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Overview

This summary provides recommendations for primary care on the diagnosis and management of children and young people with type 2 diabetes. Guidance on the diagnosis and management of type 1 diabetes in children and young people can be found here. For the full set of recommendations, see the full guideline.

Overview

This summary provides recommendations for primary care on the diagnosis and management of children and young people with type 2 diabetes. Guidance on the diagnosis and management of type 1 diabetes in children and young people can be found at guidelines.co.uk/252660.article. For the full set of recommendations, see the full guideline.

Latest guidance updates

March 2022: In the section on monitoring capillary blood glucose, wording has been added to the heading and recommendations to make it clear that recommendations apply to children and young people who are using capillary blood glucose monitoring rather than continuous glucose monitoring (CGM). See the full summary online.

This summary has been abridged for print. View the full summary at guidelines.co.uk/455509.article.

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

  • 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:
    • HbA1c monitoring and targets
    • how diet, physical activity, body weight and intercurrent illness effect blood glucose control
    • how metformin can help, 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 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.
  • Explain to children and young people with type 2 diabetes and their families or carers that, like people without diabetes, they should have:
  • 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.
  • Take particular care when communicating with children and young people with type 2 diabetes if they or their families or carers have 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 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.

Metformin

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

HbA1c targets and monitoring

  • Measure HbA1c using methods 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 families or carers that an HbA1c 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 HbA1c level above 48 mmol/mol (6.5%) that any reduction in HbA1c level reduces their risk of long-term complications.
  • Explain the benefits of safely achieving and maintaining the lowest attainable HbA1c to children and young people with type 2 diabetes and their families or carers.
  • Agree an individualised lowest achievable HbA1c 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 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 families or carers 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 who achieve an HbA1c level of 53 mmol/mol (7%) or lower.

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.

For recommendations on psychological and social issues, view the full summary online at guidelines.co.uk/455509.article

Monitoring for complications and associated conditions 

  • 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] 3–30 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.

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.

 

© NICE 2022. 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.

Published date: 01 August 2015.

Last updated: 31 March 2022.

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