Red Flags to Watch for in Diagnosing Type 1 Diabetes in Kids

Jessica Sparks Lilley, MD


January 23, 2023

Oh, January. It's no one's favorite month. The holly jolly of the holidays is behind us, the marshmallow world of fresh snow is now dingy and gray, and credit card statements from a merry December are rolling in alongside tax documents for the new year.

For doctors, the list of reasons to hate January is even longer: full census, peak burnout, and never getting to see the sun. To this dreary list, we can add one more concern: January is the month with the highest number of new-onset type 1 diabetes  (T1D) cases.

The high rate of T1D diagnoses right in the middle of peak illness season makes working in primary care, urgent care, or emergency departments especially precarious — fatigue, large patient loads, and high prevalence of other illnesses can cause missed diagnoses.

The viral triggers that began hitting susceptible patients in the late fall have had time to destroy islet cell mass to levels that will cause symptomatic hyperglycemia. Timely reminders of the signs of new-onset diabetes bear repeating widely, because eagle eyes from everyone from hairstylists to concerned grandparents have urged the appropriate workup that led to the diagnosis in my patients. The majority of patients with newly diagnosed diabetes had seen a healthcare provider within the preceding month, and the signs are frequently ignored.

Typical warning signs of new T1D include increased urination owing to increased filtration at the level of the kidney in response to hyperglycemia. The resulting volume depletion triggers increased thirst. Lack of insulin, lost glucose through urine wasting, and diminished ability to store energy as fuel causes weight loss. High glucose levels also promote the growth of yeast and impede wound healing.

Even though most medical professionals can rattle off these symptoms when asked, patients often come to us with different labels, causing us to stumble when the clock is ticking to make the correct diagnosis. Although the body can burn ketones for fuel temporarily, ketone buildup eventually causes diabetic ketoacidosis (DKA), a life-threatening metabolic crisis.

In the United States, missed diagnoses lead to unacceptably high rates of DKA at diagnosis, which is especially concerning because DKA is the most common cause of morbidity and mortality of children and young adults with T1D. When children present too late, deaths may occur at diagnosis. In a concerning trend, more patients are presenting for initial care already in DKA when compared to previous years.

Despite the large number of people living with T1D, stubborn myths persist about its causes and treatment, even among professionals who should know better. People are not born with T1D, though it may present at any age, from infants to older adults. It's not caused by poor diet or lifestyle choices.

All pediatric diabetes cases should be discussed with a pediatric diabetes specialist immediately and started on insulin urgently, usually the same day. My colleagues and I still receive routine referrals buried among our fax machines with 7-year-old children inappropriately started on metformin despite exhaustive community education, and we live in fear that these patients will slip through the cracks and suffer harm without our constant diligence.

Most people living with T1D do not have a family history of T1D. Family or personal history of autoimmune disease (including hypothyroidism, celiac disease, alopecia areata, multiple sclerosis, Crohn's disease, ulcerative colitis, lupus, rheumatoid arthritis, Addison disease, and others) should increase suspicion. Lack of known autoimmunity in the family does not exclude the possibility of T1D. A family history of type 2 diabetes certainly doesn't mean that new diabetes in a relative is also T2D. T1D symptoms may develop over just weeks to months, so routine annual screening for the condition at well-child checks may not be helpful.

Out of all my medical writing, I suspect that this article has the potential to save the most lives. Here are red flags to look out for to ensure timely diagnoses.

Vomiting without diarrhea. Gastroenteritis causes both vomiting and diarrhea. Isolated vomiting is concerning for ketoacidosis, among various other serious conditions, ranging from increased intracranial pressure from a tumor to testicular torsion. When a child presents with only vomiting, a thorough history and exam are crucial. The nearest to fatal case I have seen in my career was a child inappropriately diagnosed with viral gastroenteritis after presenting to urgent care with vomiting. She had been drinking regular Sprite for hydration all weekend before presenting obtunded with a blood glucose level > 2000 mg/dL. A simple urinalysis would have provided the diagnosis.

Yeast infections in prepubertal girls who don't wear diapers. These should not occur in immunocompetent children, but yeast flourishes when glucose values average above 200 mg/dL.

Thrush in children past infancy. Continuing on the topic of opportunistic yeast infections, I have treated many children who had been seen previously for "strep throat" that was truly thrush. A high degree of suspicion must be maintained.

"Asthma exacerbations" that are in fact Kussmaul respirations. Many children's hospitals have a specific respiratory cohort where children are triaged for presumed asthma or bronchiolitis. Sometimes clinicians will see a child after the first albuterol treatment is given and assume that a lack of wheeze may be due to treatment efficacy. Is the expiratory phase prolonged despite resolution of wheezing? Does the air smell like fingernail polish remover, a telltale sign of pathologic ketone levels? I have a child in my practice who was seen three times prior to diagnosis by three different providers for "asthma" who later came in with cerebral edema and pH of 6.7 owing to missed new-onset T1D. This child had an autoimmune condition but was obese, so suspicion of T1D was low among the previous clinicians.

Blurry vision. One of my patients was diagnosed following difficulty in getting his contacts prescription right. Fortunately, this symptom resolves when blood glucose levels stabilize.

Any abnormal blood glucose value. Even after eating a high-sugar meal, children with normal insulin function should respond normally. Any blood glucose level > 180 mg/dL is concerning and should be discussed with a pediatric endocrinologist for further work-up.

"Possible UTI." Although antibiotic stewardship is reason enough to never prescribe antibiotics over the phone for a presumed pediatric urinary tract infection (UTI), at least one quarter of my patients with new-onset T1D had presented to their pediatrician concerned about a parent-diagnosed urinary tract infection because of increased frequency of urination.

New bedwetting. Nocturia and bedwetting in a previously potty-trained child are flashing warning signs to investigate further.

Weight loss. This one is obvious, but children have many reasons to appear slimmer — from growth spurts to new stimulant medications, increased activity with a new sport, or an intentional lifestyle change. Most pediatricians know that weight loss can be a harbinger of many serious conditions, but no list of new-onset diabetes symptoms is complete without mentioning it.

Increased thirst. Although this is the most obvious sign, in the Southeast, where I live, increased thirst easily can be blamed on hot weather. Teachers may notice increased bathroom use before parents do. Once, a dentist called me with a new diagnosis because a child couldn't make it through a routine cleaning without several bathroom breaks. Increased public awareness of common signs of diabetes like these will help get children the help they need before they need intensive care — or worse.

Although there is a national shortage of both pediatric and adult endocrinologists (stay tuned for my next article), your friendly local pediatric diabetes specialist is here to help. We depend on our colleagues on the front lines to help bring patients into our care at the right time. Beyond the prevention of death and complications from DKA at diagnosis, we also know that earlier diagnosis preserves islet cells, which is becoming more important for prevention efforts. The first step in diagnosing diabetes is to consider it in the first place. Continued commitment to education in every community will save and improve lives.

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