Reasoning GP · Algorithm · 1-page summary
Suspected diabetes in children and young people
For: any child or young person under 18 in primary care with possible new diabetes, including infants. Not for: adults (use the type 1 and type 2 diabetes protocols); children with established diabetes follow their team's sick-day plan, but block 0 still applies.
Core rule: a thirsty, tired child who is losing weight and weeing a lot has diabetes until proven otherwise. Check a finger-prick glucose and ketones before they leave the room; if raised, refer the same day by phone, never a fasting test next week.
0Stop — immediate hospital transfer, 999 if unstable — do not delay transfer for further tests; alert the paediatric team
- Suspected DKA: vomiting, abdominal pain, dehydration, deep sighing (Kussmaul) breathing, pear-drop breath, drowsiness or confusion with hyperglycaemia or significant ketones → immediate transfer to a hospital with acute paediatric facilities.
- Shock or reduced consciousness (floppy, very drowsy, cool peripheries, prolonged capillary refill, tachycardia), severe dehydration, Kussmaul breathing, repeated vomiting, airway concern or deteriorating → 999
- Blood ketones ≥3 mmol/L or urine ketones ≥++ with hyperglycaemia → immediate hospital assessment for blood gas and electrolytes; 999 if unstable. Known diabetes: suspect DKA even if glucose is normal.
- While waiting: ABC, monitoring, oxygen only if indicated; glucose, ketones and IV access only if they do not delay transfer. No large fluid bolus unless shocked and directed by a senior paediatric or prehospital team (cerebral oedema). An alert, non-vomiting child may take small sips.
1Triage by finger-prick result — a triage test, not a diagnosis
| Result | Action |
|---|---|
| ↑ glucose + DKA signs or ketones ≥3 | Block 0 → Immediate hospital |
| ↑ glucose or glycosuria + symptoms | Phone the team → Same-day, even if well and not ketotic (e.g. glucose >11 mmol/L) |
| Normal glucose | Symptoms persist: repeat, dip urine, consider electrolytes, discuss with paediatrics. Dilute polyuria: consider DI, primary polydipsia, UTI; DI with dehydration or hypernatraemia → Urgent hospital |
2Screen — none of these lowers the urgency
- Infants and young children: non-specific, deteriorate fast → Same-day; onset <6 months: consider neonatal monogenic diabetes, however well
- Overweight, acanthosis nigricans, suspected type 2 or MODY → still Same-day; type 2 can present with ketosis or DKA
- "Gastroenteritis" with thirst, polyuria, deep breathing or ketones → glucose before discharge
- New bedwetting + thirst → finger-prick glucose, not a continence referral
3Assess — in the room, the same minute
☐ Capillary glucose first ☐ Blood ketones (meter preferred; urine if none) ☐ Urine dip: glucose, ketones, UTI ☐ Hydration, capillary refill, pulse, BP, RR and pattern, AVPU ☐ Weight and growth chart
Not before referral: fasting glucose, HbA1c, OGTT, antibodies, C-peptide or urine culture. No glycosuria does not exclude diabetes. DKA needs acidosis, confirmed in hospital.
4Classify — typing never delays referral; the team confirms
- Type 1 (default) — short history, weight loss, ketosis-prone, any age → assume type 1 unless strong evidence otherwise.
- Type 2 — overweight, older, acanthosis, family history, South Asian, Black or Middle Eastern, PCOS features.
- Monogenic — family history across generations, mild stable hyperglycaemia, onset <6 months. Secondary — CF, pancreatic disease, steroids.
- Mimics if glucose normal — UTI (can coexist), diabetes insipidus, primary polydipsia, hypercalcaemia, hyperthyroidism; weight loss: coeliac, eating disorder, malignancy.
- Uncertain — early diabetes can give intermittent readings; reassess actively, do not discharge.
5Treat today — recognition and transfer, not treatment
- Phone the on-call paediatric diabetes team, not a letter: glucose, ketones, hydration, conscious level, duration, weight trend.
- Keep hydrated: oral fluids if alert and not vomiting; sugar-free not mandatory; the receiving team advises.
- Do not start insulin or metformin unless within an established specialist protocol with direct specialist instruction.
- Explain calmly: likely diabetes, hospital today, admission likely; not the family's fault.
6Follow up — the GP role once diagnosed
- Immunisations: routine schedule, annual flu; pneumococcal as indicated by the Green Book.
- Sick-day rules are the team's: reinforce, don't rewrite; basal insulin is not stopped in illness unless the team says so.
- Safeguarding, mental health, eating difficulties, insulin omission, recurrent DKA; brief reception on the 4 T's.
7Never reassure by
- A normal appetite, a child who looks well, or a recent viral illness.
- Being overweight or having acanthosis: do not downgrade to "type 2, routine".
- A "gastroenteritis" label in a vomiting child who is thirsty, polyuric or ketotic.
- A single normal finger-prick or no glycosuria when symptoms persist.
- A fasting glucose, HbA1c or home glucose checks with "review next week".
8Safety-net — most important while awaiting the specialist team
999 / A&E “Go to A&E now if your child keeps vomiting, has tummy pain, fast or deep sighing breathing, breath smelling of pear drops, is very drowsy or floppy, cannot keep fluids down, looks dehydrated, has rising glucose or ketones, or is confused. Call 999 if they collapse, are very drowsy or get worse quickly.”
Same day “Bring your child back today for a glucose check if thirst or weeing increases, weight keeps falling, bedwetting starts, or you are still worried.”
✓Safe to leave the consultation only if — all five, documented
Glucose and ketones recorded with the time
Block 0 excluded, or immediate transfer arranged
Raised glucose: same-day team phoned; name, plan, destination
Hydration, conscious level and weight recorded
A&E/999 safety-net and team contact given to the family
Summary of the full Reasoning GP suspected diabetes in children algorithm, which holds the detail on presentation, testing, typing, mimics and family support. Sources: NICE NG18, NICE QS125, BSPED paediatric DKA guideline, UKHSA Green Book, Diabetes UK 4 T's; local paediatric diabetes service and local escalation pathway. Clinical reference — follow local paediatric pathways.