Children’s Health – Altered conscious level

Children’s Health – Altered conscious level

In module Child Health

13 year old John is brought to accident and emergency by his parents as he is having severe difficulty in breathing.

Altered conscious level ILOs

Guidance and Resources – Altered conscious level

In case Children’s Health – Altered conscious level

eBooks

Illustrated Textbook of Paediatrics 4th edition. Lissauer (Mosby Elsevier)

Web Links

For further reading about DKA please click on the following link:

BSPED Recommended Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis 2015

For further reading on Type I diabetes mellitus please click on the following link:

Diabetes (type 1 and type 2) in children and young people: diagnosis and management – NICE guideline [NG18]

CASE COMPONENT

Case Introduction – Altered conscious level

In case Children’s Health – Altered conscious level

13-year-old John is brought to accident and emergency by his parents as he is having severe difficulty in breathing.

 His parents also give a history of John having asthma, for which he is on Salbutamol inhalers.

Clinical Examination findings:

John looked pale with a dry mouth and was agitated.

John’s initial observations are as follows:

Temperature 37.1 degree C

RS

John was using his accessory muscles of respiration.

His breathing was noted to be deep and laboured with a RR of 20 per minute.

His oxygen saturations were 99% in room air.

Auscultation revealed good bilateral air entry with no wheeze or crepitations.

CVS

HR 140 BPM. Heart sounds were normal with no murmurs.

Capillary refill of 5 seconds both centrally and peripherally. Peripheral pulses thready.

Blood pressure of 90/50 mm Hg.

Abdomen

Soft and slightly tender over the liver

No palpable masses.

Neurology

Agitated at presentation but conversing spontaneously and responding to verbal commands.

Pupils reacting equally.

Further Case Information – Altered conscious level

In case Children’s Health – Altered conscious level

Gas

pH 7.15 (7.35-7.45)

pCO2 3.0 (4.5-6) kPa

pO2 11.0 (10-14) kPa

Bicarb 16 (22-26) mmol/L

BE - 20

Background Science – Altered conscious level

In case Children’s Health – Altered conscious level

What is Diabetic ketoacidosis?

Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens when a severe lack of insulin means the body cannot use intracellular glucose(starvation amidst plenty- the glucose cannot get inside cells) for energy, and the body starts to break down other body tissue as an alternative energy source. Ketones are the by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked, will cause the body to become acidic – hence the name ‘acidosis’.

DKA is a life-threatening emergency.

The most likely times for DKA to occur are:

· At diagnosis. (Some people who do not realise they have Type 1 diabetes do not get diagnosed until they are very unwell with DKA).

· When ill.

· During a growth spurt/puberty.

· Insulin omission for any reason.

· DKA usually develops over 24 hours but can develop faster particularly in young children or patients on insulin pumps(they have no long acting insulin on board so develop DKA quickly if the cannula dislodges).

Recognition, referral and diagnosis:

Measure capillary blood glucose at presentation in children and young people without known diabetes who have increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and any of the following: nausea or vomiting, abdominal pain, hyperventilation, dehydration and reduced level of consciousness.

If the plasma glucose level is above 11 mmol/litre in a child or young person without known diabetes, and they have symptoms that suggest diabetic ketoacidosis (DKA), suspect DKA and immediately send them to a hospital with acute paediatric facilities.
Be aware that children and young people taking insulin for diabetes may develop DKA with only mildly elevated blood glucose levels. Suspect DKA in a child or young person with known diabetes and any of following: nausea or vomiting, abdominal pain, hyperventilation, dehydration and reduced level of consciousness.

When DKA is suspected in a child or young person with known diabetes measure the blood ketones (beta-hydroxybutyrate), using a near-patient method if available. If the level is elevated, immediately send them to a hospital with acute paediatric facilities.
When DKA is suspected in a child or young person with known diabetes and it is not possible to measure the blood ketones (beta-hydroxybutyrate) using a near-patient method, immediately send them to a hospital with acute paediatric facilities. If DKA is suspected or confirmed in a child or young person, explain to them and to their family members or carers (as appropriate) that DKA is a serious matter that needs urgent hospital assessment.

When a child or young person with suspected or known DKA arrives at hospital, measure their: capillary blood glucose capillary blood ketones (beta-hydroxybutyrate) if near-patient testing is available, or urine ketones if it is not capillary or venous pH and bicarbonate.

Diagnose DKA in children and young people with diabetes who have:

1.    Acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 18 mmol/litre) and

2.    Ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre) or ketonuria (++ and above on the standard strip marking scale).

Diagnose severe DKA in children and young people with DKA who have a blood pH below 7.1. 

Initial management of diabetic ketoacidosis:

Inform the responsible senior clinician once a diagnosis of DKA in a child or young person is made. Explain to the child or young person with DKA and to their family members or carers (as appropriate) about their condition and the care that they may need. When DKA is diagnosed in a child or young person in hospital, record their: level of consciousness, vital signs (heart rate, blood pressure, temperature, respiratory rate [look for Kussmaul’s breathing]) history of nausea or vomiting, clinical evidence of dehydration, body weight.

The morbidity and mortality in childhood DKA is from cerebral oedema. The aim of therapy is very gentle and slow correction to avoid cerebral oedema

What is Kussmaul breathing?

Kussmaul breathing is named for Adolph Kussmaul, the 19th century German doctor who first noted it among patients with advanced diabetes mellitus. Kussmaul’s sign is also an eponymous finding attributable to Kussmaul, and should be distinguished from Kussmaul breathing.

Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiration.
In metabolic acidosis, breathing is first rapid and shallow but as acidosis worsens, breathing gradually becomes deep, labored and gasping. It is this latter type of breathing pattern that is referred to as Kussmaul breathing.

When DKA is diagnosed in a child or young person in hospital, measure and record the capillary or venous: pH and pCO2 plasma sodium, potassium, urea and creatinine plasma bicarbonate. Consider a near-patient blood ketone (beta-hydroxybutyrate) testing method for rapid diagnosis and monitoring of DKA in children and young people in hospital. Children and young people with DKA should be cared for in a facility that can provide the level of monitoring and care for DKA. Children and young people with DKA should be cared for on a recognised paediatric high-dependency unit (of a paediatric unit). If they are younger than 2 years or they have severe DKA (indicated by a blood pH below 7.1) discuss with a regional PICU.

Think about inserting a nasogastric tube if a child or young person with DKA has a reduced level of consciousness and is vomiting, to reduce the risk of aspiration. Seek urgent anaesthetic review and discuss with a paediatric critical care specialist if a child or young person with DKA cannot protect their airway because they have reduced level of consciousness. Discuss the use of inotropes with a paediatric critical care specialist if a child or young person with DKA is in hypotensive shock. Think about sepsis in a child or young person with DKA who has any of the following: fever or hypothermia, hypotension, refractory acidosis, lactic acidosis.

Fluid and insulin therapy

Treat DKA with oral fluids and subcutaneous insulin only if the child or young person is alert, not nauseated or vomiting, and not clinically dehydrated. If DKA is treated with oral fluids and subcutaneous insulin, ensure that the child or young person is recovering by monitoring for resolution of ketonaemia and acidosis. Treat DKA with intravenous fluids and intravenous insulin if the child or young person is not alert, is nauseated or vomiting or is clinically dehydrated.

Do not give oral fluids to a child or young person who is receiving intravenous fluids for DKA unless ketosis is resolving, they are alert, and they are not nauseated or vomiting.

Do not give an intravenous fluid bolus to children and young people with mild or moderate DKA (indicated by a blood pH of 7.1 or above).

Do not routinely give an intravenous fluid bolus to a child or young person with severe DKA (indicated by a blood pH below 7.1).

Do not give more than one intravenous fluid bolus of 10 ml/kg 0.9% sodium chloride to a child or young person with severe DKA (indicated by a blood pH below 7.1) without discussion with the responsible senior paediatrician.

Do not give intravenous sodium bicarbonate to children and young people with DKA.

In children and young people with DKA, calculate their total fluid requirement for the first 48 hours by adding the estimated fluid deficit to the fluid maintenance requirement. When calculating the fluid requirement for children and young people with DKA, assume: a 5% fluid deficit in mild to moderate DKA (indicated by a blood pH of 7.1 or above) a 10% fluid deficit in severe DKA (indicated by a blood pH below 7.1).

Calculate the maintenance fluid requirement for children and young people with DKA using the following ‘reduced volume’ rules: if they weigh less than 10 kg, give 2 ml/kg/hour if they weigh between 10 and 40 kg, give 1 ml/kg/hour if they weigh more than 40 kg, give a fixed volume of 40 ml/hour.

These are lower than standard fluid maintenance volumes because large fluid volumes are associated with an increased risk of cerebral oedema. Aim to replace the fluid deficit evenly over the first 48 hours in children and young people with DKA, because faster rehydration is associated with an increased risk of cerebral oedema.
Use 0.9% sodium chloride without added glucose for both rehydration and maintenance fluid in children and young people with DKA until the plasma glucose concentration is below 14 mmol/litre. Ensure that all fluids (except any initial bolus) administered to children and young people with DKA contain 40 mmol/litre potassium chloride, unless they have renal failure.

If more than 20 ml/kg of fluid has been given by intravenous bolus to a child or young person with DKA, subtract any additional bolus volumes from the total fluid calculation for the 48-hour period.

Think about inserting a urinary catheter if it is not possible to accurately measure urine output for a child or young person with DKA.

Do not give children and young people with DKA additional intravenous fluid to replace urinary losses.

Start an intravenous insulin infusion 1–2 hours after beginning intravenous fluid therapy in children and young people with DKA. When treating DKA with intravenous insulin in children and young people, use a soluble insulin infusion at a dosage between 0.05 and 0.1 units/kg/hour.

Do not give bolus doses of intravenous insulin.

If a child or young person with DKA is using insulin pump therapy, disconnect the pump when starting intravenous insulin therapy. In discussion with a diabetes specialist, think about continuing subcutaneous basal insulin in a child or young person who was using a basal insulin before the onset of DKA. Change fluids to 0.9% sodium chloride with 5% glucose and 40 mmol/litre potassium chloride once the plasma glucose concentration falls below 14 mmol/ litre in children and young people with DKA.

If during treatment for DKA a child or young person’s plasma glucose falls below 6 mmol/litre: increase the glucose concentration of the intravenous fluid infusion, and if there is persisting ketosis, continue to give insulin at a dosage of least 0.05 units/kg/ hour.

If the blood beta-hydroxybutyrate level is not falling within 6–8 hours in a child or young person with DKA, think about increasing the insulin dosage to 0.1 units/kg/hour or greater. Think about stopping intravenous fluid therapy for DKA in a child or young person if ketosis is resolving, they are alert, and they can take oral fluids without nausea or vomiting.

Do not change from intravenous insulin to subcutaneous insulin in a child or young person with DKA until ketosis is resolving, they are alert, and they can take oral fluids without nausea or vomiting.

Start subcutaneous insulin in a child or young person with DKA at least 30 minutes before stopping intravenous insulin. For a child or young person with DKA who is using insulin pump therapy, restart the pump at least 60 minutes before stopping intravenous insulin. Change the insulin cartridge and infusion set, and insert the cannula into a new subcutaneous site.

Monitoring during therapy

1.    Monitor and record the following at least hourly in children and young people with DKA: capillary blood glucose, ketones, vital signs (heart rate, blood pressure, temperature, respiratory rate [look for Kussmaul breathing]) fluid balance, with fluid input and output charts level of consciousness (using the modified Glasgow coma scale).

2.    Monitor and record the level of consciousness (using the modified Glasgow coma scale) and the heart rate (to detect bradycardia) every 30 minutes in: children under 2 years with DKA children and young people with severe DKA (indicated by a blood pH below 7.1). This is because these children and young people are at increased risk of cerebral oedema.

3.    Monitor children and young people receiving intravenous therapy for DKA using continuous electrocardiogram (ECG) to detect signs of hypokalaemia, including ST-segment depression and prominent U-waves.

4.    At 2 hours after starting treatment, and then at least every 4 hours, carry out and record the results of the following blood tests in children and young people with DKA: glucose (laboratory measurement) blood pH and pCO2 plasma sodium, potassium and urea.

5.    A doctor involved in the care of the child or young person with DKA should review them face-to-face at diagnosis and then at least every 4 hours, and more frequently if: they are aged under 2 years they have severe DKA (indicated by a blood pH below 7.1) there are any other reasons for special concern.

6.    At each face-to-face review of children and young people with DKA, assess the following: clinical status, including vital signs and neurological status results of blood investigations, ECG trace cumulative fluid balance record.

7.    Update the child and young person with DKA and their family members or carers (as appropriate) regularly about their progress.

Complications of diabetic ketoacidosis

Cerebral oedema

Immediately assess children and young people with DKA for suspected cerebral oedema if they have any of these early manifestations:

1.    headache

2.    agitation or

3.    irritability

4.    unexpected fall in heart rate increased blood pressure.

Immediately treat for cerebral oedema using the most readily available of mannitol (20%, 0.5–1 g/kg over 10–15 minutes) or hypertonic sodium chloride (2.7% or 3%, 2.5–5 ml/kg over 10–15 minutes) if a child or young person with DKA develops any of these signs: deterioration in level of consciousness abnormalities of breathing pattern (for example respiratory pauses), oculomotor palsies, pupillary inequality or dilatation. After starting treatment for cerebral oedema with mannitol or hypertonic sodium chloride in a child or young person with DKA, immediately seek specialist advice on further management, including which care setting would be best.

Hypokalaemia

If a child or young person with DKA develops hypokalaemia (potassium below 3 mmol/litre): think about temporarily suspending the insulin infusion. Discuss hypokalaemia management urgently with a paediatric critical care specialist, because a central venous catheter is needed for intravenous administration of potassium solutions above 40 mmol/litre.

Venous thromboembolic disease

Be aware of the increased risk of venous thromboembolism in children and young people with DKA, especially those with central venous catheters.

Avoiding future episodes of diabetic ketoacidosis

After a child or young person with known diabetes has recovered from an episode of DKA, discuss with them and their family members or carers (if appropriate) the factors that may have led to the episode. Think about the possibility of non-adherence to therapy in children and young people with established type 1 diabetes who present with DKA, especially if the DKA is recurrent. Advise children and young people who have had an episode of DKA and their family members or carers (if appropriate) how to reduce the risk of future episodes. In particular, advise them of the importance of managing intercurrent illnesses. Make sure the family have a copy of the ACDC sick day rules.

Type 1 Diabetes Mellitus

What is Type 1 Diabetes Mellitus?

Type 1 Diabetes Mellitus (T1DM) is an auto-immune condition which develops when there is not enough insulin around to keep the body’s blood glucose levels within normal limits. There are several hormones which can elevate blood glucose but only insulin can lower blood glucose. So when there is no insulin around, blood glucose levels remain high even if no glucose containing food is eaten.

Incidence, prevalence, and patient characteristics:

· 27,115 children and young people with Type 1 diabetes were reported to the audit in 2015/16 (96.0% of the total cohort).

· The prevalence of Type 1 diabetes in children and young people aged 0 to 15 years old in England and Wales in 2015/16 is 195.4 per 100,000 of the general population.

· There were 2,834 children and young people aged 0 to 15 years old diagnosed with Type 1 diabetes in England and Wales in 2015/16, giving an incidence of 25.9 per 100,000 general population.

· Prevalence and incidence of Type 1 diabetes is higher amongst males than females.

· There has been a year on year increase in the incidence of Type 1 diabetes since the 2013/14 audit, with the greatest increase amongst females.

Diagnosis of Type 1 Diabetes Mellitus:

The characteristics of type 1 diabetes in children and young people include:

1.    Hyperglycaemia (random plasma glucose more than 11 mmol/litre)

2.    Polyuria

3.    Polydipsia

4.    Weight loss

5.    Excessive tiredness

Confirm type 1 diabetes in children and young people using the plasma glucose criteria specified in the World Health Organization’s 2006 report on the diagnosis and classification of diabetes mellitus.

The current WHO diagnostic criteria for diabetes are as follows:

fasting plasma glucose ≥ 7.0mmol/l (126mg/dl)
or
2–h plasma glucose ≥ 11.1mmol/l (200mg/dl).

When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there are strong indications of type 2 diabetes, monogenic or mitochondrial diabetes .

Think about the possibility of type 2 diabetes in children and young people with suspected diabetes who:

1.    have a strong family history of type 2 diabetes

2.    are obese at presentation

3.    are of black or Asian family origin

4.    have no insulin requirement, or have an insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase

5.    show evidence of insulin resistance (for example, acanthosis nigricans).

Think about the possibility of types of diabetes other than types 1 or 2 (such as other insulin resistance syndromes, or monogenic or mitochondrial diabetes) in children and young people with suspected diabetes who have any of the following features:

1.    diabetes in the first year of life

2.    rarely or never develop ketone bodies in the blood (ketonaemia) during episodes of hyperglycaemia

3.    associated features, such as optic atrophy, retinitis pigmentosa, deafness, or another systemic illness or syndrome

4.    Strong family history of diabetes(however type 1 diabetes also has a genetic component)

Do not measure C-peptide and/or diabetes-specific autoantibody titres at initial presentation to distinguish type 1 diabetes from type 2 diabetes.

Consider measuring C-peptide after initial presentation if there is difficulty distinguishing type 1 diabetes from other types of diabetes. Be aware that C-peptide concentrations have better discriminative value the longer the interval between initial presentation and the test. Check GAD antibodies- suggests type 1 diabetes.

Perform genetic testing if atypical disease behaviour, clinical characteristics or family history suggest monogenic diabetes.

Insulin therapy for children and young people with type 1 diabetes:

While the insulin regimen should be individualised for each patient, there are 3 basic types of insulin regimen:

1.    Multiple daily injection basal–bolus insulin regimens: injections of short-acting insulin before meals, together with 1 daily injection of long-acting insulin.

2.    Continuous subcutaneous insulin infusion (insulin pump therapy): a programmable pump and insulin storage device that gives a regular or continuous amount of insulin (usually a rapid-acting insulin analogue or short-acting insulin) by a subcutaneous needle or cannula.

Blood glucose and HbA1c targets and monitoring for children and young people with type 1 diabetes:

Blood glucose targets:

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the optimal target ranges for short-term plasma glucose control are:

1.    Fasting plasma glucose level of 4–7 mmol/litre on waking

2.    a plasma glucose level of 4–7 mmol/litre before meals at other times of the day

3.    a plasma glucose level of 5–9 mmol/litre after meals

4.    a plasma glucose level of at least 5 mmol/litre when driving

Blood glucose monitoring:

Advise children and young people with type 1 diabetes and their family members or carers (as appropriate) to routinely perform at least 5 capillary blood glucose tests per day.

Advise children and young people with type 1 diabetes and their family members or carers (as appropriate) that more frequent testing is often needed (for example with physical activity and during intercurrent illness), and ensure they have enough test strips for this.

HbA1c targets and monitoring:

Use methods to measure HbA1c that have been calibrated according to International Federation of Clinical Chemistry (IFCC) standardisation.
Explain the benefits of safely achieving and maintaining the lowest attainable HbA1c to children and young people with type 1 diabetes and their family members or carers (as appropriate).

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.

Explain to children and young people with type 1 diabetes who have an HbA1c level above the ideal target of 48 mmol/mol (6.5%) and their family members or carers (as appropriate) that any reduction in HbA1c level reduces the risk of long-term complications

Agree an individualised lowest achievable HbA1c target with each child or young person with type 1 diabetes and their family members or carers (as appropriate), taking into account factors such as daily activities, individual life goals, complications, comorbidities and the risk of hypoglycaemia.

Support children and young people with type 1 diabetes and their family members or carers (as appropriate) to safely achieve and maintain their individual agreed HbA1c target level.

Offer children and young people with type 1 diabetes measurement of their HbA1c level 4 times a year (more frequent testing may be appropriate if there is concern about suboptimal blood glucose control).

Hypoglycaemia in children and young people with type 1 diabetes

Immediately treat mild to moderate hypoglycaemia in children and young people with type 1 diabetes as follows:

Give fast-acting glucose (for example, 10–20 g) by mouth (liquid carbohydrate may be taken more easily than solid). Be aware that fast-acting glucose may need to be given in frequent small amounts, because hypoglycaemia can cause vomiting

Recheck blood glucose levels within 15 minutes (fast-acting glucose should raise blood glucose levels within 5–15 minutes) and repeat fast-acting glucose if hypoglycaemia persists.

As symptoms improve or normoglycaemia is restored, give oral complex long-acting carbohydrate to maintain blood glucose levels, unless the child or young person is: about to have a snack or meal receiving a continuous subcutaneous insulin infusion

Treat severe hypoglycaemia in children and young people with type 1 diabetes who are in hospital and in whom rapid intravenous access is possible by giving 10% intravenous glucose. Give a maximum dose of 500 mg/kg body weight (equivalent to a maximum of 5 ml/kg).

Treat severe hypoglycaemia in children and young people with type 1 diabetes who are not in hospital or who do not have rapid intravenous access available as follows:

Use intramuscular glucagon or a concentrated oral glucose solution (for example Glucogel). Do not use oral glucose solution if the level of consciousness is reduced as this could be dangerous.

If using intramuscular glucagon:

give children and young people over 8 years old (or who weigh 25 kg or more) 1 mg glucagon.

give children under 8 years old (or who weigh less than 25 kg) 500 micrograms of glucagon. Seek medical assistance if blood glucose levels do not respond or symptoms persist for more than 10 minutes.

Explain to young people with type 1 diabetes the effects of alcohol consumption on blood glucose control, and in particular that there is an increased risk of hypoglycaemia including hypoglycaemia while sleeping.

Explain to young people with type 1 diabetes who drink alcohol that they should:

1.    Eat food containing carbohydrate before and after drinking monitor their blood glucose levels regularly and aim to keep the levels within the recommended range by eating food containing carbohydrate.

2.    Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that when alcohol causes or contributes to the development of hypoglycaemia, glucagon may be ineffective in treating the hypoglycaemia and intravenous glucose will be required.

Diabetes teams should consider referring children and young people with type 1 diabetes who have frequent hypoglycaemia and/or recurrent seizures for assessment of cognitive function, particularly if these occur at a young age.

Monitoring for complications and associated conditions of type 1 diabetes

Offer children and young people with type 1 diabetes monitoring for:

1.    Thyroid disease at diagnosis and annually thereafter until transfer to adult services

2.    Diabetic retinopathy- annually from 12 years

3.    Moderately increased albuminuria (albumin:creatinine ratio [ACR] 3–30 mg/mmol; ‘microalbuminuria’) to detect diabetic kidney disease- annually from 12 years

4.    Hypertension- annually from 12 years.

Be aware of the following rare complications and associated conditions with type 1 diabetes:

1.    Juvenile cataracts

2.    Necrobiosis lipoidica

3.    Addison’s disease.

In addition Children and Young People with Type 1 DM get screened for Coeliac Disease at diagnosis. For guidance on monitoring for coeliac disease in children and young people with type 1 diabetes, see the NICE guideline on coeliac disease.

For guidance on managing foot problems in children and young people with type 1 diabetes, see the NICE guideline on diabetic foot problems.

Diabetic retinopathy in children and young people with type 1 diabetes

1.    Monitoring for diabetic retinopathy begins at 12 years because retinopathy that needs treatment is extremely rare in children and young people under 12.

2.    Background retinopathy is often found through monitoring and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy.

3.    Annual monitoring from 12 years is important because, if significant diabetic retinopathy is found, early treatment will improve the outcome.

4.    GPs should refer children to the local diabetic eye screening programme before they reach 12 years of age.

Diabetic kidney disease in children and young people with type 1 diabetes

1.    Monitoring for moderately increased albuminuria (ACR 3–30 mg/mmol; ‘microalbuminuria’) to detect diabetic kidney disease begins at 12 years because diabetic kidney disease in children and young people under 12 is extremely rare.

2.    Using the first urine sample of the day (‘early morning urine’) to screen for moderately increased albuminuria is important, as this reduces the risk of false positive results.

3.    If moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease.

4.    Annual monitoring from 12 years is important because, if diabetic kidney disease is found, early treatment will improve the outcome.

CASE COMPONENT

Case Conclusion – Altered conscious level

In case Children’s Health – Altered conscious level

John was diagnosed with DKA on clinical assessment. It was felt that John was 5% dehydrated. He was given boluses of intravenous fluids in the form of 0.9% normal saline in view of his poor perfusion. Fluids were calculated as per the NICE DKA management guidelines. He was also commenced on intravenous insulin once his perfusion improved. John’s agitation settled soon after commencing treatment. His blood sugars and ph normalised in the next 36 hours.

Formative Assessment – Altered conscious level