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Paediatric diabetes (Diabetes and Endocrinology)

PAEDIATRIC

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Adult conditions

Pancreatic disease

  • Diabetic ketoacidosis  - A
  • Diabetes and severe vomiting -A
  • Acute severe hyperglycaemia
  • Acute severe hypoglycaemia -A
  • Hyperosmolar hyperglycaemic state (HHS) -A
  • Newly diagnosed type 1 diabetes –B (call registrar or consultant on call)
  • Foot ulcer with infection and systemically unwell or febrile -A
  • Invasive infection or rapidly spreading cellulitis of the foot (defined by peripheral redness around the wound >2cm) -A
  • Acute foot ischaemia -A
  • Wet gangrene foot -A

Urgent cases – (refer to key below)
A – client to present to emergency department immediately
B – client to present to diabetes specialist service within 24 hours.  If no specialist service is available, present to an emergency department.

High Risk Foot

  • Foot ulcer with infection and systemically unwell or febrile
  • Invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm)
  • Acute ischaemia
  • Wet gangrene
  • Acute or suspected Charcot

Thyroid disorders

  • Hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
  • Neutropenic sepsis in patient taking carbimazole or propylthiouracil
  • Hyperthyroidism with hypokalaemia or paralysis
  • Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)
  • Stridor associated with a thyroid mass
  • Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

Adrenal disease

  • Addisonian crisis
  • Suspected or confirmed acute adrenal insufficiency
  • Phaeochromocytoma in crisis with uncontrolled hypertension
  • Malignant hypertension

Pituitary disorders

  • All patients with visual field loss (usually temporal and classically bitemporal superior quadrantinopia/hemianopia)
  • Pituitary tumour with severe headache
  • Pituitary tumour with evidence of symptomatic cortisol insufficiency
  • Hyperprolactinaemia with visual impairment or other neurological signs

Oligo/amenorrhoea, hirsutism, acne, female infertility

  • Signs in the central nervous system that could indicate a pituitary tumour (visual field defect headaches)

Calcium, electrolyte and metabolic bone disorders

  • Acutely symptomatic hypocalcaemia (e.g. tetany) with serum calcium <2.0mmol/L
  • Severe symptomatic hypercalcaemia (usually serum calcium > 3.0 mmol/l)
  • Hypernatraemia or hyponatraemia with acute confusion/delirium
  • Suspected or confirmed diabetes insipidus with hypernatraemia

Paediatric Conditions

Paediatric diabetes

  • New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
  • Ketoacidosis in a known diabetic with any of the following
    • systemic symptoms (fever, lethargy) or
    • vomiting or
    • inability to eat (even if not vomiting) or
    • abdominal pain or
    • headache

Growth failure

  • Suspected pituitary mass (visual field loss/CNS signs)
  • Addisonian crisis (including unexplained hyponatraemia & hypoglycaemia)
  • Myxoedema coma
  • New onset diabetes insipidus (including unexplained hypernatraemia)
  • Hypocalcaemia (including acute rickets) with seizures

 

  • Refer to local Healthpathways or local guidelines
  • All newly diagnosed/ suspected type 1 diabetes must be seen as an emergency as soon as the diagnosis is suspected. Do not wait for test results to become available except near patient testing of blood sugar level.
  • To avoid delay in diagnosis, physicians need to take due care in their detection of diabetes in a patient and in defining its clinical sub‐type, since delayed diagnosis of type 1 diabetes in a child or adolescent is associated with an increased risk of DKA and subsequent morbidity and mortality.
  • In rural and remote areas, it is preferable that local health professionals, who have access to the specialist paediatric diabetes team, provide ongoing support and education. If the child/adolescent/family is unable to access these health professionals, support with education should be provided by the experienced health professional at the provincial or tertiary diabetes centre, via videoconference or phone.
  • Groups for whom inpatient management is necessary at diagnosis include
    • individuals with diabetic ketoacidosis, significant comorbidities, inadequate social support or mental health issues
    • children under 2 years of age
    • those in geographically remote areas
    • non-English speakers
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long-term complications.
  • Refer to local/regional diabetes education/dietetic services.  Registration with NDSS (National diabetes services scheme).
  • Develop an individualised management plan, which includes planned interaction with local diabetes educators, dietetic inputs, caregivers, local health team and visiting specialists where necessary.
  • Provide ongoing clinical advice and support to local health team and family
  • Refer/explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) how to find information about government and benefits available.
  • Disability benefits. It is important to monitor the school performance of children who developed diabetes before age 5–7 years, and those with a history of significant hypoglycaemic episodes or chronic poor blood glucose control.
  • Offer children and young people with type 1 and type 2 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders and family conflict) or psychosocial difficulties that can impact on the management of diabetes and wellbeing.
  • Encourage children and young people with type 1 diabetes to wear or carry something that identifies them as having type 1 diabetes (for example, a bracelet).

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Suspected type 2 diabetes where
      • child/adolescent assessed to be well and without ketosis. Health care provider confident of type 2 diagnosis
      • unstable known type I diabetes transferring care
  • Category 2
    (appointment within 90 calendar days)
    • Stable known type I diabetic transferring care
  • Category 3
    (appointment within 365 calendar days)
    • No category 3 criteria

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • History of the presentation including reasons why this is thought to be type 2 diabetes rather than type 1 (e.g. strong family history of type 2, obesity, evidence of insulin resistance [e.g. acanthosis nigricans])
  • Report presence or absence of concerning features:
    • polyuria or polydipsia
    • recent weight loss
    • recent onset enuresis
    • ketosis on urine or blood testing.
  • HbA1c, FBC, ELFTs, CRP, TFT
  • Plasma glucose (fasting)
  • Ketones (blood or urine) – if positive send direct to emergency

NB follow up/review patients will have pathology attended to in the clinic, the patient is not required to get blood tests prior to attending on an ongoing referral

 

3. Additional referral information Useful for processing the referral

Highly desirable information – may change triage category

  • Mode of presentation, whether insidious or acute
  • Other past medical history
  • Family history, especially of diabetes, PCOS and other endocrine conditions
  • Height/weight/head circumference and growth charts with prior measurements if available

Desirable Information - will assist at consultation

  • Birth history
  • Immunisation history
  • Developmental history
  • Medication history
  • Allergies
  • Significant psychosocial risk factors (especially parents’ mental health, family violence, housing and financial stress, department of child safety involvement)
  • Other physical examination findings inclusive of CNS, birthmarks or dysmorphology
  • Any other relevant laboratory tests or medical imaging

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.