in primary care to have a higher index of suspicion for Type 1 diabetes in children with common childhood illnesses.
Campaign materials have been developed to improve public awareness Campaign content includes suggestions from consumers consulted during the DKA project and the parent survey to ascertain parent’s knowledge to seek medical care for the 4T symptoms of high blood glucose. A survey of 102 parents, which was assisted by Playgroup Queensland, found that only 23% of parents know a medical review is required if their child has signs of thirst, tiredness, or going to the toilet frequently.
To improve public awareness of the 4T signs of high blood glucose in children, the Diabetes: Know the signs, Ask campaign will be launched on 14th November for World Diabetes Day. The campaign is collaborating with stakeholders around Queensland in schools, early childcare and primary health networks to spread campaign materials to improve the public awareness of the 4T symptoms and DKA.
Nurses working with families in primary care can help reduce DKA at diagnosis by displaying campaign materials in their clinics and waiting areas. Primary care nurses are well placed to recognise the 4T symptoms in children and young people as well as improving parents’ child health literacy. Please download and print a colour copy of the campaign poster from the Statewide Diabetes Clinical Network website.
Reducing DKA makes a real difference
Reducing DKA at diagnosis will reduce the emotional burden on families who are devastated by not only the diagnosis of a lifelong chronic illness, but also a critically ill child.
Children with DKA at diagnosis don’t go through a honeymoon period with gradual loss of beta cell function. It is associated with suboptimal diabetes leading to long-term kidney and eye complications related to high blood glucose levels.
Children with DKA can die from cerebral oedema and the long-term impacts cannot be understated and warrants efforts to reduce the unacceptable rates in Queensland through improving public and professional awareness.9
As a nurse working in primary care, you can make a difference to this important health issue.
Checklist for parents
Thirst: is your child always thirsty?
This sign can be difficult for parents to pick up, especially during the hotter summer months in Queensland. Infants under two are most at risk of DKA as they cannot let you know they are thirsty. Observe any increase in demands for breastfeeds, volume in sip cups and bottles. If your child cannot quench their thirst this needs urgent assessment with a blood glucose check to rule out Type 1 diabetes.
Toilet: has your child returned to wetting the bed or does your child frequently go to the toilet to pass urine?
This sign can be particularly challenging to identify in infants under two wearing disposable nappies. If in doubt, increase the frequency of nappy changes and keep a close watch on the weight of the nappies. Don’t delay seeing the closest doctor as soon as possible, because infants under two have the greatest risk of developing DKA.
Childcare educators and teachers are often the first to notice a child asking to be excused to go to the toilet during play or class time. It is important to let parents know that this sign needs urgent review by a doctor, even though the child appears to be well.
Tired: is your child always tired?
They may have trouble getting up in the morning, be uninterested or unmotivated to go and play with siblings or friends and be sleepier than usual. School age children and teens may have difficulty concentrating in class. They may find it difficult to see the whiteboard due to changes in eyesight from high blood glucose.
Thinner: is your child losing weight despite a healthy appetite?
Don’t put this down to a growth spurt. Often grandparents and relatives who don’t see the child everyday notice weight loss. Don’t delay taking your child urgently to see a doctor and ask about the possibility of type 1 diabetes.
Type 1 Diabetes in Children: The facts
Type 1 diabetes is the most common childhood chronic condition, with the incidence peaking in children aged 11 to 13.
In 2017 there were 6500 Australian children under 14 living with Type 1 – a rate of 141 per 100,000.10
The cost of an average intensive care length of stay of 1.5 days is $6489. This totalled $285,521 for the Queensland Children’s Hospital in 2018-19.11
Reflect on the need to have a higher index of suspicion of high blood glucose in all children presenting with common childhood illnesses.
How can you improve your nursing assessment, observations and documentation for children in primary care?
How can you improve your listening and parent interview skills?
Reflect on health encounters with parents and the opportunities you have to improve their awareness of the 4T signs of high blood glucose.
DKA at diagnosis is considered preventable if the early signs of high blood glucose are recognised and treated. Be part of the solution to reduce DKA at diagnosis of type 1 diabetes by participating in the Queensland public awareness campaign this world diabetes day on 14th November 2020.
Harris et al. Consistently high incidence of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes. Letter to MJA 19August 2013.
Jacobs, S et al. Unpublished work by Jacobs S, Harris M, Johnson S. (2020) Diabetic Ketoacidosis in children with newly diagnosed Type 1 Diabetes
Lokulo-Sodipe, K. et al. Identifying target to reduce the incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes in the UK. Arch Dis Child 2014; 99:438-442.
Biu H. et al. Is diabetic ketoacidosis at disease onset a result of missed diagnosis? J Pediatrics 2010; 156:472-7.
Pawlowicz M. et al. Difficulties of mistakes in diagnosing type 1 diabetes in children: demographic factors influencing delayed diagnosis. Pediatric Diabetes 2009:10:542-549
King BR. et al. A diabetes awareness campaign prevents diabetic ketoacidosis in children at their initial presentation with type 1 diabetes. Pediatric Diabetes 2012:13:647-651.
Cherubini, V. et al. Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents. Diabetologia 2020. https://doi.org/10.1007/s00125-020-05152-1
Jefferies, C. et al. 15-year incidence of diabetic ketoacidosis at onset of type 1 diabetes in children from a regional setting, Auckland, New Zealand. Sci.Rep 2015
Cameron FJ.(2014) Neurological Consequences of Diabetic Ketoacidosis at Initial Presentation of Type 1 Diabetes in a Prospective Cohort Study of Children. Diabetes Care 37:1554-1562