See also

Diabetes insipidus
Diabetic ketoacidosis
Diabetes mellitus: Management of unwell children with established diabetes at home
Diabetes mellitus: Management of unwell children with established diabetes in hospital
Diabetes mellitus and surgery
Hyperosmolar hyperglycaemic state

Key points

1. This CPG is for children with a new diagnosis of diabetes mellitus who are not in diabetic ketoacidosis (DKA)
2. A blood glucose level (BGL) should be checked in most acutely unwell children, as diabetes can present non-specifically
3. Random BGL ≥11.1 mmol/L or fasting BGL ≥7.0 mmol/L, together with symptoms of hyperglycaemia, are diagnostic of diabetes in a child
4. A child with a new diagnosis of diabetes mellitus who is not in DKA can be managed with subcutaneous insulin injections

Background

• Classic symptoms of hyperglycaemia that should prompt consideration of diabetes include:
  • polydipsia (excessive thirst)
  • polyuria (excessive urination)
  • new onset nocturnal enuresis (ie in a child who was previously dry overnight)
  • unexplained weight loss
  • unexplained fatigue
• Other non-specific presentations (which may indicate ketosis/ketoacidosis) include vomiting, respiratory distress, dehydration, abdominal pain, altered consciousness
• A diagnosis of diabetes should not be based on a single BGL reading in the absence of symptoms of hyperglycaemia. If the diagnosis is in doubt additional testing may be required (eg HbA1c, OGTT, continued monitoring of BGLs) in discussion with a paediatric specialist
• Most cases of diabetes in children are due to Type 1 diabetes mellitus
• The possibility of other types of diabetes should be considered in the following circumstances, when diabetes autoantibodies are negative:
  • Type 2 diabetes: obesity, acanthosis nigricans, strong family history
  • Monogenic diabetes: <6 months of age at presentation (neonatal diabetes mellitus), autosomal dominant family history of diabetes (MODY)
• Diabetes can also be secondary to certain medications (eg glucocorticoids, tacrolimus) and other disease processes that can affect the pancreas eg cystic fibrosis, hereditary haemochromatosis

Assessment

History

• Presence and duration of symptoms:
  • excessive thirst
  • excessive urination
  • weight loss
  • vomiting
  • abdominal pain
  • fatigue
• Concurrent illness
• Medications
• Past medical history
• Family history of diabetes and other autoimmune conditions

Examination

• Conscious state (AVPU/GCS)
• Respiratory signs: respiratory rate, increased work of breathing
• Assess hydration status
• Weight

Management

Investigations

• Formal serum blood glucose level
• Point of care blood ketones if random BGL ≥11.1 mmol/L
  • urine ketones may be used for initial assessment if blood ketones are unavailable
• Venous blood gas

If pH <7.3 or bicarbonate <18 mmol/L, manage as per Diabetic ketoacidosis

Other investigations

• UEC
• Diabetes autoantibodies: anti-GAD, insulin autoantibodies (IAA), insulinoma-associated-2 autoantibodies (anti-IA2), zinc transporter 8 (ZnT8)
• Coeliac serology (transglutaminase IgA and total IgA)
• TSH, FT4
• Additional investigations may be required as part of diagnostic workup, or for associated conditions
  • C-peptide
  • Insulin level
  • Thyroid autoantibodies: thyroid peroxidase, thyroglobulin
  • Coeliac screen
  • Lipid profile
  • Liver function tests

Treatment

Intravenous fluids if required for dehydration. See Intravenous fluids

Choice of insulin therapy

Note that some centres use different management guidelines, see local protocols

Subcutaneous insulin (for children not in DKA)

If ketones are elevated (≥0.6) insulin should be started as soon as possible to prevent DKA

The two most common regimens for insulin dosing are fixed multiple daily injection (MDI) and flexible insulin dosing

• MDI insulin dosing (also called basal-bolus insulin):
  • Calculate total daily insulin (TDD), see guide below. Give 40% as long-acting basal insulin (daily) and 60% as rapid-acting insulin divided into 3 x boluses with meals ie 20% TDD rapid-acting insulin with each meal
• Flexible insulin dosing:
  • The dose of rapid-acting insulin is calculated before each meal (or snack) based on pre-meal BGL and the amount of carbohydrates being consumed
  • In addition, rapid acting insulin is given to correct hyperglycaemia before and between meals
  • The insulin carbohydrate ratio (ICR) is the number of grams of carbohydrate that require 1 unit of insulin to be administered, and is used to determine the rapid-acting insulin dose for a quantity of carbohydrates
  • The insulin correction factor (CF) is the expected BGL decrease (in mmol/L) with 1 unit of insulin administered, and is used to determine the rapid-acting insulin dose to correct hyperglycaemia
    Note: the CF is also called the insulin sensitivity factor (ISF)
  • Long-acting insulin is given daily, typically in the evening
  Note: twice daily (BD dosing) injections are rarely used as a standard regimen and are limited to extremely rare circumstances where more precise dosing cannot be achieved in extraneous circumstances

A guide to initial insulin doses is given below. Insulin regimens will need to be individualised to the child's needs as indicated by BGL levels

• Where possible, discuss ongoing insulin dosing with a paediatric endocrinologist or paediatrician with experience in paediatric diabetes and always consult local guidelines where available
• Pre-meal BGL target is 4-8 mmol/L. If BGL >8 mmol/L use CF to determine dose of rapid-acting insulin to return BGL to 6 mmol/L (unless insulin has already been given in preceding 2 hours)
• Pre-meal rapid-acting insulin should be given 15 minutes prior to the meal (except Fiasp®, which can be given at the time of the meal due to faster onset)

Suggested dosing for initiation of subcutaneous insulin therapy

*Note: many children will be started on a continuous glucose monitor (CGM) early in their admission. Finger prick BGL may vary in this instance. Please see CGM

Ketone monitoring

• If ketones are present at diagnosis, continue to measure with each BGL every 2 hours until ketones <0.6
• As part of ongoing management, ketones should be checked whenever
  BGL ≥15 or child is unwell

Consider consultation with local paediatric team

• For all new presentations of diabetes in children. In most centres these children need to be admitted for initiation of insulin therapy and diabetes education
• In some tertiary centres, hospital in the home (HITH)/ambulatory care programs may be considered in appropriate cases; discuss with paediatric endocrinology team first

Consider transfer when

Child requiring care beyond the level of comfort of the treating hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Child tolerating oral intake
• Child linked in with local diabetes care team and contact information provided
• Initial diabetes education completed, usually involves input from diabetes nurse educator, dietician, social work
• Family competent in monitoring BGLs and administering insulin and treating hypoglycaemia

Parent information

Kids Health Information: Diabetes

Diabetes Australia

RCH-specific info:

Sick day and ketone management for injections

Sick day and ketone management for pumps

Diabetes at the RCH

Diabetes at the RCH : Type 1 diabetes toolkit

Appendix 1: Initial recommended insulin:carbohydrate ratio (ICR), correction factor (CF) and long-acting insulin

Appendix 2: Flexible dosing insulin with variable ICR throughout the day

Takes into account insulin sensitivity variation throughout the day

Last updated March 2025