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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.

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 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

Education and information

  • 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
  • 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

  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) about general health problems associated with smoking and in particular the risks of developing vascular complications
  • Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) about the general dangers of substance misuse and the possible effects on blood glucose control

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

  • 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
  • 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

  • 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

Psychological and social issues

  • 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
  • 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

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
    • 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
  • 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

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 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 confirmed 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
  • 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 sufficient 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

© NICE 2016. 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: August 2015.

Last updated: November 2016.