Type 2 Diabetes in Children and Young People: Diagnosis and Management

Overview

This Guidelines summary provides recommendations for primary care on the diagnosis and management of children and young people with type 2 diabetes. For the full set of recommendations, see the full guideline.

Further Guidelines summaries of NICE diabetes guidance:

• Type 1 Diabetes in Children and Young People: Diagnosis and Management
• Type 1 Diabetes in Adults: Diagnosis and Management 
• Type 2 Diabetes in Adults: 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

• 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

• When giving children and young people, or their families or carers, information about type 2 diabetes:
  • tailor the timing, content and delivery of information to their needs and preferences, paying particular attention to people with additional needs such as autistic people or those with learning disabilities, people who have physical or sensory disabilities and people who have difficulties speaking or reading English
  • ensure that the information given supports shared decision making between the child or young person and the multidisciplinary diabetes team.
    
    Follow the recommendation in NICE's guideline on shared decision making and babies, children and young people's experience of healthcare.
     
• Offer children and young people with type 2 diabetes and their families or carers a continuing programme of education from diagnosis. Include the following core topics:
  • the importance of managing glucose levels, including achieving and maintaining glucose and HbA_1c targets 
  • how and when to take capillary blood glucose measurements (self-monitoring)
  • how diet, increasing physical activity and reducing body weight can reduce the symptoms of type 2 diabetes and lead to remission
  • how diet, physical activity, body weight and intercurrent illness affect blood glucose control
  • how metformin can help, and possible adverse effects
  • the complications of type 2 diabetes and how to prevent them.
    
    See also the recommendations for children and young people in NICE's guideline on identifying, assessing and managing obesity, lifestyle interventions, behavioural interventions, physical activity and dietary approaches for weight management, and the recommendations on psychological and social issues in this guideline.
     
• Tailor the education programme to each child or young person with type 2 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.
• Give children and young people with type 2 diabetes who are taking insulin, and their families or carers, information and education about:
  • insulin therapy (including its aims and how it works)
  • insulin delivery (including rotating injection sites within the same body region)
  • dosage adjustment
  • the recognition and management of hypoglycaemia
  • the importance of monitoring their glucose levels.
• Give children and young people with type 2 diabetes who are offered continuous glucose monitoring (CGM), and their families and carers, information about how to use their chosen device, as part of their continuing programme of education.
• Explain to children and young people with type 2 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 every 2 years.
• Encourage children and young people with type 2 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 2 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.
• Explain to children and young people with type 2 diabetes and their families or carers how to find out about possible government disability benefits.

Smoking and Substance Misuse

• Encourage children and young people with type 2 diabetes not to start smoking. Explain the general health problems smoking causes, in particular the risks of 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 2 diabetes who smoke. See also the NICE guideline on tobacco: preventing uptake, promoting quitting and treating dependence.
• Explain to children and young people with type 2 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 2 diabetes and their families or carers that the Public Health England Green Book recommends they have:
  • annual immunisation against influenza
  • immunisation against pneumococcal infection, if they are taking insulin or oral hypoglycaemic medicines.

Dietary Management

• At each contact with a child or young person with type 2 diabetes who is overweight or obese, advise them and their families or carers about the benefits of exercise and weight loss, and provide support towards achieving this. See also the NICE guidelines on preventing excess weight gain and managing obesity.
• Offer children and young people with type 2 diabetes dietetic support to help optimise body weight and blood glucose levels.
• At each contact with a child or young person with type 2 diabetes, explain to them and their families or carers how healthy eating can help to:
  • reduce hyperglycaemia
  • reduce cardiovascular risk
  • promote weight loss (see the first recommendation in this section).
• Provide dietary advice to children and young people with type 2 diabetes and their families or carers in a sensitive manner. Take into account the difficulties that many people have with losing weight, and how healthy eating can also help with blood glucose levels and avoiding complications. 
• Take into account social and cultural considerations when providing dietary advice 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 or significant changes in weight because these may reflect changes in blood glucose levels.
• Provide arrangements for weighing children and young people with type 2 diabetes that respect their privacy.

At Diagnosis

• Refer children and young people with suspected type 2 diabetes to a multidisciplinary paediatric diabetes team for specialist review to:
  • confirm diagnosis and
  • provide immediate and continuing care.
• Offer children and young people with type 2 diabetes:
  • advice and support on dietary management (see the section, Dietary Management)
  • a metformin monotherapy formulation in line with their own preferences
  • equipment for capillary blood glucose monitoring.
    
    See also the recommendation on screening for diabetic retinopathy in this guideline. 

    In May 2023, the use of formulations other than standard-release metformin was off-label. See NICE's information on prescribing medicines.

• In addition, offer children and young people with type 2 diabetes:
  • insulin if their HbA_1c level is 69 mmol/mol (8.5%) or more
  • basal-bolus insulin if they have ketosis but not diabetic ketoacidosis (DKA).
    
    If the child or young peron with type 2 diabetes exhibits signs and symptoms of DKA, see the section on the DKA in this guideline. 

Monitong Blood Glucose Levels and Reviewing Treatment

• Four weeks after diagnosing type 2 diabetes and starting metformin in a child or young person, review data from glucose monitoring and, if needed, change treatment (see recommendations on adding liraglutide, dulaglutide, or empagliflozin for people on metformin only or for people on metformin and insulin).
• Review treatment for children and young people with type 2 diabetes, as needed, at least every 3 months. Assess glucose trends using available data from glucose monitoring and HbA_1c measurements.
• If HbA_1c monitoring cannot be used because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose levels using one of the following:
  • glucose profiles
  • total glycated haemoglobin estimation (if abnormal haemoglobins)
  • fructosamine estimation.
• Adjust the frequency of capillary blood glucose monitoring based on the person's treatment and whether they are using CGM. Ensure they have enough test strips for capillary blood glucose monitoring.

HbA_1c Targets and Monitoring

• Measure HbA_1c using methods that have been calibrated according to International Federation of Clinical Chemistry standardisation.
• Explain to children and young people with type 2 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 2 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.
• Explain the benefits of safely achieving and maintaining the lowest attainable HbA_1c to children and young people with type 2 diabetes and their families or carers.
• Agree an individualised lowest achievable HbA_1c target with each child or young person with type 2 diabetes and their families or carers. Take into account factors such as their daily activities, individual life goals, complications and comorbidities.
• Measure HbA_1c levels every 3 months in children and young people with type 2 diabetes
• Support children and young people with type 2 diabetes and their families or carers to safely achieve and maintain their individual agreed HbA_1c target level.
• Diabetes services should document the proportion of children and young people with type 2 diabetes who achieve an HbA_1c level of 53 mmol/mol (7%) or lower.

For recommendations on continuous glucose monitoring for children and young people with type 2 diabetes, refer to the full guideline.

Continuous Glucose Monitoring

• Offer real-time continuous glucose monitoring (rtCGM) to children and young people with type 2 diabetes if any of the following apply. They:
  • have a need, condition or disability (including a mental health need, learning disability or cognitive impairment) that means they cannot engage in monitoring their glucose levels by capillary blood glucose monitoring
  • would otherwise be advised to self-monitor at least 8 times a day
  • have recurrent or severe hypoglycaemia.
• Consider rtCGM for children and young people with type 2 diabetes who are on insulin therapy.
• Consider intermittently scanned continuous glucose monitoring (isCGM, commonly referred to as 'flash') for children and young people with type 2 diabetes aged 4 years and over who are on insulin therapy if:
  • rtCGM is contraindicated for them or
  • they express a clear preference for isCGM.
    
    In May 2023, use of isCGM for children aged 3 years and under was off-licence. 
• When offering CGM to children and young people with type 2 diabetes, choose the appropriate device with them, based on their individual preferences, needs, characteristics, and the functionality of the devices available. See box 1 in the full guideline for factors to consider as part of this discussion.
• When choosing a CGM device, if multiple devices meet the person's needs and preferences, offer the device with the lowest cost.
• CGM should be provided by a team with expertise in its use to support children and young people to self-manage their type 2 diabetes.
• Advise children and young people with type 2 diabetes who are using CGM, and their families or carers, that they will still need to take capillary blood glucose measurements, but they can do this less often. Explain that this is because they will need the capillary blood glucose measurements:
  • to check the accuracy of their CGM device
  • as a back-up (for example, if the device stops working).
• Monitor and review the child or young person's use of CGM when 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. 

When to Reduce Insulin for People Who Have Been on it from Diagnosis

• For children and young people with type 2 diabetes who have been on insulin therapy from diagnosis, gradually reduce with the aim of stopping insulin therapy if they have achieved:
  • an HbA_1c level of 48 mmol/mol (6.5%) or less or
  • a plasma glucose level of 4 mmol/litre to 7 mmol/litre, on 4 or more days a week, when fasting or before meals or
  • a plasma glucose level of 5 mmol/litre to 9 mmol/litre, on 4 or more days a week, 2 hours after meals.
    
    See also recommendations on insulin therapy for children and young people with type 2 diabetes in this guideline.

Adding Liraglutide, Dulaglutide, or Empagliflozin

People on Metformin Only

• Offer liraglutide or dulaglutide, depending on the person's preference, in addition to metformin, to children and young people aged 10 or over with type 2 diabetes if they have:
  • an HbA_1c level of more than 48 mmol/mol (6.5%) or
  • a plasma glucose level of more than 7 mmol/litre, on 4 or more days a week, when fasting or before meals or
  • a plasma glucose level of more than 9 mmol/litre, on 4 or more days a week, 2 hours after meals.
    
    In May 2023, this was was an off-label use of dulaglutide. See NICE's information on prescribing medicines.
• Consider empagliflozin, in addition to metformin, for children and young people aged 10 or over with type 2 diabetes who:
  • meet any of the criteria listed in the first recommendation of this section
  • are not able to tolerate liraglutide or dulaglutide or have a clear preference for empagliflozin.
    
    In May 2023, this was an off-label use of empagliflozin. See NICE's information on prescribing medicines.

When to Add Insulin for People on Metformin With or Without One of Liraglutide, Dulaglutide or Empagliflozin

• Offer insulin to children and young people with type 2 diabetes in whom an HbA_1c level of 48 mmol/mol (6.5%) or less cannot be achieved using metformin with one medicine among liraglutide, dulaglutide or empagliflozin.

People on Metformin and Insulin

• Offer liraglutide or dulaglutide in addition to current treatment, rather than increasing insulin, for a child or young person aged 10 or over with type 2 diabetes if:
  • they are already on insulin therapy and
  • their HbA_1c or glucose levels do not meet the conditions in the section on when to reduce insulin for people who have been on it from diagnosis.
    
    See also the first recommendation in the section, Dietary Management. 

    In May 2023, this was an off-label use of dulaglutide. See NICE's information on prescribing medicines.

• Consider empagliflozin in addition to current treatment, rather than increasing insulin, for a child or young person aged 10 or over with type 2 diabetes if:
  • they are already on insulin therapy and
  • their HbA_1c or glucose levels do not meet the conditions in the section on when to reduce insulin for people who have been on it from diagnosis and
  • they are not able to tolerate liraglutide or dulaglutide or have a clear preference for empagliflozin.
    
    See also the first recommendation in the section, Dietary Management. 
    
    In May 2023, this was an off-label use of empagliflozin. See NICE's information on prescribing medicines.

When to Increase Insulin for People on Metformin and Insulin With or Without One of Liraglutide, Dulaglutide or Empagliflozin

• Only increase insulin for a child or young person aged 10 or over with type 2 diabetes who is on metformin and insulin if their HbA_1c or glucose levels are not in the target ranges listed in the section on when to reduce insulin for people who have been on it from diagnosis and:
  • they are already also taking liraglutide, dulaglutide or empagliflozin, or a combination of them or
  • liraglutide, dulaglutide and empagliflozin are not tolerated or contraindicated.

Dose of Liraglutide, Dulaglutide or Empagliflozin

• For children and young people aged 10 or over with type 2 diabetes who are on liraglutide, dulaglutide or empagliflozin, maintain the lowest dose that enables them to achieve the target ranges specified in the section on when to reduce insulin for people who have been on it from diagnosis. 
  
  See relevant Medicines and Healthcare products Regulatory Agency (MHRA) advice on the use of SGLT2 inhibitors and specific BNF advice on the use of empagliflozin.

Insulin Therapy 

• When insulin therapy is appropriate (as per the recommendations about prescribing insulin at diagnosis or when to subsequently add insulin in this guideline), discuss the choice of insulin regimen with the child or young person and their family:
  • explain the advantages and disadvantages of the different options and whether only basal or a combination of basal and meal-time insulin is required
  • discuss their personal circumstances and preferences
  • help them make an informed decision between the options that are available to them.
• Provide children and young people with type 2 diabetes insulin injection needles that are the right length for their body fat.
• Provide children and young people with type 2 diabetes and their families or carers with:
  • 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 2 diabetes a review of injection sites at each clinic visit.
• If a child or young person with type 2 diabetes does not have optimal blood glucose levels (see the recommendations in this guideline on HbA_1c target and HbA_1c and plasma glucose targets), offer additional support, such as more contact with their diabetes team.

Changing Treatments and Updating Healthcare Plans 

• Ensure that the paediatric diabetes team updates the child or young person's school healthcare plan as soon as treatment changes in a way that affects the school's involvement, and annually.
  
  For recommendations about involving children and young people, and their family and carers, in making decisions about treatment, see:
  • the section Service Provision in this guideline
  • sections 1.2 to 1.4 in NICE's guideline on shared decision making.

Psychological and Social Issues

• 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 families or carers emotional support after diagnosis, and tailor this 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), and these can affect their wellbeing and diabetes management.
• Be aware that a lack of adequate psychosocial support for children and young people with type 2 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 2 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 assessment for anxiety and depression to children and young people with type 2 diabetes who have persistent difficulty with blood glucose management.
• Refer children and young people with type 2 diabetes and suspected anxiety or depression promptly to child mental health professionals.
• Ensure that children and young people with type 2 diabetes and their families or carers 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
  • moderately increased albuminuria (albumin:creatinine ratio [ACR] 3 mg/mmol to 30 mg/mmol) to detect diabetic kidney disease, starting at diagnosis.
• Explain to children and young people with type 2 diabetes and their families or carers the importance of annual monitoring for hypertension, dyslipidaemia and diabetic kidney disease.
• Refer children and young people with type 2 diabetes for diabetic retinopathy screening from 12 years, in line with Public Health England’s diabetic eye screening programme.
• For guidance on managing foot problems in children and young people with type 2 diabetes, see the NICE guideline on diabetic foot problems.

Periodontitis

• Advise children and young people with type 2 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 2 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.

For further recommendations on hypertension, dyslipidaemia, diabetic retinopathy, and diabetic kidney disease in children and young people with type 2 diabetes, refer to the full guideline.

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 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.

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.
• 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.
• 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 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.