Type 1 Diabetes in Children and Young People: Diagnosis and Management

Overview

This is a summary of NICE's updated guideline on the diagnosis and management of type 1 diabetes in children and young people. This is a summary of recommendations for primary care; for the complete set of recommendations, see the full guideline.

Further Guidelines summaries on NICE diabetes guidance:

• Type 1 Diabetes in Adults: Diagnosis and Management
• Type 2 Diabetes in Adults: Management
• Type 2 Diabetes in Children and Young People: Diagnosis and Management
• Type 2 Diabetes: Prevention in People at High Risk
• Diabetes in Pregnancy: Management From Preconception to the Postnatal Period.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Diagnosis

• Be aware that signs of type 1 diabetes in children and young people include:
  • hyperglycaemia (random plasma glucose more than 11 mmol/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 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
  • are from a Black or Asian family background
  • do not need insulin, or need 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 other types of diabetes (not type 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:
  • diabetes in the first year of life
  • rarely or never develop ketones 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 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 needed to distinguish between type 1 diabetes and 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.

Education and Information

• Offer children and young people with type 1 diabetes and their families or carers a continuing programme of education from diagnosis. Include the following core topics:
  • insulin therapy (including its aims and how it works), insulin delivery (including rotating injection sites within the same body region) and dosage adjustment
  • blood glucose monitoring, including blood glucose and HbA_1c targets
  • how diet, physical activity and intercurrent illness affect blood glucose levels
  • managing intercurrent illness ('sick-day rules', including monitoring of blood ketones [beta-hydroxybutyrate])
  • detecting and managing hypoglycaemia, hyperglycaemia and ketosis
  • the importance of good oral hygiene and regular oral health reviews for preventing periodontitis.
• Tailor the education programme to each child or young person with type 1 diabetes and their families or carers, 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, and explain that regular contact with the diabetes team will help them maintain optimal blood glucose levels.
• Explain to children and young people with type 1 diabetes and their families or carers that, like people without diabetes, they should have:
  • regular dental examinations (see the NICE guideline on dental checks: intervals between oral health reviews)
  • an eye examination by an optician at least every 2 years.
• Encourage children and young people with type 1 diabetes and their families or carers 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 families or carers information about 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 tells people they have type 1 diabetes (for example, a bracelet).
• Explain to children and young people with type 1 diabetes and their families or carers how to find out about government disability benefits.
• Take particular care when communicating with children and young people with type 1 diabetes if they or their families or carers have physical or sensory disabilities, or difficulties speaking or reading English.
• Diabetes teams should offer comprehensive advice to children and young people with type 1 diabetes who want to play sports that have particular risks for people with diabetes. Support groups and organisations (including sports organisations) may be able to provide more information.
• Offer education for children and young people with type 1 diabetes and their families or carers about the practical issues around long-distance travel, such as when best to eat and inject insulin when travelling across time zones.

Smoking and Substance Misuse

• Encourage children and young people with type 1 diabetes not to start smoking. Explain the general health problems smoking causes, in particular the risks of developing vascular complications.
• For more guidance on preventing smoking, see also the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence.
• Offer smoking cessation programmes to children and young people with type 1 diabetes who smoke. See also the the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence.
• Explain to children and young people with type 1 diabetes and their families or carers about the general dangers of substance misuse and the possible effects on blood glucose levels.

Immunisation

• Explain to children and young people with type 1 diabetes and their families or carers that the Public Health England Green Book recommends they have:
  • annual immunisation against influenza, starting when they are 6 months old.
  • immunisation again pneumococcal infection if they are taking insulin or oral hypoglycaemic medicines.

Insulin Therapy

• Discuss the choice of insulin regimen with the child or young person and their family:
  • explain the advantages and disadvantages of the different options
  • discuss their personal circumstances and preferences
  • help them to make an informed decision between the options that are available to them.
• Offer children and young people with type 1 diabetes a multiple daily injection basal–bolus insulin regimen from diagnosis.
• If multiple daily insulin injections are not appropriate for a particular child or young person, consider an insulin pump, as recommended in the NICE technology appraisal guidance on continuous subcutaneous insulin infusion for the treatment of diabetes mellitus.
• Encourage children and young people with type 1 diabetes who are having multiple daily insulin injections to adjust the insulin dose if appropriate after each blood glucose measurement.
• Tell children and young people with type 1 diabetes who are having multiple daily insulin injections to inject rapid-acting insulin analogues before eating. Explain that this reduces blood glucose levels after meals and will help them optimise their blood glucose levels. 
• When children and young people start on an insulin pump, train them and their families and carers how to use it. A specialist team should provide ongoing support.
• Specialist teams should agree a common core of advice to give insulin pump users.
• For children and young people with type 1 diabetes who are using twice-daily injection regimens, encourage them to adjust the insulin dose according to the general trend in their pre-meal, bedtime and occasional night-time blood glucose.
• Explain to children and young people with newly diagnosed type 1 diabetes and their families or carers that:
  • they may have a partial remission phase (a 'honeymoon period') when they start using insulin
  • during this time they may only need a low dosage of insulin (0.5 units/kg body weight/day) to maintain an HbA_1c level of less than 48 mmol/mol (6.5%).
• Offer children and young people with type 1 diabetes a choice of insulin delivery systems. 
• Provide children and young people with type 1 diabetes insulin injection needles that are the right length for their body fat. 
• Provide children and young people with type 1 diabetes and their families or carers:
  • suitable containers for collecting used needles and other sharps
  • a way to safely get rid of these containers.
    
    See also the section on safe use and disposal of sharps in the NICE guideline on healthcare-associated infections.
• 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 rapid-acting insulin analogues to use during intercurrent illness or episodes of hyperglycaemia.
• If a child or young person with type 1 diabetes does not have optimal blood glucose levels (see the recommendations on blood glucose targets and HbA_1c targets and monitoring):
  • offer additional support, such as more contact with their diabetes team, and
  • if necessary, offer an alternative insulin regimen (multiple daily injections, an insulin pump, or once-, twice- or three-times daily mixed insulin injections).

Oral Medicines

• Only use metformin in combination with insulin within research studies because it is uncertain whether this combination improves blood glucose management.
• Do not offer children and young people with type 1 diabetes acarbose or sulfonylureas (glibenclamide, gliclazide, glipizide, tolbutamide) in combination with insulin, because they may increase the risk of hypoglycaemia without improving blood glucose management.

Dietary Management

• Support children and young people with type 1 diabetes and their families or carers to develop a good working knowledge of nutrition and how it affects their diabetes.
• Discuss healthy eating regularly with children and young people with type 1 diabetes and their families or carers.
  • Explain that this means eating foods with a low glycaemic index, fruit and vegetables, and appropriate types and amounts of fats.
  • Explain that healthy eating can reduce their risk of cardiovascular disease.
  • Support them to adjust their food choices accordingly.
• Take into account social and cultural considerations when providing advice on diet to children and young people with type 1 diabetes.
• Explain that children and young people with type 1 diabetes have the same basic nutritional requirements as other children and young people. Their food should provide enough energy and nutrients for their growth and development.
• For children and young people who are using a multiple daily insulin injection regimen or an insulin pump, offer level 3 carbohydrate counting education from diagnosis to them and their families or carers. Repeat this offer regularly.
• When children and young people with type 1 diabetes change their insulin regimen, offer them and their families or carers dietary advice tailored to the new treatment.
• Offer children and young people with type 1 diabetes and their families or carers education about the practical problems associated with fasting and feasting.
• Encourage children and young people with type 1 diabetes and their families or carers 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 families or carers that a low glycaemic index diet may help to improve blood glucose management and reduce the risk of hyperglycaemic episodes.
• Offer children and young people with type 1 diabetes and their families or carers advice and education to help them follow a low glycaemic index diet.
• Offer children and young people with type 1 diabetes dietetic support to help optimise body weight and blood glucose levels.
• At each clinic visit for children and young people with type 1 diabetes, measure their height and weight and plot on an appropriate growth chart. Check for normal growth or significant changes in weight, because these may reflect changes in blood glucose levels.
• Provide arrangements for weighing children and young people with type 1 diabetes that respect their privacy. 

Exercise

• Encourage children and young people with type 1 diabetes to exercise on a regular basis, and explain that this reduces their long-term risk of developing cardiovascular disease.
• Explain to children and young people with type 1 diabetes and their families or carers 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 families or carers about:
  • the effects of exercise on blood glucose levels and
  • how to avoid hypo- or hyperglycaemia during or after physical activity. 
• Encourage children and young people with type 1 diabetes and their families or carers to monitor blood glucose levels before and after exercise so that they can:
  • identify when changes in insulin or food intake are needed
  • learn how their blood glucose responds to different levels of exercise
  • watch out for exercise-induced hypoglycaemia
  • see how hypoglycaemia can occur several hours after prolonged exercise.
• Explain to children and young people with type 1 diabetes and their families or carers that:
  • they should have extra carbohydrates as needed to avoid hypoglycaemia and
  • they should have carbohydrate-based foods available during and after exercise. 
• Explain to children and young people with type 1 diabetes and their families or carers that they should have extra carbohydrates if their plasma glucose levels are less than 7 mmol/litre before they exercise.
• Explain to children and young people with type 1 diabetes and their families or carers that they may need to alter their insulin dose or carbohydrate intake if they change their daily exercise patterns.

Blood Glucose and HbA_1c Targets and Monitoring

Blood Glucose Targets

• Explain to children and young people with type 1 diabetes and their families or carers that the optimal target ranges for short-term plasma glucose management are:
  • fasting plasma glucose level of 4 mmol/litre to 7 mmol/litre on waking
  • a plasma glucose level of 4 mmol/litre to 7 mmol/litre before meals at other times of the day
  • a plasma glucose level of 5 mmol/litre to 9 mmol/litre after meals
  • a plasma glucose level of at least 5 mmol/litre when driving (see the Driver and Vehicle Licensing Agency [DVLA] guidance for people with diabetes for further details about driving).
• Explain to children and young people with type 1 diabetes and their families or carers that maintaining blood glucose levels at the lower end of the target ranges will help them achieve the lowest possible HbA_1c.
• If children and young people with type 1 diabetes experience problematic hypoglycaemia or undue emotional distress while attempting to achieve blood glucose and HbA_1c targets, discuss changing the targets with them and their families and carers.
• Be aware that blood glucose and HbA_1c targets can cause conflict between children and young people with type 1 diabetes and their families or carers, and they may need to agree a compromise.

Interpreting Blood Glucose Levels

• Explain to children and young people with type 1 diabetes and their families or carers that blood glucose levels should be interpreted in the 'whole child' context, which includes the social, emotional and physical environment. 

Continuous Glucose Monitoring

• Offer real-time continuous glucose monitoring (rtCGM) to all children and young people with type 1 diabetes, alongside education to support children and young people, and their families and carers, to use it (see the eighth recommendation in this section).
• Offer intermittently scanned continuous glucose monitoring (isCGM, commonly referred to as 'flash') to children and young people with type 1 diabetes aged 4 years and over who are unable to use rtCGM or who express a clear preference for isCGM. 
  
  In March 2022, isCGM was licensed for children aged 4 years and over.
• Offer children and young people with type 1 diabetes a choice of rtCGM device, based on their individual preferences, needs, characteristics, and the functionality of the devices available. See box 1 in the full guideline for examples of factors to consider as part of this discussion.
• When choosing a continuous glucose monitoring (CGM) device:
  • use shared decision making to identify the child or young person's needs and preferences and offer them an appropriate device
  • if multiple devices meet their needs and preferences, offer the device with the lowest cost.
• CGM should be provided by a team with expertise in its use, as part of supporting children and young people to self-manage their diabetes.
• Advise children and young people with type 1 diabetes who are using CGM (and their families or carers) that they will still need to take capillary blood glucose measurements (although they can do this less often). Explain that is because:
  • they will need to use capillary blood glucose measurements to check the accuracy of their CGM device
  • they will need capillary blood glucose monitoring as a back-up (for example, when their blood glucose levels are changing quickly or if the device stops working).
    
    Provide them with enough test strips to take capillary blood glucose measurements as needed.
• If a person cannot use or does not want rtCGM or isCGM, offer capillary blood glucose monitoring.
• Include CGM in the continuing programme of education provided to all children and young people with type 1 diabetes and their families or carers (see the section on education and information).
• Monitor and review the child or young person's use of CGM as part of reviewing their diabetes care plan, and explain to them the importance of continuously wearing the device.
• If the child or young person is not using their CGM device at least 70% of the time:
  • ask if they are having problems with their device
  • look at ways to address any problems or concerns to improve their use of the device, including further education and emotional and psychological support. 

For recommendations on addressing inequalities in CGM access and uptake, refer to the full guideline.

Monitoring Capillary Blood Glucose for Children and Young People Not Using Continuous Glucose Monitoring

• Advise children and young people with type 1 diabetes who are using capillary blood glucose monitoring (and their families or carers) to routinely perform at least 5 capillary blood glucose tests per day. 
• Advise children and young people with type 1 diabetes who are using capillary blood glucose monitoring (and their families or carers) that more frequent testing is often needed (for example, with physical activity and during intercurrent illness). Ensure they have enough test strips for this. 
• Offer children and young people with type 1 diabetes who are using capillary blood glucose monitoring (and their families or carers) a choice of equipment for monitoring, so they can optimise their blood glucose management in response to changes in their insulin, diet and exercise.

HbA_1c Targets and Monitoring

• Measure HbA_1c using methods that have been calibrated according to International Federation of Clinical Chemistry 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 families or carers.
• Explain to children and young people with type 1 diabetes and their families or carers that an HbA_1c target level of 48 mmol/mol (6.5%) or lower will minimise their risk of long-term complications.
• Explain to children and young people with type 1 diabetes who have an HbA_1c level above 48 mmol/mol (6.5%) that any reduction in HbA_1c level reduces their risk of long-term complications.
• Agree an individualised lowest achievable HbA_1c target with each child or young person with type 1 diabetes and their families or carers. Take into account factors such as their daily activities, individual life goals, complications, comorbidities and the risk of hypoglycaemia.
• Support children and young people with type 1 diabetes and their families or carers to safely achieve and maintain their individual agreed HbA_1c target level.
• Measure HbA_1c level 4 times a year in children and young people with type 1 diabetes. Think about more frequent testing if they are having difficulty with blood glucose management.
• Diabetes services should document the proportion of children and young people with type 1 diabetes who achieve an HbA_1c level of 53 mmol/mol (7%) or lower. 

Hyperglycaemia, Blood Ketone Monitoring and Intercurrent Illness

• Provide children and young people with type 1 diabetes and their families or carers with 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 get further advice or help.
    
    Revisit the advice at least annually.
• Offer children and young people with type 1 diabetes blood ketone testing strips and a meter. Advise them and their families or carers to test for ketonaemia if they are ill or have hyperglycaemia.
• Explain to children and young people with type 1 diabetes and their families or carers that they should not use blood ketone testing strips after the use-by date.

Hypoglycaemia

• Explain to children and young people with type 1 diabetes and their families or carers how they can avoid and manage hypoglycaemia.
• Offer education for children and young people with type 1 diabetes and their families, carers, and teachers about recognising and managing hypoglycaemia.
• Explain to children and young people with type 1 diabetes and their families or carers that they should always have access to an immediate source of fast-acting glucose and blood glucose monitoring equipment, so that they can check for hypoglycaemia and manage it safely.
• Train and equip families, carers, and (if appropriate) school nurses and other carers 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 oral fast-acting glucose (for example, 10 to 20 g; liquid carbohydrate may be easier to swallow 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 to 15 minutes), and give more fast-acting glucose if they still have hypoglycaemia.
  • As symptoms improve or blood glucose levels return to normal, 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
    • having a continuous subcutaneous insulin infusion.
• Explain to young people with type 1 diabetes how alcohol affects blood glucose levels, and in particular the 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 carbohydrates.
• Explain to children and young people with type 1 diabetes and their families or carers that when alcohol causes or contributes to hypoglycaemia, glucagon may be ineffective and they may need intravenous glucose.

For recommendations on referral for assessment of cognitive function and treating severe hypoglycaemia both in and out of hospital, refer to the full guideline.

Difficulties with Maintaining Optimal Blood Glucose Levels

• Think about the possibility of non-adherence to therapy in children and young people with type 1 diabetes who have difficulty with blood glucose management, especially in adolescence.
• Be aware that young people with type 1 diabetes can have difficulty with blood glucose management during adolescene, and this 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 families or carers in a sensitive manner.
• Be aware of the possible negative psychological impact of setting targets that may be difficult for a child or young person with type 1 diabetes to achieve and maintain.

Psychological and Social Issues

• 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 families or carers emotional support after diagnosis, and tailor this to their emotional, social, cultural and age-dependent needs.
• Assess the emotional and psychological wellbeing of young people with type 1 diabetes who have frequent episodes of diabetic ketoacidosis (DKA).
• Be aware that a lack of adequate psychosocial support for children and young people with type 1 diabetes has a negative effect on various outcomes (including blood glucose management), and can also reduce their self-esteem.
• Offer children and young people with type 1 diabetes and their families or carers timely and ongoing access to mental health professionals with an understanding of diabetes. This is 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.
• See the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people for guidance on managing these conditions.
• Diabetes teams should have access to mental health professionals to support them in psychological assessment and providing psychosocial support.
• Offer children and young people with type 1 diabetes who have behavioural or conduct disorders, and their families or carers, access to 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 if there are concerns about their psychological wellbeing. Choose a type of therapy based on what the child or young person needs help with:
  • 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 management if they have high HbA_1c levels (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 persistent difficulty with blood glucose management.
• Be aware that children and young people with type 1 diabetes may develop anxiety or depression, particularly when they have difficulty with self-management when they have had diabetes for a long time.
• Refer children and young people with type 1 diabetes and suspected anxiety or depression promptly to child mental health professionals.
• Be aware that children and young people with type 1 diabetes (in particular, young women) have an increased risk of eating disorders. For more guidance on assessing and managing eating disorders, see also the NICE guideline on eating disorders.
• Be aware that children and young people with type 1 diabetes and an eating disorder may have associated difficulties with:
  • blood glucose management (both hyperglycaemia and hypoglycaemia)
  • symptoms of gastroparesis.
• For children and young people with type 1 diabetes and an eating disorder, 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 then annually until transfer to adult services
  • moderately increased albuminuria (albumin:creatinine ratio [ACR] 3 mg/mmol to 30 mg/mmol) to detect diabetic kidney disease, annually from 12 years
  • hypertension, annually from 12 years.
• Refer children and young people with type 1 diabetes for diabetic retinopathy screening from 12 years, in line with Public Health England's diabetic eye screening programme.
• 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 families or carers the importance of annual monitoring from 12 years for diabetic kidney disease.

Diabetic Retinopathy

• For children and young people with type 1 diabetes who are having eye screening, explain to them and their families or carers that:
  • monitoring for diabetic retinopathy begins at 12 years (see the second recommendation in the section, Monitoring for Complications and Associated Conditions of Type 1 Diabetes) because diabetic retinopathy that needs treatment is extremely rare in children and young people under 12
  • annual monitoring from age 12 is important because if significant diabetic retinopathy is found, early treatment will improve the outcome (for more information see Public Health England's diabetic eye screening programme)
  • it will help them to keep their eyes healthy and help prevent problems with their vision
  • the screening service is effective at identifying problems so that they can be treated early.

Diabetic Kidney Disease

• Explain to children and young people with type 1 diabetes and their families or carers that:
  • monitoring for moderately increased albuminuria (ACR 3 mg/mmol to 30 mg/mmol) 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 management will reduce the risk of this progressing to significant diabetic kidney disease
  • annual monitoring from 12 years is important because if they have diabetic kidney disease, early treatment will improve the outcome.
• Use the first urine sample of the day ('early morning urine') to measure the ACR. 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 ACR 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 ACR is 30 mg/mmol or more (proteinuria).

Periodontitis

• Advise children and young people with type 1 diabetes and their families and carers at their regular diabetes reviews that:
  • they are at higher risk of periodontitis
  • if they get periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia.
• Advise children and young people with type 1 diabetes to have regular oral health reviews (their oral healthcare or dental team will tell them how often, in line with the NICE guideline on dental checks: intervals between oral health reviews).
• For guidance for oral healthcare and dental teams on how to provide oral health advice, see the NICE guideline on oral health promotion.

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
  • nausea, vomiting, abdominal pain, hyperventilation, dehydration or reduced level of consciousness.
• For children or young people without known diabetes who have a plasma glucose level above 11 mmol/litre and symptoms that suggest diabetic ketoacidosis (DKA; see the previous recommendation), 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 the 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 their blood ketones (beta-hydroxybutyrate), using a near-patient method if available. Immediately send them to a hospital with acute paediatric facilities if:
  • their blood ketones are elevated
  • a near-patient method for measuring their blood ketones is not available.
• If DKA is suspected or confirmed in a child or young person, explain to them and to their families or carers that DKA is serious and that they need urgent hospital assessment.
• Diagnose DKA in children and young people with diabetes who have:
  • hyperglycaemia (plasma glucose more than 11 mmol/litre) and
  • acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 15 mmol/litre) and
  • ketonaemia (indicated by blood beta-hydroxybutyrate above 3 mmol/litre) or ketonuria (++ and above on the standard strip marking scale).
• Diagnose DKA severity as follows:
  • mild DKA if blood pH is below 7.3 or plasma bicarbonate is below 15 mmol/litre
  • moderate DKA if blood pH is below 7.2 or plasma bicarbonate is below 10 mmol/litre
  • severe DKA if blood pH is below 7.1 or plasma bicarbonate is below 5 mmol/litre.

For recommendations on initial management of diabetic ketoacidosis, fluid and insulin therapy, monitoring during therapy, and complications of diabetic ketoacidosis, refer to the full guideline.

Avoiding Future Episodes of Diabetic Ketoacidosis

• After a child or young person with known diabetes has recovered from an episode of DKA, discuss what may have led to the episode with them and their families or carers.
• 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 they have had multiple episodes of DKA.
• Advise children and young people who have had DKA and their families or carers how to reduce the risk of future episodes. In particular, explain 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.
• The diabetes team should include members with 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 families or carers 24-hour access to advice from their diabetes team.
• Involve children and young people with diabetes and their families or carers in making decisions about the package of care provided by their diabetes team.
• At diagnosis, offer children and young people with diabetes either home-based or inpatient management, depending on their clinical need, family circumstances and preferences. Explain that home-based care with support from the local paediatric diabetes team (including 24-hour telephone access) is safe, and is as effective as initial inpatient management.
• Offer initial inpatient management to children with diabetes who are under 2 years old.
• 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 way from the hospital.
• Diabetes teams should speak regularly with school staff who look after children and young people with type 1 diabetes, to provide 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

• Give children and young people with diabetes enough time to understand how transition from paediatric to adult services will work, because this improves clinic attendance.
• Agree specific local protocols for transferring young people with diabetes from paediatric to adult services.
• Base the decision on when a young person should transfer to the adult service on their physical development and emotional maturity, and on local circumstances.
• Ensure that transition from the paediatric service occurs at a time of relative stability in the young person's health, and that it 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.