Latest posts by Bronwyn Buckley (see all)

“Primary care Nurses make the difference”

For more than two decades, 45 to 50% of Queensland children with Type 1 diabetes haven’t been diagnosed until they develop a preventable, severe and life-threatening complication called diabetic ketoacidosis (DKA).1,2

DKA is a metabolic emergency caused by insulin deficiency and can lead to cerebral oedema, so children require intensive care support. DKA at diagnosis of Type 1 diabetes is considered preventable if the early symptoms of high blood glucose are recognised by parents and early assessment is undertaken with a simple and inexpensive random finger-prick blood glucose check.

Unfortunately, children are typically seen two to three times in primary care before being diagnosed with DKA.3,4,5

Primary health clinicians can urgently refer children with a random blood glucose level ≥ 11mmol/L to the closest emergency department.

Nurses working in primary care settings are well placed to improve parent’s health literacy and play an important role in the prevention and early identification of children with the 4T symptoms of high blood glucose.

The 4T symptoms are Thirsty, going to the Toilet frequently to urinate, Tired, losing weight and getting Thinner. If these symptoms exist, the child may have Type 1 diabetes.

Early recognition of the 4T symptoms is key to preventing DKA at the diagnosis of Type 1 diabetes.

Primary care Nurses Key in reducing DKA at Diagnosis of Type 1 Diabetes in Children

In 2019, Clinical Excellence Queensland provided funds to the Statewide Diabetes Clinical Network to consult consumers and clinicians to prepare a well-informed implementation plan for a sustainable statewide campaign to reduce the rate of DKA at diagnosis in children under 16.

A campaign in Newcastle reduced rates to less than 13.8% within a short period.6 New Zealand has closely monitored rates and reduced and maintained a rate of about 25%. Rates in Scandinavian countries, with improved public health literacy, have been 14% for years.7,8

After extensive consumer and stakeholder consultation, an implementation plan was developed, and primary care Nurses emerged as key clinicians who can play an important role in reducing DKA at diagnosis.

Primary care nurses are key to the early diagnosis of Type 1 diabetes, especially in children, to ensure prompt treatment which is essential for preventing DKA. The outstanding work of nurses will be recognised by the International Diabetes Federation in this year’s theme for World Diabetes Day on 14 November 2020, Nurses: Make the Difference for Diabetes.

A Continuing professional development session on this topic has been made conveniently and freely available at the Nurses for Nurses CPD Institute or on iLearn for Queensland Health nurses. Reflective questions for AHPRA CPD records are included at the end of this article.

Click to view the Session Now


DKA Type 1 Diabetes in Children


New Resources and Strategies for reducing DKA at Diagnosis of Type 1 Diabetes in Children

A range of implementation strategies have been developed to become best practice. Content on recognising the signs and symptoms of hyperglycaemia have been added to the Queensland Health Child and Youth Health Practice Manual.

The child health booklet in the personal health record has been updated with the 4T signs as a reason for parents to seek medical care. Child health Nurses working at the 13Health contact centre have been provided with a factsheet for parents calling with subtle symptoms because high blood glucose often masquerades as other common childhood illnesses requiring medical review.

A new RACGP consensus guideline has been developed for the early recognition of hyperglycaemia in children under 16 in primary care. The guideline encourages GPs and nurses working in primary care to have a higher index of suspicion for Type 1 diabetes in children with common childhood illnesses.

Campaign materials have been developed for a public awareness campaign. This content includes input from consumers who were consulted during the DKA project as well as the parent survey to ascertain parent’s knowledge to seek medical care for the 4T symptoms of high blood glucose. A survey of 102 parents, which was assisted by Playgroup Queensland, found that only 23% of parents know a medical review is required if their child has signs of thirst, tiredness, or going to the toilet frequently.

Diabetes: Know the Signs

To improve public awareness of the 4T signs of high blood glucose in children, the Diabetes: Know the signs, Ask campaign will be launched on 14 November 2020, coinciding with World Diabetes Day. The campaign is collaborating with stakeholders around Queensland in schools, early childcare and primary health networks to spread campaign materials to improve the public awareness of the 4T symptoms and DKA.

Nurses working with families in primary care can help reduce DKA at diagnosis by displaying campaign materials in their clinics and waiting areas. Primary care nurses are well placed to recognise the 4T symptoms in children and young people as well as improving parents’ child health literacy.

Download the DKA Poster


Reducing DKA makes a Real Difference

Reducing DKA at diagnosis will reduce the emotional burden on families who are devastated by not only the diagnosis of a lifelong chronic illness but also a critically ill child. Children with DKA at diagnosis don’t go through a honeymoon period with gradual loss of beta cell function. It is associated with suboptimal diabetes leading to long-term kidney and eye complications related to high blood glucose levels.

Children with DKA can die from cerebral oedema and the long-term impacts cannot be understated and warrants efforts to reduce the unacceptable rates in Queensland through improving public and professional awareness.

As a Nurse working in primary care, you can make a difference to this important health issue.


DKA Type 1 Diabetes in Children

Type 1 Diabetes in Children: The Facts

  • Type 1 diabetes is the most common childhood chronic condition, with the incidence peaking in children aged 11 to 13
  • In 2017 there were 6500 Australian children under 14 living with Type 1 diabetes, a rate of 141 per 100 00010
  • The cost of an average intensive care length of stay of 1.5 days in $6489. This totalled $285 521 for the Queensland Children’s Hospital in 2018-1911

Reflective Questions

  • Reflect on the need to have a higher index of suspicion of high blood glucose in all children presenting with common childhood illnesses.
  • How can you improve your nursing assessment, observations and documentation for children in primary care?
  • How can you improve your listening and parent interview skills?
  • Reflect on health encounters with parents and the opportunities you have to improve their awareness of the 4T signs of high blood glucose.



  1. Harris et al. Consistently high incidence of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes. Letter to MJA 19 August 2013.
  2. Jacobs, S et al. Unpublished work by Jacobs S, Harris M, Johnson S. (2020) Diabetic Ketoacidosis in children with newly diagnosed Type 1 Diabetes
  3. Lokulo-Sodipe, K. et al. Identifying target to reduce the incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes in the UK. Arch Dis Child 2014; 99:438-442.
  4. Biu H. et al. Is diabetic ketoacidosis at disease onset a result of missed diagnosis? J Pediatrics 2010; 156:472-7.
  5. Pawlowicz M. et al. Difficulties of mistakes in diagnosing type 1 diabetes in children: demographic factors influencing delayed diagnosis. Pediatric Diabetes 2009:10:542-549
  6. King BR. et al. A diabetes awareness campaign prevents diabetic ketoacidosis in children at their initial presentation with type 1 diabetes. Pediatric Diabetes 2012:13:647-651.
  7. Cherubini, V. et al. Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents. Diabetologia 2020.
  8. Jefferies, C. et al. 15-year incidence of diabetic ketoacidosis at onset of type 1 diabetes in children from a regional setting, Auckland, New Zealand. Sci.Rep 2015
  9. Cameron FJ.(2014) Neurological Consequences of Diabetic Ketoacidosis at Initial Presentation of Type 1 Diabetes in a Prospective Cohort Study of Children. Diabetes Care 37:1554-1562
  10. Cited online 3/7/2020.
  11. DKA Prevention project diagnostic report prepared for Type 1 working party of the Statewide Diabetes Clinical Network