Diabetes in children and young adults is increasing. In 2013-2014, the National Diabetes Audit in the UK found that 26,500 children had been diagnosed with type 1 diabetes and 500 children with type 2 diabetes.1
This article is a summary of the 2015 NICE guidance on diabetes in children and young people,2 which replaces the previous 2004 guidance. Diagnosis of type 1 diabetes in children is almost always confirmed in the hospital setting; however, it is useful for GPs to have an understanding of the main treatment priorities. Due to the rising obesity epidemic, it is more likely that GPs will face diagnosing type 2 diabetes in children. The guidance emphasises the care of this group for the first time.
Type 1 diabetes
In the latest guidance tighter HBA1c targets in types 1 are advised. An HBA1c of 48mmol/l (≤6.5%) is ideal to minimise the risk of long-term complications. The 2004 guidelines advised obtaining an HBA1c of less than 7.5% (IFCC 58mmol/mol).
Blood glucose targets in patients with type 1 diabetes should be:
- 4–7mmol/l before breakfast and before meals during the day
- 5–9 mmol/l after meals
- at least 5mmol/l when driving
These are stricter targets than the 2004 guidelines, which advised a pre-prandial blood glucose of between 4-8mmol/l and less than 10mmol/l after meals.
The guideline suggests offering basal bolus regimen insulin from the start of diagnosis. If this is not suitable for the child, consider an insulin pump. The 2004 guidelines advised offering for pre-school and primary school children the ‘most appropriate insulin regimen’ and for young people with diabetes a ‘multiple daily injection regimen’.
Level 3 carbohydrate-counting education should now be offered to children with type 1 diabetes on basal bolus regimens or insulin pumps. This allows the child and parent to adjust the insulin dose according to the amount of carbohydrate consumed.
It is recommended that blood glucose is monitored five times a day in all children with type 1 diabetes. The 2004 guidelines recommended encouraging children and young adults to self-monitor as this is associated with reductions in HBA1c, but did not specify the exact number of times the monitoring should be done.
If frequent blood glucose monitoring is not possible, then continuous glucose monitoring systems with alarms should be fitted (ie in patients with cognitive disabilities, impaired hypoglycaemia awareness or frequent severe hypoglycaemia, also in neonates, infants and pre-school children, those with co-morbidities or those who participate in high level sports).
Patients and their carers should be taught how insulin treatment works, how to adjust doses according to the carbohydrates consumed and how diet and exercise can affect glucose levels. They should also be taught how to manage hypo and hyperglycaemia as well as ketosis. Ketone test strips and a meter should be given to children with type 1 diabetes and they and their parents/carers advised to check for ketonaemia if unwell or hyperglycaemic.
Diet advice should include eating low glycaemic index foods, good fats and five portions of fruit and vegetables a day, as this will reduce the risk of cardiovascular disease.
Access to mental health services should be provided to children and young adults with diabetes, as there is an increased risk of psychosocial problems.
Annual monitoring for retinopathy and kidney disease related to diabetes should commence from 12 years of age. Retinopathy and kidney disease before the age of 12 is extremely rare. The 2015 guidelines have added that hypertension monitoring should be done annually from age 12.
Recognising diabetic ketoacidosis
GPs should ensure that capillary glucose levels are checked in any child presenting with increased thirst, increased urination, excessive tiredness or recent unexplained weight loss, and any of the following: nausea and vomiting, abdominal pain, hyperventilation, dehydration, decreased level of consciousness (new recommendation).
If DKA is suspected, urgent admission should be arranged for the same day to the paediatric multidisciplinary team.
DKA can develop in a child with type 1 diabetes with normal blood glucose levels; therefore have a low index of suspicion for this possibility. If DKA is suspected, measure blood ketone levels and if above 3mmol/l, arrange urgent admission.
Treating hypoglycaemia in type 1 diabetes
Treat mild-moderate hypoglycaemia (glucose <4mmol/l, child shaky/sweaty but conscious), by giving rapid-acting glucose by mouth (10-20g carbohydrate, eg a glass of fruit juice). Repeat blood glucose in 15 minutes. If it is still low then give more fast-acting carbohydrate as above. Once glucose has normalised give a complex carbohydrate snack (eg two biscuits), unless the child is on an insulin pump or about to eat their meal.
Severe hypoglycaemia (where the child is fitting or unconscious) in a hospital setting would be treated with 10% glucose IV at a rate of 500mg/kg body weight. If severe hypoglycaemia occurs outside of hospital children 8 years or older should be given 1mg glucagon IM; those less than 8 years old should have 500 micrograms of glucagon IM.
If blood glucose levels do not improve after 10 minutes, seek assistance. If the patient is maintaining a normal glucose, give a complex carbohydrate (eg a sandwich) to keep the blood glucose raised.
Type 2 diabetes
Type 2 diabetes is becoming more common in children due to rising obesity levels. Consider type 2 diabetes in children who are symptomatic and have the following characteristics:
- A strong family history of type 2 diabetes
- Of black or Asian origin
- No insulin requirement
- Evidence of insulin resistance, eg acanthosis nigricans.
The latest guidance recommends that structured education should be provided from diagnosis. Dietary advice should be given in a sensitive way and healthy eating should be promoted as a way to improve blood glucose and reducing complications. Cultural and social factors should be considered when giving dietary advice.
The guidelines advise that metformin (standard release) should be offered from diagnosis to all type 2 children and young adults.
An HBA1c target of 48mmol/l or lower is recommended in order to prevent long-term complications, and should be measured every three months.
Children with diabetes have an increased risk of psychological problems, which can have a negative impact on their blood glucose control. The NICE guidance on depression in children and young adults3 should be referred to.
Annual monitoring for hypertension should be made from diagnosis for these children. If the blood pressure is found to be >95th centile repeatedly, the patient should have a 24-hour blood pressure monitor before starting treatment. Also, check their lipids at diagnosis and measure albumin-creatinine ratio. These parameters should be measured annually.
Follow the NICE guidance on diabetic foot problems4 in children and young adults with type 2 diabetes.
Retinopathy monitoring is advised from age 12 years, but if the blood sugars are persistently high and the child is under 12, then consider referring to an ophthalmologist earlier.
Case history 1
An 8-year-old South Indian child who is overweight has been complaining of increased skin infections and thirst. A capillary glucose test has revealed that his level is 13mmol/l. A urine dipstick is negative for ketones. He is found to be on the 90th centile for weight. His blood pressure is checked and is found to be normal.
This child has a diagnosis of type 2 diabetes and should be started on metformin standard release tablets. A blood test should be organised to check for dyslipidaemia and urine test sent for albumin:creatinine ratio.
The child and carers should be referred to the paediatric multidisciplinary team for structured education and advice regarding weight loss and healthy eating. The child should have annual reviews also at the GP diabetic clinic to ensure that regular monitoring of blood pressure, feet checks, and albumin:creatinine ratios are performed. Ongoing support should be offered regarding education about exercise and healthy eating and an HBA1c target of 48mmol/l aimed for.
Case history 2
A 15-year-old girl presents to you with vague central abdominal pain with weight loss and tiredness. You test her urine and find that there is glycosuria and ketonuria.
This presentation suggests DKA. The patient should be referred on the same day to the paediatric team on call for management and to start a basal bolus regimen of insulin.
Case history 3
A 10-year-old girl with type 1 diabetes attends the practice for her annual flu jab. She suddenly feels faint and collapses in the waiting room. The nurse checks the blood glucose and it is 2.4mmol/l.
This child is obviously hypoglycaemic. Glucagon 1mg IM should be administered and then the blood glucose checked after 15 minutes. If the level has normalised and the child is conscious, a complex carbohydrate snack should be given to maintain the sugar level. If the sugar level does not increase sufficiently after 15 minutes, then an ambulance should be called for urgent assistance and admission to the local paediatric team.
- Dr Farid is a GP in London
|Key learning points|
- National Paediatric Diabetes Audit report 2013–14.
- NICE Guideline NG18. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. Published August 2015.
- NICE Guideline CG28. Depression in children and young people: identification and management in primary, community and secondary care. Published September 2005, updated June 2015.
- NICE Guideline NG19. Diabetic foot problems: prevention and management. Published August 2015.