14.1.7.1. Relative value placed on the outcomes considered

The guideline development group had hoped to find evidence to determine the optimal HbA1c target for children and young people with type 2 diabetes to minimise the risk of long-term complications without incurring an increase in hypoglycaemic episodes. In particular, the group had hoped to find evidence related to the following long-term complications: hypertension; retinopathy; and nephropathy. The group also hoped to find evidence related to glycaemic control and changes in BMI SDS. They group wished to know whether there was any impact on psychosocial outcomes including health-related quality of life and the satisfaction of hildren, young people and families with treatment.

14.1.7.2. Consideration of clinical benefits and harms

The group was aware that the NICE guideline on type 2 diabetes in adults recommended a target level for HbA1c of 6.5% or less to minimise the risk of long-term complications. The group considered whether this would also be an appropriate target for children and young people with type 2 diabetes. It was noted that if the target was set at an unachievably low level, this would lead to children and young people disengaging with the process of effective HbA1c monitoring. In addition, the group did not wish to set a target that was so low that, were it to be achieved, it would increase the risk of hypoglycaemia. However, it was felt important to set an aspirational target which would have a meaningful effect on the child or young person's long-term health. If the target HbA1c level was set too high, the guideline development group felt that children and young people would be less likely to drive themselves to achieving even lower targets for HbA1c.

Ultimately, the group agreed that 6.5% was an appropriate target for children and young people as it was a safe target that was also aspirational without risking being unachievable. As was the case for the HbA1c target for children and young people with type 1 diabetes, the guideline development group expressed the target HbA1c value in IFCC units (48 mmol/mol).

The group recognised that for some children and young people with type 2 diabetes the specified target for HbA1c may be unattainable. Although efforts should be made towards the ideal HbA1c target, the group's clinical experience suggested that any reduction in HbA1c would be associated with a decreased risk of long-term complications and this would be of clinical benefit. However, the group considered that setting the lowest attainable target of HbA1c should be an a priori decision based on the child or young person's individual circumstances, recognising the important role of support from healthcare professionals towards achieving this aim.

14.1.7.3. Consideration of health benefits and resource use

Achieving a target may have opportunity costs both in terms of the interventions and actions required to improve glycaemic control. The guideline development group recognised that any reduction towards the normal range would improve long-term outcomes for children and young people with type 2 diabetes and thereby reduce the chance of further treatment being required. There was a lack of evidence for a specific HbA1c target in children and young people with type 2 diabetes. The group also felt that the target they had recommended was not so low as to increase the risk of hypoglycaemic episodes. Given this, they agreed that the target for HbA1c of 6.5% was very likely to be cost effective.

14.1.7.4. Quality of evidence

No relevant studies were identified for this review question and so the group relied on other NICE guidance in conjunction with their clinical and patient experience to make recommendations.

14.1.7.5. Other considerations

The group agreed that when setting targets for achieving outcomes with children and young people, it is extremely important to be supportive and encouraging. They noted that for some children and young people it would be extremely difficult to achieve a target HbA1c of 6.5% and so any form of reduction should be praised as the reduction would have some benefit for the future health of the child or young person.

Although the review question did not specifically address the frequency at which HbA1c monitoring should be performed, there was a recommendation in the 2004 guideline about the frequency at which HbA1c monitoring should be performed in children and young people with type 1 diabetes. The group agreed that it would be appropriate to specify the frequency of HbA1c monitoring for type 2 diabetes and hence, based on their clinical and patient experience, they agreed that a 3-monthly schedule for measuring the HbA1c level of the child or young person would be reasonable.

14.1.7.6. Key conclusions

The guideline development group concluded that a strong recommendation to measure HbA1c every 3 months in children and young people with type 2 diabetes, and to aim for an HbA1c level of 48 mmol/mol (6.5%) or lower, was warranted. The group specifically recommended that healthcare professionals should 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.

The group also mirrored several recommendations related to the HbA1c target for children and young people with type 1 diabetes, including those related to:

• calibrating HbA1c results according to IFCC standardisation
• explaining that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long-term complications
• explaining that any reduction in HbA1c level reduces the risk of long-term complications
• diabetes services documenting the proportion of children and young people who achieve an HbA1c level of 53 mmol/mol (7%) or lower.