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NICE Guideline, No. 18
This guideline is a partial replacement for CG15.
QS125 is based on this guideline.
Overview
This guideline focuses on the diagnosis and treatment of type 1 and type 2 diabetes in children and teenagers under 18. It provides recommendations on how to achieve tight control of blood glucose levels to reduce the long-term risks associated with diabetes.
Who is it for?
Recommendations
Individuals have the right to actively participate in discussions and decisions regarding their care, as outlined in the decision-making processes.
Guidelines for decision-making based on NICE guidelines explain the strength of recommendations and provide information on prescribing medications, professional standards, and legal aspects.
Blood glucose and plasma glucose
In this guideline, the term ‘plasma glucose’ is used instead of ‘blood glucose,’ except for specific concentrations. Patient-held glucose meters are calibrated to plasma glucose equivalents.
1.1. Diagnosis
If type 1 diabetes is suspected in children, they should be referred to a multidisciplinary pediatric diabetes team on the same day for confirmation and immediate care.
Assume type 1 diabetes in children unless strong evidence suggests type 2, monogenic, or mitochondrial diabetes.
Initial differentiation of diabetes types should not involve measuring C-peptide or diabetes-specific autoantibodies. Consider genetic testing for monogenic diabetes based on clinical features or family history.
1.2. Type 1 diabetes
Education and information
Provide education on insulin therapy, delivery, and dosage, including managing illnesses and oral health to prevent periodontitis.
Encourage regular clinic visits to maintain optimal blood glucose levels and address any concerns with the diabetes team.
Inform about diabetes support groups, wearing diabetes identifiers, and offering guidance on government disability benefits.
Special attention should be given when communicating with individuals with physical disabilities or difficulty understanding English.
Offer advice on playing sports and guidance for long-distance travel.
Smoking and substance misuse
Promote the avoidance of smoking and provide cessation programs. Educate on the dangers of substance misuse.
Immunisation
Offer immunization against pneumococcal infection to insulin users.
Insulin therapy
Offer multiple daily injections or insulin pump therapy, promote dose adjustments, and administer rapid-acting insulin before meals.
Training for insulin pump usage should be provided, along with core advice for pump users.
Provide choices for insulin delivery systems and proper needle sizes for injection sites.
Consider alternative regimens and use rapid-acting insulin analogues for illness or hyperglycemia as necessary.
Oral medicines
Use metformin cautiously and avoid combining sulfonylureas with insulin due to increased risk of hypoglycemia.
Dietary management
Solidify understanding of nutrition and the impact of glycemic index, taking social and cultural factors into consideration.
Ensure nutritional requirements for growth and development are met like other children.
Provide level 3 carbohydrate counting education to children and young people with type 1 diabetes and their families or carers. Reinforce regularly. [2015]
Offer personalized dietary advice when children and young people with type 1 diabetes alter their insulin regimen. [2015]
Discuss practical issues related to fasting and feasting. [2004, amended 2015]
Coordinate with the diabetes team on snack composition and timing. [2015]
Encourage the intake of 5 portions of fruits and vegetables daily. [2015]
Explain the advantages of a low glycemic index diet. Provide guidance and education on how to follow it. [2015]
Offer dietetic support to optimize body weight and blood glucose levels. [2004]
Measure height and weight during each clinic visit to monitor normal growth or significant weight changes. [2004, amended 2015]
Respect privacy when weighing individuals. [2004]
Exercise
Promote regular exercise to reduce long-term cardiovascular risks. [2004, amended 2015]
Explain that all forms of exercise are acceptable, with adjustments to insulin and dietary management. [2004]
Consume additional carbohydrates if plasma glucose levels are below 7 mmol/litre before exercise. [2004, amended 2015]
Adjust insulin dosage or carbohydrate intake based on changes in daily exercise routines. [2004]
Blood glucose and HbA1c targets and monitoring
Blood glucose targets
Maintain blood glucose levels towards the lower end of the target ranges to achieve the lowest HbA1c. [2015]
If problematic hypoglycemia or emotional distress occurs, consider adjusting targets. [2015]
Address potential conflicts in setting targets and come to compromises. [2015]
Interpreting blood glucose levels
Interpret blood glucose levels in the context of the ‘whole child.’ [2004]
Continuous glucose monitoring
Provide real-time continuous glucose monitoring (rtCGM) to all individuals alongside proper education. [2022]
For children aged 4 years and above who prefer it, provide isCGM. [2022]
isCGM is authorized for children aged 4 years and above.
Offer a range of rtCGM devices, considering individual preferences and needs. [2022]
Involve shared decision-making in selecting a device based on various factors. [2022]
rtCGM should be provided by a team with expertise. [2022]
Include capillary blood glucose monitoring as a backup. [2022]
Supply an adequate amount of test strips for capillary blood glucose measurements as needed. [2022]
Incorporate CGM into the educational program for all children and young people. [2022]
Monitor the use of CGM and address any issues to enhance device usability. [2022]
Refer to the rationale and impact section for further information on continuous glucose monitoring.
Monitoring capillary blood glucose
Recommend performing at least 5 capillary blood glucose tests daily. [2015, amended 2022]
Consider more frequent testing, especially during physical activity and illness periods. [2015, amended 2022]
Offer a selection of monitoring equipment to optimize blood glucose management. [2004, amended 2022]
HbA1c targets and monitoring
Calibrate HbA1c measurements following the International Federation of Clinical Chemistry standards. [2015]
Explain the advantages of reaching and maintaining low HbA1c levels to reduce long-term risks. [2015]
Set an HbA1c target of 48 mmol/mol (6.5%) or lower to minimize complications. [2015]
Lowering HbA1c levels reduces the risk of long-term complications. [2015]
Establish the lowest achievable HbA1c target for each child or young person with type 1 diabetes, considering factors such as daily activities, life goals, complications, comorbidities, and hypoglycemia risk.
Support children and young people with type 1 diabetes and their families in achieving and maintaining their agreed-upon HbA1c target level safely.
Check HbA1c levels 4 times a year for children and young people with type 1 diabetes, considering more frequent testing if blood glucose management is challenging.
Document the percentage of children and young people with type 1 diabetes achieving an HbA1c level of 53 mmol/mol (7%) or lower.
Hyperglycemia, blood ketone monitoring, and intercurrent illness
Review guidance at least annually.
Provide children and young people with type 1 diabetes blood ketone testing strips and a meter for ketone testing when ill or experiencing hyperglycemia.
Advise against using expired blood ketone testing strips.
Hypoglycemia
Educate children and young people with type 1 diabetes and their families on how to prevent and manage hypoglycemia.
Provide instruction on recognizing and managing hypoglycemia.
Ensure access to fast-acting glucose and glucose monitoring equipment for safe management of hypoglycemia.
Train families and caregivers on administering intramuscular glucagon for severe hypoglycemia.
In cases of severe hypoglycemia in hospitalized children, use intravenous glucose if rapid access is available.
Difficulties with blood glucose control
Consider non-adherence to therapy for children and young people with type 1 diabetes struggling with blood glucose management, particularly during adolescence.
Sensitively address non-adherence to therapy with children and their families.
Surgery
Ensure surgeries are performed in centers with pediatric diabetes facilities.
Establish protocols for safe surgery in centers caring for children with type 1 diabetes.
Discuss care for children with diabetes before elective or emergency surgery.
Psychological and social issues
Be mindful of the increased risk of emotional and behavioral difficulties in children with type 1 diabetes.
Offer tailored emotional support to children and their families post-diagnosis to meet their needs.
Assess the welfare of adolescents with type 1 diabetes who frequently experience episodes of diabetic ketoacidosis.
Ensure access to mental health professionals for continuous assistance.
Introduce family-based interventions to address diabetes-related conflicts within the family.
Screen for anxiety and depression in children struggling with consistent management of blood glucose levels.
Promptly refer children showing signs of anxiety or depression to mental health experts.
Recognize the potential risk of eating disorders in adolescents with type 1 diabetes.
Provide collaborative management involving diabetes and mental health professionals for those dealing with eating disorders.
Monitoring for complications and associated conditions of type 1 diabetes
Regularly check for moderately elevated levels of albuminuria (ACR 3 mg/mmol to 30 mg/mmol) starting at age 12 to detect early signs of diabetic kidney disease.
Refer adolescents with type 1 diabetes for diabetic retinopathy screening from age 12 as per the guidelines of Public Health England’s diabetic eye screening program. [2015]
Adhere to NICE guidelines for monitoring coeliac disease and managing diabetic foot problems in adolescents with type 1 diabetes. [2015]
Highlight the significance of annual monitoring starting at age 12 for diabetic kidney disease to adolescents and their families or caregivers. [2015]
Diabetic retinopathy
Commence screening for diabetic retinopathy at age 12 since it is uncommon in children under 12, and early detection leads to better outcomes. Follow the diabetic eye screening program of Public Health England for detailed information. [2015, amended 2020]
Diabetic kidney disease
Start monitoring for moderately elevated levels of albuminuria (ACR 3 mg/mmol to 30 mg/mmol) at age 12 to promptly identify diabetic kidney disease. Use the first urine sample of the day for screening to minimize false positives. Enhance blood glucose control upon detection of moderately elevated albuminuria to prevent progression to significant diabetic kidney disease. Timely treatment can enhance outcomes. [2015]
Repeat the ACR test if initial results fall between 3 mg/mmol and 30 mg/mmol. Further investigation is necessary if the result is 30 mg/mmol or higher. [2015]
Periodontitis
Effective management of periodontitis can enhance blood glucose regulation and reduce the risk of hyperglycemia. Encourage regular oral health assessments and follow NICE guidelines for dental examinations and oral health promotion. [2022]
1.3. Type 2 diabetes
Education and information
Provide tailored information to cater to individual needs, including individuals with additional needs such as autism or learning disabilities, and encourage shared decision-making. Educate on glucose management, diet, physical activity, and weight management. [2023]
Offer guidance on utilizing continuous glucose monitoring (CGM) and address concerns with the diabetes team. Inform about diabetes support groups, governmental disability benefits, smoking risks, and substance abuse. [2015]
Immunisation
Administer immunizations for pneumococcal infection when taking insulin or oral hypoglycemic medications. [2004, amended 2015]
Dietary management
Advise on physical activity and weight reduction for individuals with type 2 diabetes who are overweight. Provide dietary support for achieving optimal body weight and blood glucose levels. Offer dietary recommendations sensitively, considering social and cultural factors, and promote the consumption of fruits and vegetables. [2015]
Monitor growth and weight variations for indications of blood glucose levels. Ensure privacy during weigh-ins. [2004, amended 2015]
At diagnosis
Consult section 1.4 on DKA if signs and symptoms are present. [2023]
Monitoring blood glucose levels and reviewing treatment
Review glucose data and consider adjustments in treatment four weeks after initiating metformin. Evaluate treatment every 3 months and modify blood glucose monitoring frequency based on the treatment. Maintain HbA1c targets to prevent long-term complications. [2023]
Regularly monitor HbA1c levels in adolescents with type 2 diabetes every 3 months. [2015]
Provide support to assist them in achieving their agreed-upon HbA1c target level. [2015]
Document the percentage of individuals attaining an HbA1c level of 53 mmol/mol (7%) or below. [2015]
Continuous glucose monitoring
Consider real-time CGM for those unable to monitor glucose levels via capillary blood glucose testing. [2023]
Use of intermittently scanned CGM for children under 3 years off-label in May 2023. [2023]
Engage adolescents in choosing the appropriate CGM device based on their preferences and requirements. [2023]
Select the most cost-effective CGM device if multiple options meet their needs. [2023]
Provide CGM support from an experienced team to encourage self-management of type 2 diabetes. [2023]
Address and resolve any issues to enhance device utilization, including education and emotional support. [2023]
Reducing insulin dosage
Consider reducing insulin dosage if fasting or pre-meal glucose levels range between 4 and 7 mmol/litre, or post-meal levels range from 5 to 9 mmol/litre.
Adding liraglutide, dulaglutide, or empagliflozin
For those on metformin only
Off-label use of empagliflozin noted in May 2023. Refer to NICE’s prescribing information for details. [2023]
Considering insulin addition
Offer insulin if an HbA1c level of 48 mmol/mol (6.5%) or lower cannot be achieved with metformin and one of the aforementioned medications. [2023]
For those on metformin and insulin
If HbA1c or glucose levels do not meet the specified criteria, assess the necessity for insulin adjustment.
If liraglutide or dulaglutide are not feasible options, or if empagliflozin is preferred.
Increasing insulin dosage
Dosage of liraglutide, dulaglutide, or empagliflozin
Maintain the minimum effective dose to achieve target ranges for individuals aged 10 and above. [2023]
Insulin therapy
Determine insulin options and provide suitable injection needles. [2023]
Regularly assess injection locations during clinic visits. [2023]
Adjusting treatments and updating healthcare plans
Update healthcare plans following treatment modifications and annually for school involvement. [2023]
Surgery
Ensure that surgeries are performed in facilities with specialized pediatric services. [2004, amended 2015]
Facilities taking care of these patients should have established protocols for safe surgeries. [2004, amended 2015]
Psychological and social support
Adolescents with type 2 diabetes may encounter emotional hurdles, provide tailored assistance. [2004, amended 2015]
Offer emotional support and promptly address psychological conditions. [2015]
Access mental health services and professionals as required. [2015]
Monitoring for diabetes complications
Commence monitoring for kidney disease and other related conditions at the time of diagnosis. [2015]
Explain the significance of annual checks for hypertension, dyslipidemia, and kidney disease. [2015]
Refer for retinopathy screening from age 12. [2015]
Routinely monitor for complications to enable timely interventions. [2015]
Hypertension
Monitor blood pressure and start treatment promptly upon detecting hypertension. [2015]
Use an appropriate cuff size for accurate blood pressure measurements. [2015]
Confirm hypertension via ambulatory monitoring prior to initiating treatment. [2015]
Dyslipidemia
Elucidate the importance of monitoring and early treatment for dyslipidemia. [2015]
Include total cholesterol, HDL, non-HDL, and triglycerides in the monitoring process. [2015]
Verify with repeat samples before deciding on the course of management. [2015]
Diabetic retinopathy
Background retinopathy can be identified through screening, and managing blood glucose can help prevent progression to significant diabetic retinopathy. Annual monitoring is crucial for early treatment and improved outcomes. For children with type 2 diabetes under 12 years, consider a referral to an ophthalmologist if blood glucose management is challenging.
Diabetic kidney disease should be screened using the first urine sample of the day. Managing blood glucose can prevent progression to significant kidney disease. Further investigation is needed for proteinuria. Periodontitis management can enhance blood glucose control and reduce hyperglycemia risk. Regular oral health checks are advised. Dental teams should provide oral health advice following NICE guidelines.
Recognition, referral, and diagnosis of diabetic ketoacidosis (DKA) are essential. Symptoms like nausea, vomiting, and abdominal pain should be taken seriously. Hypovolemia management with intravenous fluids and insulin is crucial, especially in cases of dehydration.
Initial management of DKA involves informing senior clinicians, explaining DKA to patients and caregivers, and continuous monitoring for proper care. Facilities should provide adequate monitoring for DKA treatment. In severe cases, further interventions may be necessary.
Treatment for diabetic ketoacidosis (DKA) involves administering intravenous fluids and insulin, providing potassium chloride, and monitoring sodium levels. Achieving a careful balance and correcting any electrolyte imbalances are crucial for successful treatment of DKA. It is essential to promptly start insulin infusion after fluid therapy and make adjustments based on glucose levels.
Consider increasing the insulin dosage if the blood beta-hydroxybutyrate level remains high in a child with DKA. Consult a senior pediatrician before transitioning from IV to oral fluids in a child with mild acidosis. Wait for the resolution of ketosis before shifting from IV to subcutaneous insulin in a child with DKA. Start subcutaneous insulin 30 minutes before discontinuing IV insulin in a child with DKA. Restart the insulin pump 60 minutes before stopping IV insulin in a child with DKA. For a detailed explanation of the rationale and impact of the 2020 recommendations on fluid therapy, refer to the relevant section. Refer to evidence review A for specifics on fluid therapy in DKA management.
During therapy, it is important to monitor children with DKA for signs of cerebral edema. Use continuous ECG to detect any signs of hypokalemia. Healthcare professionals should be familiar with monitoring protocols and when to seek advice. Keeping the child and their family informed about their progress during treatment is vital.
Complications of DKA include cerebral edema, hypokalemia, and venous thromboembolic disease. Immediate treatment should be administered for suspected cerebral edema in a child with DKA. Discuss the management of hypokalemia urgently with a pediatric critical care specialist. Be cautious of the risk of venous thromboembolism in children with DKA, especially those with central venous catheters.
To prevent future episodes of DKA, discuss triggers with the child and their family, especially in cases of non-adherence in children with type 1 diabetes. Educate the child and their family on reducing the risk of future DKA episodes. Provide comprehensive care for children with diabetes through a multidisciplinary team. This team should be proficient in various aspects of diabetes care for children.
Transitioning from pediatric to adult care should be done gradually, with ample time for young people to understand the process. Establish local protocols for transitioning young people to adult diabetes services based on their physical and emotional maturity. Coordinate the transition during stable health periods and explain upcoming changes in diabetes care during the process.
Definitions for terms used in this guideline include real-time and intermittently scanned continuous glucose monitoring, continuous subcutaneous insulin infusion, level 3 carbohydrate counting, multiple daily injection basal-bolus regimen, periodontitis, gingivitis, and multiple daily mixed insulin injections.
The committee recommends future research to evaluate the effectiveness of continuous glucose monitoring in improving glycemic control in children, assess the efficacy of glucose-lowering agents in children with type 2 diabetes, compare weekly versus daily treatment with glucose-lowering agents in children with type 2 diabetes, and determine the best adhesive for continuous glucose monitor sensors to prevent skin reactions.
The committee’s recommendations were influenced by their clinical practice experience, focusing on the benefits of real-time continuous glucose monitoring for children and young people. Recommendations were made for integrating CGM into diabetes education programs and routine healthcare, alongside discussing usage concerns and potential inequalities. The guidance aims to broaden access to CGM devices for children and young people, potentially reducing disparities in care.
The committee extrapolated from evidence in adults to determine the risk of periodontitis in children and young people with diabetes. Recommendations include routinely discussing periodontitis risk at diabetes reviews and incorporating oral hygiene education. The guidance may lead to increased awareness of periodontitis and potentially more oral health reviews in the short term, with long-term benefits expected from improved oral and diabetes health.