Excerpt

Diabetes is a long-term condition that can have a major impact on the life of a child or young person, as well as their family or carers. In addition to insulin therapy, diabetes management should include education, support and access to psychological services, as detailed here and in this guideline. Preparations should also be made for the transition from paediatric to adult services, which have a somewhat different model of care and evidence base.

Type 1 diabetes is becoming more common in the UK and since 2004 type 2 diabetes has also been diagnosed with increasing frequency. The 2013 to 2014 National Diabetes Audit identified 26,500 children and young people in the UK with type 1 diabetes and 500 with type 2^d. Much of the general care for type 2 diabetes is the same as for type 1 diabetes, but the initial management is different. In addition, the overweight and obesity associated with type 2 diabetes bring an increased risk of renal complications in particular, and of problems such as hypertension and dyslipidaemia. These differences in management and complications need guidance specific to type 2 diabetes, which is included here for the first time.

A variety of genetic conditions (such as maturity-onset diabetes in the young) and other conditions (such as cystic fibrosis-related diabetes) may also lead to diabetes in children and young people, but the care of these diverse conditions is beyond the scope of this guideline.

Since 2004 there have been major changes to the routine management of type 1 diabetes in an attempt to achieve much stricter targets for blood glucose control in order to further reduce the long-term risks associated with the condition. This national guidance is the first for children and young people to recommend attempting to reach a glycated haemoglobin (HbA1c) level in the normal range and near normoglycaemia. This tight control may be achieved by intensive insulin management (multiple daily injections or insulin pump therapy) from diagnosis, accompanied by carbohydrate counting. Newer technology, such as continuous subcutaneous glucose monitoring, may also help children and young people to have better blood glucose control, although this is not currently recommended for all children and young people with type 1 diabetes.

The guideline development group believes that by implementing the strict blood glucose control recommended in this guideline, improvements can be made to diabetes care that reduce the impact of the condition on the future health of children and young people.

Contents

• 1. Guideline summary
  • 1.1. Guideline development group membership, NCC-WCH staff and acknowledgements
  • 1.2. Foreword
  • 1.3. Care pathway/algorithm
  • 1.4. Key priorities for implementation
  • 1.5. Recommendations
  • 1.6. Research recommendations
  • 1.7. Schedule for updating the guideline
• 2. Introduction
  • 2.1. Diabetes in children and young people
  • 2.2. For whom is this guideline intended
  • 2.3. Related NICE guidance
• 3. Guideline development methodology
  • 3.1. Original (2004) methodology
  • 3.2. Methodology for 2015 update
• 4. Diagnosis of diabetes
  • 4.1. Introduction
  • 4.2. Clinical diagnosis of diabetes
  • 4.3. C-peptide and antibody tests for distinguishing type 1 and type 2 diabetes
• 5. Education for children and young people with type 1 diabetes
  • 5.1. Introduction
  • 5.2. Education at diagnosis
  • 5.3. General and ongoing education
  • 5.4. Structured education
  • 5.5. Long-distance travel
  • 5.6. Immunisation
  • 5.7. Recommendations
  • 5.8. Research recommendations
• 6. Management of type 1 diabetes – insulin, oral drug therapy, dietary advice and exercise
  • 6.1. Insulin treatment for type 1 diabetes
  • 6.2. Natural history of type 1 diabetes
  • 6.3. Oral drug treatment for type 1 diabetes
  • 6.4. Dietary management in type 1 diabetes
  • 6.5. Exercise
• 7. Management of type 1 diabetes – targets for and monitoring of glycaemic control
  • 7.1. Introduction
  • 7.2. Clinical monitoring of blood glucose
  • 7.3. Self-monitoring of blood glucose
  • 7.4. Frequency and timing of measuring glycaemic parameters
  • 7.5. Methods of self-monitoring blood glucose
  • 7.6. Recommendations
  • 7.7. Research recommendations
  • 7.8. Management of type 1 diabetes – ketone monitoring
• 8. Management of type 1 diabetes – hypoglycaemia
  • 8.1. Introduction
  • 8.2. What is the optimum treatment of mild to moderate hypoglycaemia in children and young people with type 1 diabetes?
  • 8.3. What is the optimum treatment of severe hypoglycaemia in children and young people with type 1 diabetes?
  • 8.4. Long-term effects of hypoglycaemia
  • 8.5. Recommendations
• 9. Management of type 1 diabetes in special circumstances – during intercurrent illness or surgery
  • 9.1. Intercurrent illness
  • 9.2. Surgery
• 10. Psychological and social issues in children and young people with type 1 diabetes
  • 10.1. Introduction
  • 10.2. Emotional and behavioural problems
  • 10.3. Anxiety and depression
  • 10.4. Eating disorders
  • 10.5. Cognitive disorders
  • 10.6. Behavioural and conduct disorders
  • 10.7. Non-adherence
  • 10.8. Psychological interventions
  • 10.9. Adolescence
  • 10.10. Advice on alcohol, smoking and recreational drugs for children and young people with type 1 diabetes
  • 10.11. Recommendations
  • 10.12. Research recommendations
• 11. Monitoring for associated conditions and complications of type 1 diabetes
  • 11.1. Introduction
  • 11.2. Screening for coeliac disease and hypothyroidism
  • 11.3. Other medical conditions
  • 11.4. Screening for microvascular and other complications
  • 11.5. Recommendations
  • 11.6. Research recommendation
• 12. Education for children and young people with type 2 diabetes
  • 12.1. Review question
  • 12.2. Introduction
  • 12.3. Description of included studies
  • 12.4. Evidence profile
  • 12.5. Evidence statements
  • 12.6. Health economics profile
  • 12.7. Evidence to recommendations
  • 12.8. Recommendations
• 13. Management of type 2 diabetes – dietary and weight loss advice and oral drug treatment
  • 13.1. Dietary advice
  • 13.2. Weight loss advice
  • 13.3. Metformin treatment
• 14. Management of type 2 diabetes – targets for and monitoring of glycaemic control
  • 14.1. Optimal HbA1c target
• 15. Management of type 2 diabetes in special circumstances – during intercurrent illness or surgery
  • 15.1. Introduction
  • 15.2. Recommendations
• 16. Psychological and social issues in children and young people with type 2 diabetes
  • 16.1. Psychological interventions
• 17. Monitoring for associated conditions and complications of type 2 diabetes
  • 17.1. Monitoring for hypertension
  • 17.2. Monitoring for dyslipidaemia
  • 17.3. Monitoring for retinopathy
  • 17.4. Monitoring for nephropathy
  • 17.5. Recommendations
• 18. Diabetic ketoacidosis
  • 18.1. Introduction
  • 18.2. Recognition, referral and diagnosis
  • 18.3. Treatment of diabetic ketoacidosis – initial management
  • 18.4. Fluid and insulin therapy
  • 18.5. Monitoring during therapy
  • 18.6. Complications of diabetic ketoacidosis
  • 18.7. Avoiding future episodes of diabetic ketoacidosis
• 19. Service provision
  • 19.1. Multidisciplinary teams
  • 19.2. Communication between organisations
  • 19.3. Transition from paediatric to adult care
  • 19.4. Recommendations
  • 19.5. Research recommendation
• 20. Health economics
  • 20.1. Introduction
  • 20.2. Review of the literature
  • 20.3. Cost effectiveness of multiple daily injections compared with mixed insulin injections in children and young people with type 1 diabetes
  • 20.4. Cost effectiveness of different frequencies of capillary blood glucose monitoring in children and young people with type 1 diabetes
  • 20.5. Cost effectiveness of blood ketone monitoring compared with urine ketone monitoring in children and young people with type 1 diabetes
• 21. References
• 22. Abbreviations
• Appendices
  • Appendix A. Recommendations from NICE clinical guideline 15 (2004) that have been amended
  • Appendix B. 2015 update scope
  • Appendix C. Stakeholder organisations
  • Appendix D. Declarations of interest
  • Appendix E. Review protocols
  • Appendix F. Search strategies
  • Appendix G. Summary of identified studies
  • Appendix H. Excluded studies
  • Appendix I. Evidence tables
  • Appendix J. Forest plots
  • Appendix K. GRADE tables
  • Appendix L. Research recommendations
  • Appendix M. Young people's consultation day
  • Appendix N. Superseded text from 2004 guideline

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and/or their guardian or carer.