SELF-ASSESSMENT

Self-assessment
Questions
Case 1 1. How would you manage this girl? Please select ONE
A 10-year-old girl presents to Accident and Emergency with answer only:
a history of being unwell for the last 4 weeks. She initially a. Immediately give her 20 ml/kg fluid bolus followed
had mild viral symptoms but these resolved over 72 h. She by another 20 ml/kg fluid bolus if she is not
is reported to have poor concentration levels and is irritable responding.
in class. Despite eating and drinking well she has lost b. Give her 10 ml/kg fluid bolus followed by a bolus dose of
weight. She has wet her bed at night on several occasions subcutaneous insulin to lower the blood glucose level.
over the last 2 weeks. On examination she looks tired, she is c. Start her immediately on some iv insulin and then
tachycardic and her lips are dry. start iv fluids based on her deficit and maintenance
1. What two other clinical findings may be evident on requirements an hour later.
examination? Please select TWO answers only: d. Start her on iv fluid based on her deficit and main-
a. Viltiligo tenance requirements followed by some iv insulin an
b. Severe pallor hour after the fluids have been running.
c. Hepatosplenomegaly 2. After initial assessment of airway, breathing and circu-
d. Mild jaundice lation (A, B and C), and stabilizing the patient which of
e. Vaginal thrush the following on-going monitoring would you perform?
f. Pan systolic murmur Please select ONE answer only:
2. Which TWO investigations would be MOST useful in a. Neurological observations, fluid input and output,
establishing a diagnosis? Please select any TWO answers: cardiac monitoring, blood electrolyte levels, blood
a. Urinalysis glucose and ketone levels.
b. Coeliac screen b. Neurological observations, fluid input and output,
c. Renal profile cardiac monitoring, blood electrolyte levels, HbA1c
d. Random blood glucose levels.
e. Thyroid peroxidase (TPO) antibodies c. Urine dipsticks for glucosuria and ketonuria, fluid
f. Glycosylated haemoglobin A1 (HbA1c) input and output, cardiac monitoring, blood electro-
lyte levels.
Case 2
A 14-year-old girl with known Type 1 diabetes is brought to Case 3
the hospital by ambulance. She is confused and agitated. Her Thirteen-year-old Ahmed has had Type 1 diabetes for 6
blood glucose meter readings are reading “hi”. Her mother years. He is well managed on a combination of a long-acting
reports that she had been unwell with a flu-like illness the day insulin that he gives at night, and short acting insulin which
before. On examination she is vomiting, has a heart rate of he gives to cover his meals and snacks. He calculates his
140 bpm with deep, sighing respiration and a prolonged short acting insulin using a carbohydrate counting ratio of
capillary refill time. Her blood results show: 1.5 units of insulin for 10 g of carbohydrate. He is travelling
away for an activity camp with his school for the weekend.
Random glucose 29 mmol/litre (NR: 3.0e6.0 mmol/litre) 1. What would be the best advice to give him for while he
Sodium 145 mmol/litre (NR: 133e144 mmol/litre) is away? Please select ONE answer:
Potassium 6.9 mmol/litre (NR: 3.5e5.4 mmol/litre) a. He needs to increase the amount of insulin he is
Urea 10.6 mmol/litre (NR: 1.6e6.0 mmol/litre) giving and also to increase the amount of food he eats
Creatinine 58 mmol/litre (NR: 23e66 mmol/litre) at each mealtime so he has enough energy and
pH 7.0 (NR: 7.25e7.35) doesn’t go hypoglycaemic.
HCO3 8 mmol/litre (NR: 16e30 mmol/litre) b. He needs to decrease the amount of long-acting insulin
BE
17 mmol/litre (NR: 0e2 mmol/litre) he gives to prevent him going hypoglycaemic and he
needs to test his blood glucose levels more frequently.
c. He needs to decrease his carbohydrate counting ratio
Tafadzwa Makaya MBChB MMedSci (Endocrinology) MRCPCH is a Specialist and give less insulin for each carbohydrate portion,
Paediatric Registrar in Endocrinology and Diabetes at Sheffield as this will mean he doesn’t have to test his blood
Children’s Hospital, Sheffield, UK. Conflicts of interests: None. glucose levels as often and he is less likely to go
hypoglycaemic.
Jerry K H Wales DM MA BM BCh MRCP FRCPCH (Hon) DCH (Hon) is a Senior d. As long as he limits himself to moderate activity he
Lecturer in Paediatric Endocrinology at Sheffield Children’s Hospital, should be fine and not need to make any adjustments
Sheffield, UK. Conflicts of interests: None. to his diabetes care.

PAEDIATRICS AND CHILD HEALTH 22:2 81 Ó 2011 Elsevier Ltd. All rights reserved.
 SELF-ASSESSMENT
2. While out rock climbing with the rest of the group
Ahmed starts to feel unwell. When he tests his blood
glucose level it is 3.2 mmol/litre. What would you
advice he does? Please select ONE answer.
a. He must drink 60 ml of LucozadeÔ or take 3e5
glucose tablets then retest his blood glucose level
again after 10 min.
b. He must eat a digestive biscuit then retest his blood
glucose level again after 10 min.
c. He must eat a chocolate bar then retest his blood
glucose levels again after 10 min.
d. He must give himself an injection of intramuscular
glucagon then retest his blood glucose levels again
after 10 min.
Answers
Case 1
1. a. Vitiligo
e. Vaginal thrush
2. a. Urinalysis
d. Random blood glucose
Diagnosis of Type 1 diabetes
Type 1 diabetes mellitus (T1DM) is characterized by severe
insulin deficiency and a dependence on exogenous insulin
to prevent ketosis and to move glucose into cellular
metabolism. T1DM is the commonest form of diabetes in
the paediatric population. In 2009 it was estimated that
25,000 people under the age of 25 years were living with
T1DM in the UK.
Most patients who develop T1DM will present in child-
hood and the peak age for diagnosis is between the ages of
10 and 14 years. The history is usually one of an insidious
onset with the classical triad of symptoms of polyuria,
polydipsia and loss of weight despite polyphagia. There is
often accompanying lethargy, and secondary bed-wetting
can be a useful feature to highlight in programs designed
to detect the illness early. Girls may also present with
candidal vaginitis, while uncircumcised boys may present
with candidal balanitis. Other signs of autoimmunity may
also be evident, for example vitiligo. A history of recurrent
skin infections is not uncommon. About 15e70% of chil-
dren will present with ketoacidosis but this is very variable
in different regions.
The diagnosis of T1DM is made by biochemical findings
of hyperglycaemia in association with glucosuria with or
without ketonuria. Current American Diabetes Association
(ADA) guidance suggests that:
 in the presence of symptoms suggestive of diabetes then
the following are diagnostic:
A random venous plasma glucose 11.1 mmol/litre, or
a fasting plasma glucose of 7.0 mmol/litre. (NB when the
classic symptoms of polyuria and polydipsia are associated
with glycosuria and hyperglycaemia as above then the oral
glucose tolerance test (OGTT) is not required).
 in the absence of symptoms the diagnosis should not be
based on a single glucose value. There should be at least
PAEDIATRICS AND CHILD HEALTH 22:2
one other confirmatory glucose test on another day with
a value in the diabetic range. This can be either fasting,
from a random sample or from an OGTT (a value of 11.1
mmol/litre 2 h after 1.75 g/kg up to 75 g anhydrous
glucose). If the fasting or random values are not diag-
nostic the 2-h value should be used.
Recent changes in the WHO/ADA guidance state that
from January 2011 HbA1c can be used in the diagnosis of
diabetes, but in young people with T1DM there is rarely any
doubt about the diagnosis. From 1st October 2011 all HbA1c
results in England will be reported in the International
Federation of Clinical Chemistry and Laboratory Medicine
(IFCC) units of mmol/mol, instead of using the DCCT-
aligned % measure. Thus measurements in HbA1c of 48
mmol/mol (6.5%) would be indicative of diabetes.
At the time of diagnosis other bloods will usually be
done including renal profile, antibodies for thyroid peroxi-
dase and tissue transglutaminase (for coeliac screening).
FURTHER READING
Bonora E, Tuomilehto J. ‘The pros and cons of diagnosing diabetes
with HbA1c’. Diabetes Care 2011; 34: 184e90.
Diabetes UK. ‘Diabetes in the UK 2010: key statistics on diabetes’
2010. http://www.diabetes.org.uk/Documents/Reports/Diabetes_
in_the_UK_2010.pdf.
Diagnosis and classification of diabetes mellitus. American
Diabetes Association. Diabetes Care 2010; 33(Suppl 1): S62.
Sperling MA, Weinzimer SA, Tamborlane WV. ‘Diabetes Mellitus’. In:
Sperlings, ed. Paediatric Endocrinology. Saunders, Elsevier. 3rd Edn.
2008: 374e421 [Chapter 10].
Case 2
1. d. Start her on intravenous fluids followed by some iv
insulin an hour after the fluids have been running.
2. a. Neurological observations, fluid input and output,
cardiac monitoring, blood electrolytes, blood glucose
and ketone levels.
Diabetic ketoacidosis
Diabetic ketoacidosis (DKA) is the leading cause of
mortality in diabetic children. In established T1DM the
incidence of DKA is 1e10% per patient per year, while the
incidence at initial presentation varies between 15e70% in
various areas. In established diabetics episodes of DKA can
be precipitated by patients omitting insulin doses, or during
episodes of increased metabolic stress such as fever or
illness. The classic triad of DKA is hyperglycaemia, hyper-
ketonamia and hyperosmolarity. DKA is diagnosed based
on the biochemical findings of:
 a plasma glucose 11.1 mmol/litre,
 venous pH 7.3, or bicarbonate less than15 mmol/litre;
or
 ketonuria/ketonaemia. (þ to þþ urine ketones equates to
1.1e3.0 mmol/litre blood ketones; þþþ to þþþþ urine
ketones equates to more than 3.0 mmol/litre blood ketones.)
Children with DKA can present very unwell. The hyper-
osmolar state encourages diuresis that can be severe, with
82 Ó 2011 Elsevier Ltd. All rights reserved.
 SELF-ASSESSMENT
resultant dehydration and electrolyte imbalance. It is
however important to note that a significant mortality in
children with DKA has been linked to over-zealous fluid
therapy. The management protocol for DKA was developed
as part of the International Society for Pediatric and Adoles-
cent Diabetes (ISPAD) consensus, and modified by the
British Society for Paediatric Endocrinology and Diabetes
(BSPED). It emphasizes a cautious approach to managing
these children. The salient points of the guidelines are:
 A restrictive view to fluid resuscitation. Research has
shown that children who receive an excess of 40 ml/kg of
fluid boluses at resuscitation have a higher risk of devel-
oping cerebral oedema. Therefore it is important not to
overestimate the level of dehydration. It is recommended
to use not more than 8% dehydration levels. Resuscitation
fluid given to restore the circulating volume should be
given in 10 ml/kg boluses, up to an absolute maximum of
30 ml/kg. Shock with haemodynamic compromise is rare
in DKA and on-going signs of shock should raise the
possibility of sepsis. All fluid given should be documented
carefully, and resuscitation fluid should be subtracted from
the requirement fluid calculation, i.e.: Requirement ¼
Maintenance þ Deficit
fluid already given.
 APLS fluid rates over-estimate fluid requirements, there-
fore the protocol recommends the following:
0e12.9 kg 80 ml/kg/24
13e19.9 kg 65 ml/kg/24
20e34.9 kg 55 ml/kg/24
35e59.9 kg 45 ml/kg/24
Adult (>60 kg) 35 ml/kg/24
1 a very tight glycaemic control may develop blunting of their
24 h maintenance þ deficit
resuscitation fluid
 Hourly rate ¼ 2 hypoglycaemic response and develop hypoglycaemic
24
An online calculation can be done at:http://www.bsped.
org.uk/professional/guidelines/docs/DKACalculator.pdf
It requires only the child’s weight, percentage dehy-
dration and the volume of any resuscitation fluid given. It
will then calculate the on-going fluid requirement, and it
can be printed out for the notes.
 Insulin therapy should only be started an HOUR AFTER
fluids have been running. This is because there is
evidence that cerebral oedema is more likely if insulin
therapy is started too early. The insulin should be deliv-
ered as a continuous intravenous infusion.
Cerebral oedema occurs in upto 1% of all paediatric
DKA episodes and it is the most common cause of mortality
in children with DKA accounting for 60e90% of all paedi-
atric DKA deaths. Approximately 66% of cases present in
the first 6e7 h of treatment. It is important that children
being managed for DKA are closely monitored and this
monitoring while including the usual biochemical, cardiac
and fluid monitoring should also include regular neurology
observations. Signs and symptoms of cerebral oedema can
include headache, irritability, confusion, altered level of
PAEDIATRICS AND CHILD HEALTH 22:2
consciousness and signs of raised intracranial pressure
including bradycardia, decreased saturations and an
elevated blood pressure.
FURTHER READING
Edge, JA. BSPED Recommended DKA Guidelines. http://www.bsped.
org.uk/professional/guidelines.
Steel S, Tibby SM. ‘Paediatric diabetic ketoacidosis’. Cont Edu
Anaesth Crit Care & Pain 2009; 9: 194e9.
Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. ‘Factors associated
with the presence of diabetic ketoacidosis at diagnosis of diabetes in
children and young adults: a systematic review’. BMJ 2011; 343: 137.
Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W,
Rosenbloom A, Sperling M, Hanas R. ‘ISPAD Clinical Practice
Consensus Guideline 2009 Compendium. Diabetic ketoacidosis
in children and adolescents with diabetes’. Paediatric Diabetes
2009; 10: 118e33.
Case 3
1. b. He needs to decrease the amount of long-acting
insulin he gives to prevent him going hypoglycaemic and
he needs to test his blood glucose levels more frequently.
2. a. He must drink 60 ml of LucozadeÔ or take 3e5 glucose
tablets then retest his blood glucose level again after 10 min.
Hypoglycaemia
In patients with diabetes hypoglycaemia is usually defined
h
a blood glucose level of less than 4.0 mmol/litre. Sometimes
h
patients will report hypoglycaemic symptoms at a higher
h
level, in particular if they have been poorly controlled and
h
running high blood glucose levels, which resets their hypo-
h
glycaemic awareness set point. Conversely, children who run
unawareness due to frequently running low blood glucose
levels. Hypoglycaemia in diabetes can be precipitated by
 Inadequate/delayed/inappropriate substrate.
 Excess/extra activity.
 Illness e in particular gastroenteritis in younger diabetic
patients.
 Too much insulin (deliberate/accidental).
 Hot weather.
 Alcohol.
In children who are going to be taking part in sports or
physical activities it is advised that they check their blood
glucose levels before they start the sport. If the levels are
borderline low then it is recommended that they take a snack.
For sporting weekends the advice is generally to decrease the
long-acting insulin (or the basal insulin rate if on continuous
subcutaneous insulin infusion therapy). It is usually advised
to check blood glucose levels at half time intervals for
sporting matches or if symptomatic if performing some other
physical activity. Symptoms of hypoglycaemia include
feeling hunger, headache, feeling shaky or tired, loss of
concentration or feeling disorientated. Signs include pallor,
sweatiness, aggressive behaviour or seizures. Treatment
guidelines for hypoglycaemia are as follows:
83 Ó 2011 Elsevier Ltd. All rights reserved.
 SELF-ASSESSMENT
 First line (mild hypo):
 3e5 glucose tabs or
 100e200 ml fizzy, full sugar pop or
 60e100 ml of LucozadeÔ.
 Second line (moderate hypo):
 one tube of GlucoGel into cheek cavity, rubbed
onto gums.
 Third line (severe hypo/needing 3rd party assistance/
decreased level of consciousness):
 i.m/sc Glugacon injection, less than 5 yearse0.5 mg,
more than 5 yearse1.0 mg.
Some centres advocate the use of the mini-glucagon
regimen. This suggests the use of much smaller subcuta-
neous doses of glucacon. The advantage of this is that the
child experiences less of the side effects associated with
larger doses of glucagon, in particular nausea and vomiting.
The recommended dosing regimen for mini-glucagon is:
PAEDIATRICS AND CHILD HEALTH 22:2
 20 mg for children 2 years or less
 10 mg for each year of age from 2 years to 15 years (e.g.
30 mg for 3-year-old, 40 mg for a 4-year-old)
 150 mg for children 15 years or older.
Foods such as chocolate while being calorie dense do not
provide a quick release of sugar due to the high fat content.
Initial treatment of a hypo should always be followed by
re-testing and providing a longer acting carbohydrate such
as a digestive biscuit or pasta meal.
FURTHER READING
Dr Ragnar Hanas. ‘Hypoglycaemia and treating hypoglycaemias’. In:
Richenda Milton-Thompson, ed. Type 1 diabetes in children,
adolescent and young adults: how to become an expert in your
own diabetes’. Class Publishing Ltd, 3rd Edn. 2007; 39e67
[Chapters 8 and 9].
84 Ó 2011 Elsevier Ltd. All rights reserved.