My Patient Has Diabetes – Now What?

If a pediatric patient with signs/symptoms/history consistent with diabetes is seen in the urgent-care or outpatient clinic setting and has any signs of hemodynamic instability (hypo/hypertension, tachycardia, or tachypnea), the patient should immediately be sent to the local emergency department (ED) for further evaluation.

Laboratory evaluation should not delay presentation to the ED.

If the patient is hemodynamically stable, prompt, same-day laboratory evaluation is needed, as discussed in the “Laboratory Evaluation” Chapter.

Based on the laboratory results, a local pediatric endocrinologist or the local tertiary care PICU should be contacted to discuss further patient disposition from ANY setting (urgent care, clinic, or the ED). Disposition may vary depending on your local tertiary care center’s practice preferences, as discussed below.

It is potential malpractice to send a patient with suspected diabetes home with only a written referral to an endocrinologist. A written or electronic referral can be lost or take several days to be seen. During that time, patients with new-onset diabetes without confirmed etiology can become critically ill from DKA and potentially die.

All new-onset diabetes mellitus is considered a pediatric emergency in which children are assumed to have Type 1 diabetes mellitus until proven otherwise. This is because Type 1 diabetes is statistically the most prevalent type of diabetes in children and adolescents AND can have overlapping symptoms with Type 2 diabetes. Further, Type 1 patients with untreated hyperglycemia may rapidly develop diabetic ketoacidosis in a matter of hours, leading to metabolic decompensation and cardiovascular collapse/death.

What to do with the otherwise well child with new-onset diabetes that is not in DKA can be variable depending on the local Children’s hospital system to which the child presents or is transferred. It is important to know your local hospital system’s preferences and policies wherever you end up practicing.

When in doubt, contact the local endocrinologist on-call!

Here at the University of Iowa Stead Family Children’s Hospital:

We admit:

1. The pediatric endocrinology team coordinates most new-onset pediatric diabetes patients for inpatient diabetes education.
2. Known diabetic patients with DKA
   • Patients with simple hyperglycemia and ketosis without acidosis (thus not in DKA) can often be managed at home with close communication with the on-call pediatric endocrinologist or in the emergency department

The admission location (PICU vs. the pediatric endocrinology service) depends upon the severity of the patient’s presentation. Admission criteria are listed below:

Images/Figures:

1. Figure 1: Image created by Dr. Alex Tuttle with the following images: Image Attributions: “Vitals signs” at https://www.nicepng.com and “Emergency” from https://resources.ourhealthcalifornia.org/er-or-urgent/
2. Figure 2: Image created by Dr. Alex Tuttle comprised of the following images: Image Attributions: “Vitals signs” at https://www.nicepng.com , “Illustration of medical test tube with blood” by Yulia Drozdova at Alamy.com, and“Voice On Phone – Voice Call” at https://www.pngkit.com