A 16-year-old girl with type 1 diabetes for 10 years attends for transition planning to adult services. Her HbA1c has been consistently between 65-72 mmol/mol over the past 2 years. Annual screening shows persistent microalbuminuria (ACR 4.8 mg/mmol) and background diabetic retinopathy with scattered microaneurysms bilaterally. She is on appropriate therapy including an ACE inhibitor. She asks about her long-term prognosis. What is the most appropriate counselling regarding her microvascular complications?

Optimizing glycaemic control now can still slow progression even with established complications

Microalbuminuria at this stage is irreversible regardless of subsequent glycaemic control

With current control, progression to end-stage renal disease is inevitable within 10 years

Background retinopathy always progresses to proliferative retinopathy requiring laser therapy

Presence of two microvascular complications indicates imminent need for renal transplantation

A 4-year-old boy with newly diagnosed generalized epilepsy is being commenced on sodium valproate. His mother asks about potential side effects. Which of the following monitoring investigations should be performed before starting sodium valproate and at regular intervals during treatment?

Liver function tests, full blood count, and serum ammonia

Full blood count, renal function, and thyroid function tests

Electrocardiogram, liver function tests, and lipid profile

Full blood count, vitamin D levels, and bone density scan

Renal function, serum drug levels, and electroencephalogram

A 13-year-old boy with type 1 diabetes for 7 years presents with intermittent episodes of abdominal bloating, early satiety, nausea, and vomiting, particularly after meals. He reports that vomiting sometimes contains food eaten several hours earlier. His HbA1c is 82 mmol/mol. On examination, he has mild epigastric tenderness and a succussion splash. Screening for coeliac disease is negative. What is the most likely diagnosis?

Gastroparesis secondary to diabetic autonomic neuropathy

Diabetic ketoacidosis with gastric stasis

Superior mesenteric artery syndrome

Helicobacter pylori-associated gastritis

Coeliac disease with false-negative serology

A 10-year-old girl with type 1 diabetes for 5 years uses insulin glargine 18 units once daily at bedtime and insulin aspart before meals. She participates in competitive gymnastics training 5 evenings per week from 5-7pm. Her mother reports that she frequently becomes hypoglycaemic during and after training sessions despite eating extra snacks. Pre-dinner glucose is usually 8-10 mmol/L. What is the most appropriate modification to her insulin regimen?

Reduce the pre-lunch insulin aspart dose by 30-50% on training days

Increase the pre-lunch insulin aspart dose to provide better afternoon glucose control

Switch insulin glargine from bedtime to morning administration

Add metformin to reduce insulin requirements

Split insulin glargine to twice daily administration with reduced total daily dose

A 7-year-old boy with newly diagnosed focal epilepsy is being considered for anti-epileptic drug therapy. His seizures consist of focal motor seizures affecting his right arm with preserved awareness, occurring 2-3 times per week. MRI brain shows a small left frontal cortical dysplasia. His parents are concerned about side effects of medication. Which of the following statements regarding the decision to commence anti-epileptic drug treatment is most accurate?

The presence of a structural brain lesion increases the risk of seizure recurrence and supports starting treatment

Focal seizures with preserved awareness do not require anti-epileptic treatment

Anti-epileptic drugs should be started immediately after a single unprovoked seizure to prevent recurrence

Anti-epileptic drugs are contraindicated in children under 10 years due to neurodevelopmental concerns

Treatment should be delayed until seizures occur daily to confirm the diagnosis

A 15-year-old boy with type 1 diabetes for 9 years attends clinic with his parents. Over the past year, his HbA1c has deteriorated from 58 mmol/mol to 85 mmol/mol. He admits to frequently missing insulin doses and not checking his blood glucose. He expresses frustration about being 'different' from his peers and wanting to be 'normal'. His parents report frequent arguments at home about diabetes management. What is the most appropriate initial approach to address this situation?

Explore the patient's perspective and concerns using motivational interviewing techniques

Arrange immediate referral to child and adolescent mental health services

Initiate continuous glucose monitoring to improve awareness of glucose levels

Inform the parents that they need to resume full responsibility for diabetes management

Switch to insulin pump therapy to simplify the treatment regimen

A 5-year-old girl presents to the emergency department with a 20-minute generalized tonic-clonic seizure that has not responded to two doses of buccal midazolam given by paramedics. Intravenous access is established. Blood glucose is 5.2 mmol/L. What is the most appropriate next immediate management?

Intravenous lorazepam 0.1 mg/kg

Intravenous phenytoin 20 mg/kg infusion

Intramuscular phenobarbital 20 mg/kg

Intravenous levetiracetam 40 mg/kg

Which of the following is the primary mechanism by which the ketogenic diet exerts its anti-epileptic effect in children with drug-resistant epilepsy?

Metabolic shift producing ketone bodies that stabilize neuronal membranes and alter neurotransmitter levels

Reduction in neuronal excitability through GABA receptor upregulation

Inhibition of voltage-gated sodium channels in neuronal membranes

Decreased glutamate synthesis and enhanced glycine-mediated inhibition

Direct antagonism of NMDA receptors reducing excitatory neurotransmission

A 9-year-old boy with type 1 diabetes for 4 years uses a basal-bolus insulin regimen. His parents report that his morning pre-breakfast blood glucose readings are consistently high (12-15 mmol/L), despite having good control during the day. His bedtime readings are usually 6-8 mmol/L. A continuous glucose monitor shows that his glucose drops to 3.2 mmol/L at 2am then rises sharply to 14 mmol/L by 7am. What is the most appropriate adjustment to his insulin regimen?

Decrease the evening long-acting insulin dose

Increase the evening long-acting insulin dose

Add a bedtime snack containing complex carbohydrates

Increase the lunchtime rapid-acting insulin dose

Split the long-acting insulin to twice daily dosing

Type 1 diabetes in children for UKMLA AKT: High-Yield Child Health Lessons

Quick Overview

Type 1 diabetes (T1D) in children results from autoimmune pancreatic β-cell destruction causing absolute insulin deficiency. Diagnosis requires HbA1c ≥48 mmol/mol (6.5%) or fasting glucose ≥7.0 mmol/L or random glucose ≥11.1 mmol/L with symptoms. NICE NG18 emphasizes structured management to prevent acute complications (DKA, hypoglycaemia) and long-term microvascular damage through tight glycaemic control (target HbA1c <48 mmol/mol).

Core Facts & Concepts

📊 Diagnostic Thresholds (NICE NG18)

HbA1c ≥48 mmol/mol (6.5%) OR
Fasting plasma glucose ≥7.0 mmol/L OR
Random glucose ≥11.1 mmol/L with symptoms (polyuria, polydipsia, weight loss)
C-peptide low/undetectable; diabetes autoantibodies positive (GAD, IA-2, ZnT8)

🎯 Treatment Targets

HbA1c: <48 mmol/mol (6.5%) without disabling hypoglycaemia
Pre-meal glucose: 4-7 mmol/L
Post-meal glucose: 5-9 mmol/L
Bedtime glucose: 4-7 mmol/L

Figure 1: Blood glucose meter showing reading of 2.8 mmol/L indicating hypoglycaemia

💊 Insulin Regimens

Basal-bolus: Long-acting (detemir/glargine/degludec) + rapid-acting (aspart/lispro) with meals
Insulin pump (CSII): Consider if HbA1c >69 mmol/mol despite compliance OR disabling hypoglycaemia
Total daily dose: 0.5-1.0 units/kg/day (higher in puberty ~1.5 units/kg)

Monitoring Schedule

Blood glucose: ≥5 tests/day (pre-meals, bedtime, before driving/exercise)
HbA1c: Every 3 months
Annual screening (from 12 years or 5-year duration): retinopathy, nephropathy (ACR), neuropathy, thyroid, coeliac

Problem-Solving Approach

DKA Management Protocol (pH <7.3 OR bicarbonate <15 mmol/L)

Fluid resuscitation:
- 10 mL/kg 0.9% saline bolus over 1 hour (repeat if shocked)
- Maintenance + deficit over 48 hours (avoid cerebral oedema)
- Add 0.9% saline + 40 mmol/L KCl once urine output established
Insulin: 0.05-0.1 units/kg/hour IV (start 1-2 hours after fluids)
Monitoring: Hourly glucose, 2-hourly venous gases, neuro obs (cerebral oedema risk)
Switch to SC insulin when: pH >7.3, bicarbonate >15, tolerating oral

🚩 DKA Red Flags

Headache, bradycardia, rising BP → cerebral oedema (give mannitol 0.5 g/kg)
Fluid resuscitation >10 mL/kg/hour increases cerebral oedema risk

Hypoglycaemia Management (<4 mmol/L)

Conscious: 15g fast-acting carbs (150mL juice, 4-5 glucose tablets)
Unconscious/unable to swallow: IM glucagon 0.5-1mg OR IV 10% glucose 2mL/kg
Recheck in 15 minutes; give long-acting carb after recovery

Sick Day Rules

Never stop insulin (increase by 10-20% if hyperglycaemic)
Check glucose 2-4 hourly
Check ketones if glucose >14 mmol/L
Maintain hydration; seek help if persistent vomiting/ketones

Analysis Framework

Feature	Basal-Bolus	Insulin Pump (CSII)
Indication	First-line for all	HbA1c >69 despite adherence OR disabling hypoglycaemia
Flexibility	Moderate	High (variable basal rates)
Injections/day	4-5	Continuous SC infusion
Cost	Lower	Higher
Training needs	Standard	Intensive

Differential: Hyperglycaemia Causes

Insufficient insulin dose
Missed injections/pump failure
Intercurrent illness (infection)
Steroid therapy
Growth spurt (increased insulin resistance)

Visual Aid

Complication	Screening	Frequency
Retinopathy	Digital retinal photography	Annual from age 12 or 5yr duration
Nephropathy	Urine ACR	Annual from age 12 or 5yr duration
Neuropathy	Monofilament/vibration	Annual from age 12
Thyroid disease	TSH	Annual
Coeliac disease	tTG antibodies	At diagnosis, then annual

Key Points Summary

✓ Diagnosis: HbA1c ≥48 mmol/mol or fasting glucose ≥7.0 mmol/L; target HbA1c <48 mmol/mol

✓ DKA protocol: 10 mL/kg 0.9% saline bolus, then deficit over 48 hours; insulin 0.05-0.1 units/kg/hour (start after fluids)

✓ Insulin regimens: Basal-bolus first-line; pump if HbA1c >69 mmol/mol despite adherence or disabling hypoglycaemia

✓ Hypoglycaemia (<4 mmol/L): 15g fast carbs if conscious; IM glucagon 0.5-1mg if unconscious

✓ Sick day rules: Never stop insulin (increase 10-20%); check glucose 2-4 hourly; check ketones if glucose >14 mmol/L

✓ Monitoring: Blood glucose ≥5 times/day; HbA1c every 3 months; annual complication screening from age 12

✓ Cerebral oedema (DKA complication): Headache + bradycardia + rising BP → give mannitol 0.5 g/kg immediately

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