Sharing the care of children with diabetes

The numbers of children developing type  1 and type  2 diabetes is increasing in the UK (Gale, 2002). Unfortunately, evidence suggests that many children do not achieve ideal glycaemic control (Craft, 2007) despite specific standards concerning the management of children and young people described in the National Service Framework (NSF) for diabetes (Department of Health [DH], 2001).

The treatment of children with diabetes is usually supervised by the secondary care paediatric diabetes team, as children have specific needs that are not addressed by seeing them as “little adults”. Depending on the age at diagnosis, a childhood of diabetes may require many changes in insulin doses and regimens to minimise risk of long-term complications, attain normal growth, and a good quality of life with minimal disruption to daily routine. The progression from helping the parents to manage the control of their child’s diabetes to gradual independence as the child matures is supported by the paediatric team and later, ideally, with the young people’s transition clinic team.

Increasingly, the routine management of adults with diabetes is occurring in primary care, but GPs generally have little experience in managing children’s diabetes care. As well as children receiving diabetes care in hospital clinics, the average GP list may have only one or two children with the condition. However, the GP and practice nurse will see the child for other health concerns such as common childhood infections, routine immunisations and treatment of minor injuries. It is usually the GP who makes the initial diagnosis of diabetes and arranges referral to the secondary care diabetes team. Importantly, the GP may have other family members as patients at the practice and, therefore, may be an important support at the time of diagnosis of the child and ongoing. Indeed, it is usually the GP who makes the initial diagnosis and referral. When a child has diabetes, it can have an impact on all the family members.

Other members of the primary care team will become involved in the care of the child with diabetes. The health visitor will monitor the achievement of normal childhood development milestones and height and weight in the pre-school years. The school nurse will meet the child at routine school checks but may be able to provide support in facilitating insulin injections, blood glucose monitoring, and insulin pump use during the school day, in partnership with the hospital diabetes team.

Adolescence is a notoriously difficult time in life, even in the young person without diabetes. For a teenager with the condition, the hormonal changes involved with puberty, the effects of the growth spurt, and the social pressure of not wanting to be different can result in very poor glycaemic control. At a time when their diabetes management is most challenging, the teenager may stop attending the hospital diabetes clinic. The GP, practice nurse and school nurse may be the link between the teenager and their diabetes team during this time.

The NSF for children, young people and maternity services (DH, 2004) recommends that:

• Children and young people with long-term conditions should be helped to participate fully in life.
• Children, young people and parents should be involved in decisions about care.
• Healthcare professionals should be supporting self-care.

Given the poor achievement in the management of childhood and adolescent diabetes in the UK, the collaboration between all healthcare professionals, both in primary and secondary care, generalist or diabetes specialist, involved in the healthcare of the child or young person, will be invaluable in meeting these recommendations.

The following article discusses the role of GP practices in the management of children with diabetes. Of particular importance is early diagnosis and urgent referral to prevent presentation with diabetic ketoacidosis, and the provision of a “safety net” for children and especially adolescents who do not attend the hospital paediatric diabetes clinic. Communication from primary care to the paediatric team about these patients is essential.