Intended for healthcare professionals

  1. Zosia L Beckles, information scientist1,
  2. Julie A Edge, consultant in paediatric diabetes2,
  3. Moira A Mugglestone, director1,
  4. M Stephen Murphy, clinical director for children’s health1,
  5. Jerry K H Wales, director of endocrinology and professor3
  6. On behalf of the Guideline Development Group
  1. 1National Collaborating Centre for Women’s and Children’s Health, Royal College of Obstetricians and Gynaecologists, London NW1 4RG, UK
  2. 2Oxford Children’s Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
  3. 3Lady Cilento Children’s Hospital and University of Queensland, Brisbane, QLD 4101, Australia
  1. Correspondence to: M A Mugglestone mmugglestone{at}rcog.org.uk

What you need to know

  • Immediately refer any child or young person with suspected type 1 diabetes characterised by random plasma glucose >11 mmol/L, polyuria, polydipsia, weight loss, excessive tiredness, or DKA to a multidisciplinary paediatric diabetes team

  • Agree an individualised lowest achievable HbA1c target, taking into account daily activities, life goals, complications, comorbidities, and, in type 1 diabetes, the risk of hypoglycaemia

  • For type 1 diabetes, offer multiple daily injection basal-bolus insulin regimens with level 3 carbohydrate counting education from diagnosis, provide blood ketone testing strips and a meter, and advise testing for ketonaemia if the child is ill or has hyperglycaemia

  • For type 2 diabetes, offer standard release metformin from diagnosis

Type 1 diabetes affects more than 25 000 children and young people in the United Kingdom and type 2 affects about 500, with both types becoming more common.1 Life threatening complications, including diabetic ketoacidosis (DKA), can occur with both type 1 and type 2 diabetes. Prompt recognition and effective management of diabetes and associated complications are essential. This article summarises new recommendations from the National Institute for Health and Care Excellence (NICE), which for the first time cover type 2 diabetes and the recognition and management of DKA in children and young people.2

What’s new in this guidance?

  • A reduced ideal HbA1c target

  • Multiple daily injection basal-bolus insulin regimens from diagnosis for type 1 diabetes

  • Management of type 2 diabetes

  • Recognition and management of DKA

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

General principles

Type 1 and type 2 diabetes: recognition, diagnosis, and referral

  • Be aware that characteristics of type 1 diabetes in children and young people include hyperglycaemia (random plasma glucose >11 mmol/L), polyuria, polydipsia, weight loss, and excessive tiredness.

  • When type 1 diabetes is suspected, refer immediately (for same day assessment) to a multidisciplinary paediatric diabetes team to confirm diagnosis and provide immediate care.

  • When diagnosing diabetes, assume type 1 diabetes unless there are strong indications of type 2 diabetes, monogenic diabetes (such as maturity onset diabetes of the young; MODY), or mitochondrial diabetes (maternally inherited mitochondrial mutations associated with multisystem abnormalities).

  • Consider the possibility of type 2 diabetes if diabetes is suspected and there is a strong family history of type 2 diabetes; obesity at presentation; black or Asian family origin; no insulin requirement, or an insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase; evidence of insulin resistance (for example, acanthosis nigricans; see fig 1).

Figure1

Fig 1 Example of acanthosis nigricans

See fig 2 for general principles for glycaemic control and HbA1c targets as well as monitoring of complications and associated conditions.

Psychological and social issues

  • Psychological problems (such as anxiety, depression, behavioural and conduct disorders, and family conflict) or psychosocial difficulties may arise in both types of diabetes, and they may affect wellbeing and the management of diabetes. Thus offer timely and ongoing access to mental health professionals with an understanding of diabetes. (Updated and expanded to cover type 2 diabetes.) [Based on the experience and opinion of the Guideline Development Group (GDG).]

Service provision

  • Offer an ongoing integrated package of care provided by a multidisciplinary paediatric diabetes team, including members with appropriate training in clinical, educational, dietetic, lifestyle, mental health, and foot care aspects of diabetes for children and young people.

  • Offer 24 hour access to advice from the diabetes team.

Transition from paediatric to adult care

  • Agree specific local protocols for transferring young people from paediatric to adult services.

Education and information

  • Take particular care when communicating with and providing information if the child or young person or the family members or carers have, for example, physical and sensory disabilities, or difficulties speaking or reading English. (Expanded to cover type 2 diabetes.) [Based on the experience and opinion of the GDG.]

Type 1 diabetes: specific recommendations

  • Blood glucose targets and monitoring: see fig 2.

  • Insulin therapy and dietary management:

    • -Offer multiple daily injection basal-bolus insulin regimens (injections of short acting insulin or rapid acting insulin analogue before meals, together with one or more separate daily injections of intermediate acting insulin or long acting insulin analogue) from diagnosis. If a multiple daily injection regimen is not appropriate, consider continuous subcutaneous insulin infusion (CSII) or insulin pump therapy as recommended by NICE3

    • -Provide those starting CSII therapy with specific training in its use. Provide ongoing support from a specialist team, particularly immediately after starting CSII therapy

    • -Offer level 3 carbohydrate counting education (carbohydrate counting with adjustment of insulin dosage according to an insulin:carbohydrate ratio) from diagnosis to those using a multiple daily insulin injection regimen or CSII therapy. Repeat the offer at intervals thereafter. (New recommendation.) [Based on moderate quality evidence from randomised controlled trials (RCTs).]

  • Hyperglycaemia, blood ketone monitoring, and intercurrent illness:

    • -Provide clear individualised oral and written advice (“sick day rules”) for managing diabetes during intercurrent illness or episodes of hyperglycaemia, including: monitoring blood glucose, monitoring and interpreting blood ketones (β hydroxybutyrate), adjusting the insulin regimen, food and fluid intake, when and where to seek further advice or help. Revisit the advice at least annually.

    • -Offer blood ketone testing strips and a meter, and advise testing for ketonaemia if the child or young person is ill or has hyperglycaemia. (New recommendation.) [Based on low quality evidence from an RCT and a health economic model conducted for the guideline.]

  • Recognition and management of hypoglycaemia: see box 1.

Box 1: Recognition and management of hypoglycaemia

Mild to moderate hypoglycaemia

Clinical features:

  • This complication is common and symptoms are often individual to the child or young person. The child or young person may look pale, feel hungry, and be shaky. As symptoms progress headache, confusion, slurred speech, and blurred vision may occur.

Management:

  • Give fast acting glucose (for example, 10-20 g) by mouth (liquid carbohydrate may be taken more easily than solid).

  • Recheck blood glucose levels within 15 minutes (fast acting glucose should raise blood glucose levels within 5-15 minutes) and repeat fast acting glucose if hypoglycaemia persists.

  • As symptoms improve or normoglycaemia is restored, give oral complex long acting carbohydrate to maintain blood glucose levels unless the child or young person is about to have a snack or meal, or is receiving a continuous subcutaneous insulin infusion.

Severe hypoglycaemia

Clinical features:

  • May be associated with a reduced level of consciousness and sometimes convulsions.

Management:

  • For those in hospital and in whom rapid intravenous access is possible give 10% intravenous glucose. Give a maximum dose of 500 mg/kg body weight (equivalent to a maximum of 5 mL/kg).

  • For those who are not in hospital or when rapid intravenous access is not available use intramuscular glucagon or a concentrated oral glucose solution (for example, GlucoGel. Do not use oral glucose solution if the level of consciousness is reduced because this could be dangerous. Details on the dosages to be used and subsequent management are explained in the guideline.

Type 2 diabetes: specific recommendations

  • Dietary management:

    • -At each contact with those who are overweight or obese, advise about the benefits of physical activity and weight loss, and provide support towards achieving this in accordance with NICE guidance4 5

    • -Provide dietary advice in a sensitive manner, taking into account the difficulties many people encounter with weight reduction, and emphasise the additional advantages of healthy eating for blood glucose control and avoiding complications.

  • Metformin: offer standard release metformin from diagnosis.

Diabetic ketoacidosis

See fig 3 for an overview of the diagnosis and management of diabetic ketoacidosis.

Complications of diabetic ketoacidosis—cerebral oedema

  • Immediately assess for suspected cerebral oedema if any of these early features are present: headache; agitation or irritability; unexpected fall in heart rate; increased blood pressure.

  • Immediately treat suspected cerebral oedema using the most readily available of mannitol (20%, 0.5-1 g/kg over 10-15 minutes) or hypertonic sodium chloride (2.7% or 3%, 2.5-5 mL/kg over 10-15 minutes).

  • Immediately treat for cerebral oedema (as above) in those developing any of these signs: deteriorating level of consciousness; abnormal breathing pattern—for example, respiratory pauses; oculomotor palsies; pupillary inequality or dilatation.

Overcoming barriers

  • The ideal HbA1c target of 48 mmol/mol (6.5%) or lower may be perceived as difficult to achieve. The GDG took account of this by recommending that targets should be individualised while emphasising that lowering HbA1c reduces the risk of long term complications.

  • Timely and ongoing access to mental health professionals with an understanding of diabetes was recommended in the original (2004) guideline but the GDG recognised that it was still not universally available, leading the group to identify this as a key priority for implementation.

  • Recommendations related to composition of, and 24 hour access to, the diabetes team are important for generalists to be aware of, to promote implementation of other recommendations. Similarly, effective arrangements for transition from paediatric to adult care are emphasised because they will support continuity of care.

  • A lack of recommendations on drugs for type 2 diabetes other than metformin may be perceived as an omission. The guideline scope did not, however, include consideration of other treatments, such as insulin (which would require highly specialised management). Metformin is the first line treatment and other agents should be considered only in the context of clinical trials.

How patients were involved in the creation of this article

The GDG for this update included lay members who contributed to the formulation of the recommendations summarised here and the selection of key priorities for implementation (key recommendations).

Further information on the guidance

Methods

This guideline, which is an update of the National Institute for Health and Care Excellence (NICE) 2004 guideline CG15, was developed by the National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) in collaboration with the Guideline Development Group (GDG). The group consisted of three paediatric diabetologists, two paediatric diabetes specialist nurses, a general practitioner, a dietitian, and two lay members. For certain topics a clinical psychologist and a paediatric intensivist were co-opted as expert advisers.

The GDG developed protocols to answer 47 review questions linked to clinical topics identified in the guideline scope. To this end, the NCC-WCH technical team identified and analysed clinical and health economic evidence in accordance with NICE’s 2012 guidelines manual,6 using systematic literature searches, appraisal of evidence quality according to the GRADE approach, and pair-wise meta-analysis of clinical data where appropriate. Health economic analysis was undertaken for certain prioritised areas. The GDG then developed recommendations based on the evidence presented by the technical team, which were ratified after consultation with registered stakeholders.

Four versions of this guideline are available: the full guideline,7 a summary known as the NICE or short version of the guideline,2 a lay version related to type 1 diabetes,8 and a lay version related to type 2 diabetes.9 A clinical pathway is also available on the NICE website.10 The recommendations summarised here are specific to diabetes or diabetic ketoacidosis (DKA) (or both) in children and young people. Other NICE guidelines provide recommendations for diagnosis or management (or both) of type 1 diabetes in adults,11 type 2 diabetes in adults,12 diabetes in pregnancy,13 and diabetic foot problems.14

Future updates of the guideline will be produced as part of NICE’s guideline development programme.

Future research
  • What is the effectiveness of education programmes in which young people with type 1 diabetes provide training for their peers?

  • What is the optimal upper limit and timing for blood glucose measurements after meals for children and young people with type 1 diabetes to reach an HbA1c level of 48 mmol/mol (6.5%) without unacceptable hypoglycaemia?

  • What is the impact of educating children and young people with type 1 diabetes and their family members or carers (as appropriate) about their glycaemic index from diagnosis?

  • What are the long term comparative clinical effectiveness and cost effectiveness of different metformin preparations for treating type 2 diabetes in children and young people?

  • What is the optimal dosage of intravenous insulin for managing DKA in children and young people?

Guidelines into practice

  • Have all children and young people with suspected or confirmed diabetes been referred on the same day to a multidisciplinary paediatric diabetes team?

  • Have children and young people with diabetes and their parents or carers been supplied with the appropriate test strips, meters, and other equipment, as recommended by the diabetes team, to optimise diabetes control?

Notes

Cite this as: BMJ 2016;352:i139

Footnotes

  • Members of the Guideline Development Group: Francesca Annan, Jo Dalton, Jaqueline Double, Sarah Eaton, Julie Edge (chair, DKA subgroup), Nikhil Gokani, William Lamb, Carol Metcalfe (member from June 2014), Claire Pesterfield (member until March 2014), Jerry Wales (chair). The NCC-WCH technical team included Zosia Beckles, Moira Mugglestone, and M Stephen Murphy.

  • Contributors: All authors were involved in selecting recommendations to be highlighted in the article. ZLB prepared the initial draft for the methods and future research sections and MAM prepared the initial draft for the remaining sections. All authors reviewed the initial drafts, were involved in revisions before and after submission, and agreed the final version. All authors agreed to be accountable for all aspects of the work. MAM is guarantor.

  • Funding: ZLB, MAM, and MSM are employees of the Royal College of Obstetricians and Gynaecologists, which is commissioned and funded by NICE to develop clinical guidelines. No authors received specific funding from NICE to write this summary.

  • Competing interests: We declare the following interests based on NICE’s policy on conflicts of interests (available at www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/code-of-practice-for-declaring-and-managing-conflicts-of-interest.pdf). JAE has received payment from the British National Formulary for Children and Practical Diabetes for writing on type 1 diabetes; from the International Society for Pediatric and Adolescent Diabetes (ISPAD), from the International Diabetes Federation (IDF), the Australia Paediatric Society, Diabetes UK, and Novo Nordisk for travel expenses; and from the University of York as an invited speaker. JAE’s employer has received payment from Oxford Medical Diagnostics for a research project on a device not directly linked to any of the topics in the guideline scope, from Aventis, Novo Nordisk, and Roche for sponsorship of educational meetings, and from the British Heart Foundation, Diabetes UK, the Juvenile Diabetes Research Foundation (JDRF), and the National Institute for Health Research Comprehensive Clinical Research Network (NIHR CCRN) for research projects. JAE held managerial responsibility for departmental funding from Advanced Therapeutics, Animas/LifeScan, Glucomen, Lilly, Novo Nordisk, Roche, and Aventis for sponsorship of educational meetings. JAE is chief investigator on a study of a new glucose sensor funded by Abbot Diabetes Care. JAE has attended a half day training course organised by Medtronic about continuous intravenous insulin therapy pumps. JKHW’s former employer (Sheffield Children’s Hospital Foundation Trust) has received payment from Merck Sharp & Dohme (MSD) and Parexel through the Medicines for Children Research Network (MCRN) for JKHW’s participation in research projects. JKHW was a joint chief investigator on a project funded by Diabetes UK but received no money directly. The authors’ full statements can be viewed at www.bmj.com/content/bmj/352/bmj.i139/related#datasupp.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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