Nice | Type 1 diabetes in children and young people

This is an updated guideline from Nice on diagnosing and managing diabetes (DM) in children and young people. I have separated out type 1 DM and type 2 DM for ease.

It is a long and pretty comprehensive guideline and there are a few big changes from the last guideline in 2004. Most of the management of these young people will be in secondary care, so I've tried to pull out the bits most relevant to us (or those that I've found myself feeling very ignorant of when parents bring their kids in).

Presentation

If children have symptoms of diabetes and any of the following then do a BM and refer if it is > 11:

  • nausea and vomiting
  • abdo pain
  • hyperventilation
  • dehydration
  • impaired conciousness

DKA presentation

Beware that in children on insulin, DKA can present with normoglycaemia.

Type of Diabetes

Most will be Type 1, but some will be Type 2. There are also some rare monogenic, mitochondrial and insulin resistant forms of diabetes. This will normally be decided in secondary care, but if you need to know more, there is a section in the guideline on this.

Insulin

First line should be a basal - bolus regime (1 or more injections of intermediate or long acting insulin with injections of short acting or rapid acting insulin before meals).

Second line should be a pump.

Rapid acting insulins should be provided for use in times of illness.

Carbohydrate Counting

This should be offered to all children (if you don't know what this means in practice, it is in very simple terms counting the weight of all your carbs and sugars, so that you can tailor your insulin accordingly - there's a description on the diabetes uk website).

Blood sugar monitoring

Most children will do this by using BMs, but it can also be done using continuous monitoring if children are having problems. This system measures interstitial fluid glucose, rather than blood sugar and is less invasive. There's a good description on the diabetes.co.uk website.

Target blood sugars:

  • On waking - 4-7
  • Before meals - 4-7
  • After meals - 5-9
  • Driving - at least 5
  • Exercise - if BM is below 7, additional carbohydrate should be consumed before exercise.

HbA1c

Target 48 (6.5), but a higher target may need to be agreed on in some patients.

Measure 4 times a year.

Ketone monitoring

Offer all children ketone dipstix and encourage testing on sick days and when they have hyperglycaemia.

Psychological aspects

Psychological problems are common. Children should be referred to someone with knowledge of diabetes. Family therapy may be needed if there is familial conflict over the diabetes.

Follow up

Children should be followed up 4 times a year.

  • regular dental checks
  • optician every 2 years
  • TSH annually
  • Eye screening from 12
  • BP annually from 12
  • ACR annually from 12 (if 3 - 30 mg / mmol then repeat on 2 further occasions before investigating further, if > 30 then investigate).

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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