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Diabetes (type 1 and type 2) in children and young people: diagnosis and management

Diagnosis

  • Be aware that the characteristics of type 1 diabetes in children and young people include:
    • hyperglycaemia (random plasma glucose more than 11mmol/litre)
    • polyuria
    • polydipsia
    • weight loss
    • excessive tiredness
  • Refer children and young people with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care
  • 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
  • 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:
    • have a strong family history of type 2 diabetes
    • are obese at presentation
    • are of black or Asian family origin
    • have no insulin requirement, or have an insulin requirement of less than 0.5 units/kg
    • body weight/day after the partial remission phase
    • 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:
    • diabetes in the first year of life
    • rarely or never develop ketone bodies in the blood (ketonaemia) during episodes of hyperglycaemia
    • associated features, such as optic atrophy, retinitis pigmentosa, deafness, or another systemic illness or syndrome
  • 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
  • Perform genetic testing if atypical disease behaviour, clinical characteristics or family history suggest monogenic diabetes

Care pathway

management of diabetes in children

Type 1 diabetes

Education and information for children and young people with type 1 diabetes

  • Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis. Ensure that the programme includes the following core topics:
    • insulin therapy, including its aims, how it works, its mode of delivery and dosage adjustment
    • blood glucose monitoring, including targets for blood glucose control (blood glucose and HbA1c levels)
    • the effects of diet, physical activity and intercurrent illness on blood glucose control
    • managing intercurrent illness ('sick-day rules', including monitoring of blood ketones [beta-hydroxybutyrate])
    • detecting and managing hypoglycaemia, hyperglycaemia and ketosis
  • Tailor the education programme to each child or young person with type 1 diabetes and their family members or carers (as appropriate), taking account of issues such as:
    • personal preferences
    • emotional wellbeing
    • age and maturity
    • cultural considerations
    • existing knowledge
    • current and future social circumstances
    • life goals
  • Encourage young people with type 1 diabetes to attend clinic 4 times a year because regular contact is associated with optimal blood glucose control
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that like others they are advised to have:
    • regular dental examinations
    • an eye examination by an optician every 2 years
  • Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to discuss any concerns and raise any questions they have with their diabetes team
  • Give children and young people with type 1 diabetes and their family members or carers (as appropriate) information about local and/or national diabetes support groups and organisations, and the potential benefits of membership. Give this information after diagnosis and regularly afterwards
  • Encourage children and young people with type 1 diabetes to wear or carry something that identifies them as having type 1 diabetes (for example, a bracelet)
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) how to find information about government disability benefits
  • Take particular care when communicating with and providing information to children and young people with type 1 diabetes if they and/or their family members or carers (as appropriate) have, for example, physical and sensory disabilities, or difficulties speaking or reading English
  • Children and young people with type 1 diabetes wishing to participate in sports that may have particular risks for people with diabetes should be offered comprehensive advice by their diabetes team. Additional information may be available from local and/or national support groups and organisations, including sports organisations
  • Offer education for children and young people with type 1 diabetes and their family members or carers (as appropriate) about the practical issues related to long-distance travel, such as when best to eat and inject insulin when travelling across time zones

Smoking and substance misuse

Immunisation

  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends annual immunisation agains influenza for children and young people with diabetes over the age of 6 months
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends immunisation against pneumococcal infection for children and young people with diabetes who need insulin or oral hypoglycaemic medicines

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
  • Multiple daily injection basal–bolus insulin regimens: injections of short-acting insulin or rapid-acting insulin analogue before meals, together with 1 or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue
  • 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
  • One, two or three insulin injections per day: these are usually injections of short-acting insulin or rapid-acting insulin analogue mixed with intermediate-acting insulin

  • Take into account the personal and family circumstances of the child or young person with type 1 diabetes and discuss their personal preferences with them and their family members or carers (as appropriate) when choosing an insulin regimen
  • Offer children and young people with type 1 diabetes multiple daily injection basal–bolus insulin regimens from diagnosis. If a multiple daily injection regimen is not appropriate for a child or young person with type 1 diabetes, consider continuous subcutaneous insulin infusion (CSII or insulin pump) therapy as recommended in continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (NICE technology appraisal guidance 151)
  • Encourage children and young people with type 1 diabetes who are using multiple daily insulin injection regimens and their family members or carers (as appropriate) to adjust the insulin dose if appropriate after each blood glucose measurement
  • Explain to children and young people with type 1 diabetes using multiple daily insulin injection regimens and their family members or carers (as appropriate) that injecting rapid-acting insulin analogues before eating (rather than after eating) reduces blood glucose levels after meals and helps to optimise blood glucose control
  • Provide all children and young people with type 1 diabetes who are starting continuous subcutaneous insulin infusion (CSII or insulin pump) therapy and their family members or carers (as appropriate) with specific training in its use. Provide ongoing support from a specialist team, particularly in the period immediately after starting continuous subcutaneous insulin infusion. Specialist teams should agree a common core of advice for continuous subcutaneous insulin infusion users
  • Encourage children and young people with type 1 diabetes who are using twice-daily injection regimens and their family members or carers (as appropriate) to adjust the insulin dose according to the general trend in pre-meal, bedtime and occasional night-time blood glucose
  • Explain to children and young people with newly diagnosed type 1 diabetes and their family members or carers (as appropriate) that they may experience a partial remission phase (a 'honeymoon period') during which a low dosage of insulin (0.5 units/kg body weight/day) may be sufficient to maintain an HbA1c level of less than 48 mmol/mol (6.5%)
  • Offer children and young people with type 1 diabetes a choice of insulin delivery systems that takes account of their insulin requirements and personal preferences
  • Provide children and young people with type 1 diabetes with insulin injection needles that are of an appropriate length for their body fat
  • Provide children and young people with type 1 diabetes and their family members or carers (as appropriate) with suitable containers for collecting used needles and other sharps. Arrangements should be available for the suitable disposal of these containers
  • Offer children and young people with type 1 diabetes a review of injection sites at each clinic visit
  • Provide children and young people with type 1 diabetes with rapid-acting insulin analogues for use during intercurrent illness or episodes of hyperglycaemia
  • If a child or young person with type 1 diabetes does not have optimal blood glucose control:
    • offer appropriate additional support such as increased contact frequency with their diabetes team, and
    • if necessary, offer an alternative insulin regimen (multiple daily injections, continuous subcutaneous insulin infusion [CSII or insulin pump] therapy or once-, twice- or three-times daily mixed insulin injections)

Oral medicines for children and young people with type 1 diabetes

  • Metformin in combination with insulin is suitable for use only within research studies because the effectiveness of this combined treatment in improving blood glucose control is uncertain
  • Do not offer children and young people with type 1 diabetes acarbose or sulphonylureas (glibenclamide, gliclazide, glipizide, tolazamide or glyburide) in combination with insulin because they may increase the risk of hypoglycaemia without improving blood glucose control

Dietary management for children and young people with type 1 diabetes

  • Support children and young people with type 1 diabetes and their family members or carers (as appropriate) to develop a good working knowledge of nutrition and how it affects their diabetes
  • Explain regularly to children and young people with type 1 diabetes and their family members or carers (as appropriate) how healthy eating (including eating foods with a low glycaemic index, fruit and vegetables, and appropriate types and amounts of fats) can reduce their risk of cardiovascular disease, and support them to adjust their food choices accordingly
  • Take into account social and cultural considerations when providing advice on dietary management to children and young people with type 1 diabetes
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that children and young people with type 1 diabetes have the same basic nutritional requirements as other children and young people. Children and young people's food should provide sufficient energy and nutrients for optimal growth and development
  • Offer level 3 carbohydrate-counting* education from diagnosis to children and young people with type 1 diabetes who are using a multiple daily insulin injection regimen or continuous subcutaneous insulin infusion (CSII or insulin pump) therapy, and to their family members or carers (as appropriate), and repeat the offer at intervals thereafter
  • Offer children and young people with type 1 diabetes who are changing their insulin regimen, and their family members or carers (as appropriate), dietary advice tailored to the new treatment
  • Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) education about the practical problems associated with fasting and feasting
  • Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to discuss the nutritional composition and timing of snacks with their diabetes team
  • Encourage children and young people with type 1 diabetes to eat at least 5 portions of fruit and vegetables each day
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that a low glycaemic index diet may help to improve blood glucose control and reduce the risk of hyperglycaemic episodes
  • Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) advice and education to promote a low glycaemic index diet
  • Offer children and young people with type 1 diabetes dietetic support to help optimise body weight and blood glucose control
  • At each clinic visit for children and young people with type 1 diabetes measure height and weight and plot on an appropriate growth chart. Check for normal growth and/or significant changes in weight because these may reflect changes in blood glucose control
  • Provide arrangements for weighing children and young people with type 1 diabetes that respect their privacy

Exercise for children and young people with type 1 diabetes

  • Encourage all children and young people, including those with type 1 diabetes, to exercise on a regular basis because this reduces the risks of developing cardiovascular disease in the long term
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that they can take part in all forms of exercise, provided that appropriate attention is given to changes in insulin and dietary management
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about the effects of exercise on blood glucose levels and about strategies for avoiding hypo- or hyperglycaemia during or after physical activity
  • Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to monitor blood glucose levels before and after exercise so that they can:
    • identify when changes in insulin or food intake are necessary
    • learn the blood glucose response to different exercise conditions
    • be aware of exercise-induced hypoglycaemia
    • be aware that hypoglycaemia may occur several hours after prolonged exercise
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that additional carbohydrate should be consumed as appropriate to avoid hypoglycaemia and that carbohydrate-based foods should be readily available during and after exercise
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that additional carbohydrate should be consumed if plasma glucose levels are less than 7 mmol/litre before exercise is undertaken
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that changes in daily exercise patterns may require insulin dose and/or carbohydrate intake to be altered

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:
    • fasting plasma glucose level of 4–7 mmol/litre on waking
    • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day
    • a plasma glucose level of 5–9 mmol/litre after meals
    • a plasma glucose level of at least 5 mmol/litre when driving
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that achieving and maintaining blood glucose levels towards the lower end of the target optimal ranges will help them to achieve the lowest attainable HbA1c
  • Ensure that children and young people with type 1 diabetes do not experience problematic hypoglycaemia or undue emotional distress when achieving, or attempting to achieve, blood glucose and HbA1c targets
  • Be aware that there may be conflict between children and young people with type 1 diabetes and their family members or carers about blood glucose and HbA 1c targets, and that an agreed compromise may be needed

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
  • Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) a choice of equipment for monitoring capillary blood glucose, so they can optimise their blood glucose control in response to adjustment of insulin, diet and exercise
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that blood glucose levels should be interpreted in the context of the 'whole child', which includes the social, emotional and physical environment
  • Offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have:
    • frequent severe hypoglycaemia or
    • impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety) or
    • inability to recognise, or communicate about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities)
  • Consider ongoing real-time continuous glucose monitoring for:
    • neonates, infants and pre-school children
    • children and young people who undertake high levels of physical activity (for example, sport at a regional, national or international level)
    • children and young people who have comorbidities (for example anorexia nervosa) or who are receiving treatments (for example corticosteroids) that can make blood glucose control difficult
  • Consider intermittent (real-time or retrospective) continuous glucose monitoring to help improve blood glucose control in children and young people who continue to have hyperglycaemia despite insulin adjustment and additional support

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 HbA 1c 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 HbA 1c level 4 times a year (more frequent testing may be appropriate if there is concern about suboptimal blood glucose control)
  • Diabetes services should document the proportion of children and young people with type 1 diabetes in a service who achieve an HbA1c level of 53 mmol/mol (7%) or lower

Hyperglycaemia, blood ketone monitoring and intercurrent illness in children and young people with type 1 diabetes

  • Provide each child and young person with type 1 diabetes and their family members or carers (as appropriate) with clear individualised oral and written advice ('sick-day rules') about managing type 1 diabetes during intercurrent illness or episodes of hyperglycaemia, including:
    • monitoring blood glucose
    • monitoring and interpreting blood ketones (beta-hydroxybutyrate)
    • adjusting their insulin regimen
    • food and fluid intake
    • when and where to seek further advice or help
      • revisit the advice with the child or young person and their family members or carers (as appropriate) at least annually
  • Offer children and young people with type 1 diabetes blood ketone testing strips and a meter , and advise them and their family members or carers (as appropriate) to test for ketonaemia if they are ill or have hyperglycaemia
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that it is important to ensure that blood ketone testing strips are not used after the specified ('use-by') date

Hypoglycaemia in children and young people with type 1 diabetes

  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about strategies for avoiding and managing hypoglycaemia
  • Offer education for children and young people with type 1 diabetes, their family members, carers, and schoolteachers about recognising and managing hypoglycaemia
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that they should always have access to an immediate source of fast-acting glucose and blood glucose monitoring equipment for immediate confirmation and safe management of hypoglycaemia
  • Family members or carers and, where appropriate, school nurses and other carers should be trained and equipped to give intramuscular glucagon for severe hypoglycaemia in an emergency
  • 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
    • as symptoms improve or normoglycaemia is restored, and once the child or young person is sufficiently awake, give oral complex long-acting carbohydrate to maintain normal blood glucose levels
    • recheck the blood glucose repeatedly in children and young people who have persistently reduced consciousness after a severe hypoglycaemic episode, to determine whether further glucose is needed
  • 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:
    • 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
  • 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

Difficulties with maintaining optimal blood glucose control in children and young people with type 1 diabetes

  • Think about the possibility of non-adherence to therapy in children and young people with type 1 diabetes who have suboptimal blood glucose control, especially in adolescence
  • Be aware that adolescence can be a period of worsening blood glucose control in young people with type 1 diabetes, which may in part be due to non-adherence to therapy
  • Raise the issue of non-adherence to therapy with children and young people with type 1 diabetes and their family members or carers (as appropriate) in a sensitive manner
  • Be aware of the possible negative psychological impact of setting targets that may be difficult for some children and young people with type 1 diabetes to achieve and maintain

Psychological and social issues in children and young people with type 1 diabetes

  • Diabetes teams should be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties
  • Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs
  • Assess the emotional and psychological wellbeing of young people with type 1 diabetes who present with frequent episodes of diabetic ketoacidosis (DKA)
  • Be aware that a lack of adequate psychosocial support has a negative effect on various outcomes, including blood glucose control in children and young people with type 1 diabetes, and that it can also reduce their self-esteem
  • Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders and family conflict) or psychosocial difficulties that can impact on the management of diabetes and wellbeing
  • For the treatment of depression and antisocial behaviour and conduct disorders in children and young people with type 1 diabetes see the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people
  • Diabetes teams should have appropriate access to mental health professionals to support them in psychological assessment and the delivery of psychosocial support
  • Offer children and young people with type 1 diabetes who have behavioural or conduct disorders, and their family members or carers (as appropriate), access to appropriate mental health professionals
  • Offer specific family-based behavioural interventions, such as behavioural family systems therapy, if there are difficulties with diabetes-related family conflict
  • Consider a programme of behavioural intervention therapy or behavioural techniques for children and young people with type 1 diabetes in whom there are concerns about psychological wellbeing in order to improve:
    • health-related quality of life—for example, counselling or cognitive behavioural therapy (CBT), including CBT focused on quality of life
    • adherence to diabetes treatment—for example, motivational interviewing or multisystemic therapy
    • blood glucose control in children and young people with high HbA1c levels (HbA1c above 69 mmol/mol [8.5%])—for example, multisystemic therapy
  • Offer screening for anxiety and depression to children and young people with type 1 diabetes who have persistently suboptimal blood glucose control
  • Diabetes teams should be aware that children and young people with type 1 diabetes may develop anxiety and/or depression, particularly when difficulties in self-management arise in young people and children who have had type 1 diabetes for a long time
  • Refer children and young people with type 1 diabetes and suspected anxiety and/or depression promptly to child mental health professionals
  • Diabetes teams should be aware that children and young people with type 1 diabetes, in particular young women, have an increased risk of eating disorders. See also the NICE guideline on eating disorders
  • Be aware that children and young people with type 1 diabetes who have eating disorders may have associated difficulties with:
    • suboptimal blood glucose control (both hyperglycaemia and hypoglycaemia)
    • symptoms of gastroparesis
  • For children and young people with type 1 diabetes in whom eating disorders are identified, offer joint management involving their diabetes team and child mental health professionals

Monitoring for complications and associated conditions of type 1 diabetes

  • Offer children and young people with type 1 diabetes monitoring for:
    • thyroid disease at diagnosis and annually thereafter until transfer to adult services
    • diabetic retinopathy annually from 12 years
    • moderately increased albuminuria (albumin:creatinine ratio [ACR] 3–30 mg/mmol; 'microalbuminuria') to detect diabetic kidney disease, annually from 12 years
    • hypertension annually from 12 years
  • 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
  • Be aware of the following rare complications and associated conditions when children and young people with type 1 diabetes attend clinic visits:
    • juvenile cataracts
    • necrobiosis lipoidica
    • Addison's disease
  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) the importance of annual monitoring from 12 years for diabetic retinopathy and diabetic kidney disease

Diabetic retinopathy in children and young people with type 1 diabetes

  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that:
    • monitoring for diabetic retinopathy begins at 12 years because diabetic retinopathy that needs treatment is extremely rare in children and young people under 12
    • background retinopathy is often found through monitoring, and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy
    • annual monitoring from 12 years is important because, if significant diabetic retinopathy is found, early treatment will improve the outcome

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

  • Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that:
    • 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
    • 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
    • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease
    • annual monitoring from 12 years is important because, if diabetic kidney disease is found, early treatment will improve the outcome
  • Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio. If the first urine sample of the day is not available, use a random sample, but be aware that this is associated with an increased risk of false positive results
  • If the initial albumin:creatinine ratio is above 3 mg/mmol but below 30 mg/ mmol, confirm the result by repeating the test on 2 further occasions using first urine samples of the day ('early morning urine') before starting further investigation and therapy
  • Investigate further if the initial albumin:creatinine ratio is 30 mg/mmol or more (proteinuria)

Type 2 diabetes

Education and information for children and young people with type 2 diabetes

  • Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis. Ensure that the programme includes the following core topics:
    • HbA1c monitoring and targets
    • the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control
    • the aims of metformin therapy and possible adverse effects
    • the complications of type 2 diabetes and how to prevent them
  • Tailor the education programme to each child or young person with type 2 diabetes and their family members or carers (as appropriate), taking account of issues such as:
    • personal preferences
    • emotional wellbeing
    • age and maturity
    • cultural considerations
    • existing knowledge
    • current and future social circumstances life goals
    • life goals
  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that like others they are advised to have:
    • regular dental examinations
    • an eye examination by an optician every 2 years
  • Encourage children and young people with type 2 diabetes and their family members or carers (as appropriate) to discuss any concerns and raise any questions they have with their diabetes team
  • Give children and young people with type 2 diabetes and their family members or carers (as appropriate) information about local and/or national diabetes support groups and organisations, and the potential benefits of membership. Give this information after diagnosis and regularly afterwards
  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) how to find information about possible government disability benefits
  • Take particular care when communicating with and providing information to children and young people with type 2 diabetes if they and/or their family members or carers (as appropriate) have, for example, physical and sensory disabilities, or difficulties speaking or reading English

Smoking and substance misuse

Immunisation

  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends annual immunisation against influenza for children and young people with diabetes
  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends immunisation against pneumococcal infection for children and young people with diabetes who need insulin or oral hypoglycaemic medicines

Dietary management for children and young people with type 2 diabetes

  • At each contact with a child or young person with type 2 diabetes who is overweight or obese, advise them and their family members or carers (as appropriate) about the benefits of physical activity and weight loss, and provide support towards achieving this. See also the NICE guidelines on maintaining a healthy weight and managing obesity
  • Offer children and young people with type 2 diabetes dietetic support to help optimise body weight and blood glucose control
  • At each contact with a child or young person with type 2 diabetes, explain to them and their family members or carers (as appropriate) how healthy eating can help to:
    • reduce hyperglycaemia
    • reduce cardiovascular risk
    • promote weight loss
  • Provide dietary advice to children and young people with type 2 diabetes and their family members or carers (as appropriate) in a sensitive manner, taking into account the difficulties that many people encounter with weight reduction, and emphasise the additional advantages of healthy eating for blood glucose control and avoiding complications
  • Take into account social and cultural considerations when providing advice on dietary management to children and young people with type 2 diabetes
  • Encourage children and young people with type 2 diabetes to eat at least 5 portions of fruit and vegetables each day
  • At each clinic visit for children and young people with type 2 diabetes:
    • measure height and weight and plot on an appropriate growth chart
    • calculate BMI
  • Check for normal growth and/or significant changes in weight because these may reflect changes in blood glucose control
  • Provide arrangements for weighing children and young people with type 2 diabetes that respect their privacy

Metformin

  • Offer standard-release metformin from diagnosis to children and young people with type 2 diabetes

HbA1c targets and monitoring for children and young people with type 2 diabetes

  • Use methods to measure HbA1c that have been calibrated according to International Federation of Clinical Chemistry (IFCC) standardisation
  • Explain to children and young people with type 2 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 2 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
  • Explain the benefits of safely achieving and maintaining the lowest attainable HbA 1c to children and young people with type 2 diabetes and their family members or carers (as appropriate)
  • Agree an individualised lowest achievable HbA1c target with each child or young person with type 2 diabetes and their family members or carers (as appropriate), taking into account factors such as daily activities, individual life goals, complications and comorbidities
  • Measure HbA1c levels every 3 months in children and young people with type 2 diabetes
  • Support children and young people with type 2 diabetes and their family members or carers (as appropriate) to safely achieve and maintain their individual agreed HbA1c target level
  • Diabetes services should document the proportion of children and young people with type 2 diabetes in a service who achieve an HbA1c level of 53 mmol/mol (7%) or lower

Psychological and social issues in children and young people with type 2 diabetes

  • Diabetes teams should be aware that children and young people with type 2 diabetes have a greater risk of emotional and behavioural difficulties
  • Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs
  • Be aware that children and young people with type 2 diabetes have an increased risk of psychological conditions (for example anxiety , depression, behavioural and conduct disorders) and complex social factors (for example family conflict) that can affect their wellbeing and diabetes management. See also the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people
  • Be aware that a lack of adequate psychosocial support has a negative effect on various outcomes, including blood glucose control in children and young people with type 2 diabetes, and that it can also reduce their self-esteem
  • Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders and family conflct) or psychosocial diffiulties that can impact on the management of diabetes and wellbeing
  • For the treatment of depression and antisocial behaviour and conduct disorders in children and young people with type 2 diabetes see the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people
  • Diabetes teams should have appropriate access to mental health professionals to support them in psychological assessment and the delivery of psychosocial support
  • Offer screening for anxiety and depression to children and young people with type 2 diabetes who have persistently suboptimal blood glucose control
  • Refer children and young people with type 2 diabetes and suspected anxiety and/or depression promptly to child mental health professionals
  • Ensure that children and young people with type 2 diabetes and their family members or carers (as appropriate) have timely and ongoing access to mental health services when needed

Monitoring for complications and associated conditions of type 2 diabetes

  • Offer children and young people with type 2 diabetes annual monitoring for:
    • hypertension starting at diagnosis
    • dyslipidaemia starting at diagnosis
    • diabetic retinopathy from 12 years
    • moderately increased albuminuria (albumin:creatinine ratio [ACR] 3–30 mg/mmol; 'microalbuminuria') to detect diabetic kidney disease, starting at diagnosis
  • For guidance on managing foot problems in children and young people with type 2 diabetes, see the NICE guideline on diabetic foot problems
  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) the importance of annual monitoring for hypertension, dyslipidaemia, diabetic retinopathy and diabetic kidney disease

Hypertension in children and young people with type 2 diabetes

  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that monitoring is important because if hypertension is found, early treatment will reduce the risk of complications
  • Use a cuff large enough for the child or young person with type 2 diabetes when measuring blood pressure
  • If repeated resting measurements are greater than the 95th percentile for age and sex, confirm hypertension using 24-hour ambulatory blood pressure monitoring before starting antihypertensive therapy

Dyslipidaemia in children and young people with type 2 diabetes

  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that monitoring is important because if dyslipidaemia is found, early treatment will reduce the risk of complications
  • When monitoring for dyslipidaemia in children and young people with type 2 diabetes, measure total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol and triglyceride concentrations
  • Confim dyslipidaemia using a repeat sample (fasting or non-fasting) before deciding on further management strategies

Diabetic retinopathy in children and young people with type 2 diabetes

  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:
    • background retinopathy is often found through monitoring, and improving blood glucose control will reduce the risk of this progressing to signifiant diabetic retinopathy
    • annual monitoring from 12 years is important because, if signifiant diabetic retinopathy is found, early treatment will improve the outcome
  • Consider referring children and young people with type 2 diabetes who are younger than 12 years to an ophthalmologist for retinal examination if blood glucose control is suboptimal

Diabetic kidney disease in children and young people with type 2 diabetes

  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:
    • using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria (ACR 3–30 mg/mmol; 'microalbuminuria') is important, as this reduces the risk of false positive results
    • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to signifiant diabetic kidney disease
    • annual monitoring is important because, if diabetic kidney disease is found, early treatment will improve the outcome
  • Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio. If the first urine sample of the day is not available, use a random sample, but be aware that this is associated with an increased risk of false positive results
  • If the initial albumin:creatinine ratio is above 3 mg/mmol but below 30 mg/mmol, confim the result by repeating the test on 2 further occasions using first urine samples of the day ('early morning urine') before starting further investigation and therapy
  • Investigate further if the initial albumin:creatinine ratio is 30 mg/mmol or more (proteinuria)

Diabetic ketoacidosis

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
    • 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 normal blood glucose levels
  • Suspect DKA even if the blood glucose is normal in a child or young person with known diabetes and any of following:
    • nausea or vomiting
    • abdominal pain
    • hyperventilation
    • dehydration
    • 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 confimed 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:
    • acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 18 mmol/litre) and
    • 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

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

Service provision

  • Offer children and young people with diabetes an ongoing integrated package of care provided by a multidisciplinary paediatric diabetes team. To optimise the effectiveness of care and reduce the risk of complications, the diabetes team should include members with appropriate training in clinical, educational, dietetic, lifestyle, mental health and foot care aspects of diabetes for children and young people
  • Offer children and young people with diabetes and their family members or carers (as appropriate) 24-hour access to advice from their diabetes team
  • Involve children and young people with diabetes and their family members or carers (as appropriate) in making decisions about the package of care provided by their diabetes team
  • At diagnosis, offer children and young people with diabetes home-based or inpatient management according to clinical need, family circumstances and wishes. Explain that home-based care with support from the local paediatric diabetes team (including 24-hour telephone access) is safe and as effective as inpatient initial management
  • Offer initial inpatient management to children with diabetes who are aged under 2 years
  • Think about initial inpatient management for children and young people with diabetes if there are social or emotional factors that would make home-based management inappropriate, or if they live a long distance from the hospital
  • Diabetes teams should liaise regularly with school staff supervising children and young people with type 1 diabetes to provide appropriate diabetes education and practical information
  • Record the details of children and young people with diabetes on a population-based, practice-based or clinic-based diabetes register

Transition from paediatric to adult care

  • Allow suffiient time for young people with diabetes to familiarise themselves with the practicalities of the transition from paediatric to adult services because this improves clinic attendance
  • Agree specific local protocols for transferring young people with diabetes from paediatric to adult services
  • Base the decision about the age of transfer to the adult service on the young person's physical development and emotional maturity, and local circumstances
  • Ensure that transition from the paediatric service occurs at a time of relative stability in the young person's health and is coordinated with other life transitions
  • Explain to young people with type 1 diabetes who are preparing for transition to adult services that some aspects of diabetes care will change at transition

 

* Level 3 carbohydrate counting is defied as carbohydrate counting with adjustment of insulin dosage according to an insulin:carbohydrate ratio
† For further details about driving, see the DVLA guidance for people with insulin-treated diabetes

© NICE 2015. Diabetes (type 1 and type 2) in children and young people: diagnosis and management.  Available from: www.nice.org.uk/guidance/NG18. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: September 2015.