Diabetes (type 1 and type 2) in children and young people: diagnosis and management

Offer children and young people with type 1 diabetes and their families or carers a continuing programme of education from diagnosis. Include the following core topics:

• insulin therapy (including its aims and how it works), insulin delivery (including rotating injection sites within the same body region) and dosage adjustment [2015]

• blood glucose monitoring, including blood glucose and HbA1c targets [2015]

• how diet, physical activity and intercurrent illness affect blood glucose levels [2015]

• managing intercurrent illness ('sick‑day rules', including monitoring of blood ketones [beta‑hydroxybutyrate]) [2015]

• detecting and managing hypoglycaemia, hyperglycaemia and ketosis [2015]

• the importance of good oral hygiene and regular oral health reviews for preventing periodontitis. [2022]

Tailor the education programme to each child or young person with type 1 diabetes and their families or carers, taking account of issues such as:

• personal preferences

• emotional wellbeing

• age and maturity

• cultural considerations

• existing knowledge

• current and future social circumstances

• life goals. [2015]

Encourage young people with type 1 diabetes to attend clinic 4 times a year, and explain that regular contact with the diabetes team will help them maintain optimal blood glucose levels. [2004, amended 2015]

Explain to children and young people with type 1 diabetes and their families or carers that, like people without diabetes, they should have:

• regular dental examinations (see the NICE guideline on dental checks: intervals between oral health reviews)

• an eye examination by an optician at least every 2 years. [2015, amended 2020]

Encourage children and young people with type 1 diabetes and their families or carers to discuss any concerns and raise any questions they have with their diabetes team. [2015]

Give children and young people with type 1 diabetes and their families or carers information about diabetes support groups and organisations, and the potential benefits of membership. Give this information after diagnosis and regularly afterwards. [2004, amended 2015]

Encourage children and young people with type 1 diabetes to wear or carry something that tells people they have type 1 diabetes (for example, a bracelet). [2004]

Explain to children and young people with type 1 diabetes and their families or carers how to find out about government disability benefits. [2004, amended 2015]

Take particular care when communicating with children and young people with type 1 diabetes if they or their families or carers have physical or sensory disabilities, or difficulties speaking or reading English. [2004]

Diabetes teams should offer comprehensive advice to children and young people with type 1 diabetes who want to play sports that have particular risks for people with diabetes. Support groups and organisations (including sports organisations) may be able to provide more information. [2004, amended 2015]

Offer education for children and young people with type 1 diabetes and their families or carers on the practical issues around long‑distance travel, such as when best to eat and inject insulin when travelling across time zones. [2004]

Discuss the choice of insulin regimen with the child or young person and their family:

• explain the advantages and disadvantages of the different options

• discuss their personal circumstances and preferences

• help them to make an informed decision between the options that are available to them. [2015]

Offer children and young people with type 1 diabetes a multiple daily injection basal-bolus insulin regimen from diagnosis. [2015]

If multiple daily insulin injections are not appropriate for a particular child or young person, consider an insulin pump, as recommended in the NICE technology appraisal guidance on continuous subcutaneous insulin infusion for the treatment of diabetes mellitus. [2015]

Encourage children and young people with type 1 diabetes who are having multiple daily insulin injections to adjust the insulin dose if appropriate after each blood glucose measurement. [2004, amended 2015]

Tell children and young people with type 1 diabetes who are having multiple daily insulin injections to inject rapid‑acting insulin analogues before eating. Explain that this reduces blood glucose levels after meals and will help them optimise their blood glucose levels. [2004, amended 2015]

When children and young people start on an insulin pump, train them and their families and carers how to use it. A specialist team should provide ongoing support. [2004, amended 2015]

Specialist teams should agree a common core of advice to give insulin pump users. [2004, amended 2015]

For children and young people with type 1 diabetes who are using twice-daily injection regimens, encourage them to adjust the insulin dose according to the general trend in their pre‑meal, bedtime and occasional night‑time blood glucose. [2004, amended 2015]

Explain to children and young people with newly diagnosed type 1 diabetes and their families or carers that:

• they may have a partial remission phase (a 'honeymoon period') when they start using insulin

• during this time, they may only need a low dosage of insulin (0.5 units/kg body weight/day) to maintain an HbA1c level of less than 48 mmol/mol (6.5%). [2004, amended 2015]

Offer children and young people with type 1 diabetes a choice of insulin delivery systems. [2004]

Provide children and young people with type 1 diabetes insulin injection needles that are the right length for their body fat. [2004, amended 2015]

Provide children and young people with type 1 diabetes and their families or carers:

• suitable containers for collecting used needles and other sharps

• a way to safely get rid of these containers.
  
  See also the section on safe use and disposal of sharps in the NICE guideline on healthcare-associated infections. [2015]

Offer children and young people with type 1 diabetes a review of injection sites at each clinic visit. [2004, amended 2015]

Provide children and young people with type 1 diabetes rapid‑acting insulin analogues to use during intercurrent illness or episodes of hyperglycaemia. [2015]

If a child or young person with type 1 diabetes does not have optimal blood glucose levels (see recommendation 1.2.55 and recommendation 1.2.76):

• offer additional support, such as more contact with their diabetes team and

• if necessary, offer an alternative insulin regimen (multiple daily injections, an insulin pump, or once‑, twice‑ or three‑times daily mixed insulin injections). [2015]

Only use metformin in combination with insulin within research studies because it is uncertain whether this combination improves blood glucose management. [2004]

Do not offer children and young people with type 1 diabetes acarbose or sulfonylureas (glibenclamide, gliclazide, glipizide, tolbutamide) in combination with insulin, because they may increase the risk of hypoglycaemia without improving blood glucose management. [2004, amended 2015]

Support children and young people with type 1 diabetes and their families or carers to develop a good working knowledge of nutrition and how it affects their diabetes. [2015]

Discuss healthy eating regularly with children and young people with type 1 diabetes and their families or carers.

• Explain that this means eating foods with a low glycaemic index, fruit and vegetables, and appropriate types and amounts of fats.

• Explain that healthy eating can reduce their risk of cardiovascular disease.

• Support them to adjust their food choices accordingly. [2015]

Take into account social and cultural considerations when providing advice on diet to children and young people with type 1 diabetes. [2015]

Explain that children and young people with type 1 diabetes have the same basic nutritional requirements as other children and young people. Their food should provide enough energy and nutrients for their growth and development. [2004, amended 2015]

For children and young people who are using a multiple daily insulin injection regimen or an insulin pump, offer level 3 carbohydrate counting education from diagnosis to them and their families or carers. Repeat this offer regularly. [2015]

When children and young people with type 1 diabetes change their insulin regimen, offer them and their families or carers dietary advice tailored to the new treatment. [2015]

Offer children and young people with type 1 diabetes and their families or carers education about the practical problems associated with fasting and feasting. [2004, amended 2015]

Encourage children and young people with type 1 diabetes and their families or carers to discuss the nutritional composition and timing of snacks with their diabetes team. [2015]

Encourage children and young people with type 1 diabetes to eat at least 5 portions of fruit and vegetables each day. [2015]

Explain to children and young people with type 1 diabetes and their families or carers that a low glycaemic index diet may help to improve blood glucose management and reduce the risk of hyperglycaemic episodes. [2015]

Offer children and young people with type 1 diabetes and their families or carers advice and education to help them follow a low glycaemic index diet. [2015]

Offer children and young people with type 1 diabetes dietetic support to help optimise body weight and blood glucose levels. [2004]

At each clinic visit for children and young people with type 1 diabetes, measure their height and weight and plot on an appropriate growth chart. Check for normal growth or significant changes in weight because these may reflect changes in blood glucose levels. [2004, amended 2015]

Provide arrangements for weighing children and young people with type 1 diabetes that respect their privacy. [2004]

Encourage children and young people with type 1 diabetes to exercise on a regular basis, and explain that this reduces their long-term risk of developing cardiovascular disease. [2004, amended 2015]

Explain to children and young people with type 1 diabetes and their families or carers that they can take part in all forms of exercise, provided that appropriate attention is given to changes in insulin and dietary management. [2004]

Explain to children and young people with type 1 diabetes and their families or carers about:

• the effects of exercise on blood glucose levels and

• how to avoid hypo‑ or hyperglycaemia during or after physical activity. [2004, amended 2015]

Encourage children and young people with type 1 diabetes and their families or carers to monitor blood glucose levels before and after exercise so that they can:

• identify when changes in insulin or food intake are needed

• learn how their blood glucose responds to different levels of exercise

• watch out for exercise‑induced hypoglycaemia

• see how hypoglycaemia can occur several hours after prolonged exercise. [2004, amended 2015]

Explain to children and young people with type 1 diabetes and their families or carers that:

• they should have extra carbohydrates as needed to avoid hypoglycaemia and

• they should have carbohydrate‑based foods available during and after exercise. [2004]

Explain to children and young people with type 1 diabetes and their families or carers that they should have extra carbohydrates if their plasma glucose levels are less than 7 mmol/litre before they exercise. [2004, amended 2015]

Explain to children and young people with type 1 diabetes and their families or carers that they may need to alter their insulin dose or carbohydrate intake if they change their daily exercise patterns. [2004]

Provide children and young people with type 1 diabetes and their families or carers with individualised oral and written advice ('sick‑day rules') about managing type 1 diabetes during intercurrent illness or episodes of hyperglycaemia, including:

• monitoring blood glucose

• monitoring and interpreting blood ketones (beta‑hydroxybutyrate)

• adjusting their insulin regimen

• food and fluid intake

• when and where to get further advice or help.
  
  Revisit the advice at least annually. [2015]

Offer children and young people with type 1 diabetes blood ketone testing strips and a meter. Advise them and their families or carers to test for ketonaemia if they are ill or have hyperglycaemia. [2015]

Explain to children and young people with type 1 diabetes and their families or carers that they should not use blood ketone testing strips after the use‑by date. [2015]

Explain to children and young people with type 1 diabetes and their families or carers how they can avoid and manage hypoglycaemia. [2004]

Offer education for children and young people with type 1 diabetes and their families, carers, and teachers about recognising and managing hypoglycaemia. [2004]

Explain to children and young people with type 1 diabetes and their families or carers that they should always have access to an immediate source of fast‑acting glucose and blood glucose monitoring equipment, so that they can check for hypoglycaemia and manage it safely. [2004, amended 2015]

Train and equip families, carers, and (if appropriate) school nurses and other carers to give intramuscular glucagon for severe hypoglycaemia in an emergency. [2004, amended 2015]

Immediately treat mild-to-moderate hypoglycaemia in children and young people with type 1 diabetes as follows:

• Give oral fast‑acting glucose (for example, 10 g to 20 g; liquid carbohydrate may be easier to swallow than solid).

• Be aware that fast‑acting glucose may need to be given in frequent small amounts because hypoglycaemia can cause vomiting.

• Recheck blood glucose levels within 15 minutes (fast‑acting glucose should raise blood glucose levels within 5 to 15 minutes), and give more fast‑acting glucose if they still have hypoglycaemia.

• As symptoms improve or blood glucose levels return to normal, 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

  • having a continuous subcutaneous insulin infusion. [2004, amended 2015]

For children and young people with type 1 diabetes who are in hospital, treat severe hypoglycaemia with 10% intravenous glucose if rapid intravenous access is possible. Give a maximum dose of 500 mg/kg body weight (equivalent to a maximum of 5 ml/kg). [2004, amended 2015]

For children and young people with type 1 diabetes who are not in hospital, or if rapid intravenous access is not possible, treat severe hypoglycaemia as follows:

• Use intramuscular glucagon or a concentrated oral glucose solution (for example, Glucogel). Do not use oral glucose solution if they have reduced consciousness because this could be dangerous.

• If using intramuscular glucagon:

  • give 1 mg glucagon to children and young people who are over 8 years old, or who weigh 25 kg or more

  • give 500 micrograms of glucagon to children who are under 8 years old, or who weigh less than 25 kg.

• Seek medical assistance if blood glucose levels do not respond or symptoms continue for more than 10 minutes.

• As symptoms improve or blood glucose levels return to normal, and once the child or young person is sufficiently awake, give oral complex long‑acting carbohydrate to maintain normal blood glucose levels.

• Recheck blood glucose repeatedly in children and young people who have persistently reduced consciousness after a severe hypoglycaemic episode to determine whether further glucose is needed. [2004, amended 2015]

Explain to young people with type 1 diabetes how alcohol affects blood glucose levels, and in particular the increased risk of hypoglycaemia (including hypoglycaemia while sleeping). [2004, amended 2015]

Explain to young people with type 1 diabetes who drink alcohol that they should:

• eat food containing carbohydrates before and after drinking

• monitor their blood glucose levels regularly and aim to keep the levels within the recommended range by eating food containing carbohydrates. [2004]

Explain to children and young people with type 1 diabetes and their families or carers that when alcohol causes or contributes to hypoglycaemia, glucagon may be ineffective and they may need intravenous glucose. [2004]

Diabetes teams should consider referring children and young people with type 1 diabetes for assessment of cognitive function if they have frequent hypoglycaemia or recurrent seizures, particularly if these occur at a young age. [2004]

Think about the possibility of non‑adherence to therapy in children and young people with type 1 diabetes who have difficulty with blood glucose management, especially in adolescence. [2004, amended 2015]

Be aware that young people with type 1 diabetes can have difficulty with blood glucose management during adolescence, and this may in part be due to non‑adherence to therapy. [2004]

Raise the issue of non‑adherence to therapy with children and young people with type 1 diabetes and their families or carers in a sensitive manner. [2004]

Be aware of the possible negative psychological impact of setting targets that may be difficult for a child or young person with type 1 diabetes to achieve and maintain. [2015]

Only offer surgery in centres that have dedicated paediatric facilities for children and young people with diabetes. [2004]

All centres caring for children and young people with type 1 diabetes should have written protocols on safe surgery for children and young people. The protocols should be agreed between surgical and anaesthetic staff and the diabetes team. [2004]

Surgical, anaesthetic and diabetes teams should discuss care for children and young people with type 1 diabetes before they are admitted to hospital for elective surgery, and as soon as possible after they are admitted for emergency surgery. [2004, amended 2015]

Be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties. [2004, amended 2015]

Offer children and young people with type 1 diabetes and their families or carers emotional support after diagnosis, and tailor this to their emotional, social, cultural and age‑dependent needs. [2004]

Assess the emotional and psychological wellbeing of young people with type 1 diabetes who have frequent episodes of diabetic ketoacidosis (DKA). [2004, amended 2015]

Be aware that a lack of adequate psychosocial support for children and young people with type 1 diabetes has a negative effect on various outcomes (including blood glucose management) and can also reduce their self‑esteem. [2004, amended 2015]

Offer children and young people with type 1 diabetes and their families or carers timely and ongoing access to mental health professionals with an understanding of diabetes. This is because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders, and family conflict) or psychosocial difficulties that can impact on the management of diabetes and wellbeing. [2004, amended 2015]

See the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people for guidance on managing these conditions. [2015]

Diabetes teams should have access to mental health professionals to support them in psychological assessment and providing psychosocial support. [2004]

Offer children and young people with type 1 diabetes who have behavioural or conduct disorders, and their families or carers, access to mental health professionals. [2004]

Offer specific family‑based behavioural interventions, such as behavioural family systems therapy, if there are difficulties with diabetes‑related family conflict. [2015]

Consider a programme of behavioural intervention therapy or behavioural techniques for children and young people with type 1 diabetes if there are concerns about their psychological wellbeing. Choose a type of therapy based on what the child or young person needs help with:

• health‑related quality of life – for example, counselling or cognitive behavioural therapy (CBT), including CBT focused on quality of life

• adherence to diabetes treatment – for example, motivational interviewing or multisystemic therapy

• blood glucose management if they have high HbA1c levels (above 69 mmol/mol [8.5%]) – for example, multisystemic therapy. [2015]

Offer screening for anxiety and depression to children and young people with type 1 diabetes who have persistent difficulty with blood glucose management. [2004]

Be aware that children and young people with type 1 diabetes may develop anxiety or depression, particularly when they have difficulty with self-management when they have had diabetes for a long time. [2004]

Refer children and young people with type 1 diabetes and suspected anxiety or depression promptly to child mental health professionals. [2004]

Be aware that children and young people with type 1 diabetes (in particular, young women) have an increased risk of eating disorders. For more guidance on assessing and managing eating disorders, see the NICE guideline on eating disorders. [2004, amended 2015]

Be aware that children and young people with type 1 diabetes and an eating disorder may have associated difficulties with:

• blood glucose management (both hyperglycaemia and hypoglycaemia)

• symptoms of gastroparesis. [2004, amended 2015]

For children and young people with type 1 diabetes and an eating disorder, offer joint management involving their diabetes team and child mental health professionals. [2004, amended 2015]

Offer children and young people with type 1 diabetes monitoring for:

• thyroid disease, at diagnosis and then annually until transfer to adult services

• moderately increased albuminuria (albumin to creatinine ratio [ACR] 3 mg/mmol to 30 mg/mmol) to detect diabetic kidney disease, annually from 12 years

• hypertension, annually from 12 years. [2015]

Refer children and young people with type 1 diabetes for diabetic retinopathy screening from 12 years, in line with NHS England's diabetic eye screening programme. [2015]

For guidance on monitoring for coeliac disease in children and young people with type 1 diabetes, see the NICE guideline on coeliac disease. [2015]

For guidance on managing foot problems in children and young people with type 1 diabetes, see the NICE guideline on diabetic foot problems. [2015]

Be aware of the following rare complications and associated conditions when children and young people with type 1 diabetes attend clinic visits:

• juvenile cataracts

• necrobiosis lipoidica

• Addison's disease. [2004, amended 2015]

Explain to children and young people with type 1 diabetes and their families or carers the importance of annual monitoring from 12 years for diabetic kidney disease. [2015]

When giving children and young people, or their families or carers, information about type 2 diabetes:

• tailor the timing, content and delivery of information to their needs and preferences, paying particular attention to people with additional needs such as autistic people or those with learning disabilities, people who have physical or sensory disabilities and people who have difficulties speaking or reading English

• ensure that the information given supports shared decision making between the child or young person and the multidisciplinary diabetes team.
  
  Follow the recommendation in NICE's guideline on shared decision making and babies, children and young people's experience of healthcare. [2023]

Offer children and young people with type 2 diabetes and their families or carers a continuing programme of education from diagnosis. Include the following core topics:

• the importance of managing glucose levels, including achieving and maintaining glucose and HbA1c targets

• how and when to take capillary blood glucose measurements (self-monitoring)

• how diet, increasing physical activity and reducing body weight can reduce the symptoms of type 2 diabetes and lead to remission

• how diet, physical activity, body weight and intercurrent illness affects blood glucose levels

• how metformin can help, and its possible adverse effects

• the complications of type 2 diabetes and how to prevent them.
  
  See also the recommendations for children and young people in NICE's guideline on overweight and obesity management (sections on general principles, identifying and assessing overweight and obesity, behavioural overweight and obesity management interventions, and physical activity and diet), and recommendations 1.3.68 to 1.3.70 on psychological and social issues in this guideline. [2015, amended 2023]

Tailor the education programme to each child or young person with type 2 diabetes and their families or carers, taking account of issues such as:

• personal preferences

• emotional wellbeing

• age and maturity

• cultural considerations

• existing knowledge

• current and future social circumstances

• life goals. [2015]

Give children and young people with type 2 diabetes who are taking insulin, and their families or carers, information and education about:

• insulin therapy (including its aims and how it works)

• insulin delivery (including rotating injection sites within the same body region)

• dosage adjustment

• the recognition and management of hypoglycaemia

• the importance of monitoring their glucose levels. [2023]

Give children and young people with type 2 diabetes who are offered continuous glucose monitoring (CGM), and their families and carers, information about how to use their chosen device, as part of their continuing programme of education. [2023]

Explain to children and young people with type 2 diabetes and their families or carers that, like people without diabetes, they should have:

• regular dental examinations (see the NICE guideline on dental checks: intervals between oral health reviews)

• an eye examination by an optician every 2 years. [2004, amended 2015]

Encourage children and young people with type 2 diabetes and their families or carers to discuss any concerns and raise any questions they have with their diabetes team. [2015]

Give children and young people with type 2 diabetes and their families or carers information about diabetes support groups and organisations, and the potential benefits of membership. Give this information after diagnosis and regularly afterwards. [2004, amended 2015]

Explain to children and young people with type 2 diabetes and their families or carers how to find out about possible government disability benefits. [2004, amended 2015]

At each contact with a child or young person with type 2 diabetes who is overweight or obese, advise them and their families or carers about the benefits of exercise and weight loss, and provide support towards achieving this. See also the NICE guideline on overweight and obesity management. [2015]

Offer children and young people with type 2 diabetes dietetic support to help optimise body weight and blood glucose levels. [2004, amended 2015]

At each contact with a child or young person with type 2 diabetes, explain to them and their families or carers how healthy eating can help to:

• reduce hyperglycaemia

• reduce cardiovascular risk

• promote weight loss (see recommendation 1.3.15). [2015]

Provide dietary advice to children and young people with type 2 diabetes and their families or carers in a sensitive manner. Take into account the difficulties that many people have with losing weight, and how healthy eating can also help with blood glucose levels and avoiding complications. [2015]

Take into account social and cultural considerations when providing dietary advice to children and young people with type 2 diabetes. [2015]

Encourage children and young people with type 2 diabetes to eat at least 5 portions of fruit and vegetables each day. [2015]

At each clinic visit for children and young people with type 2 diabetes:

• measure height and weight and plot on an appropriate growth chart

• calculate body mass index.
  
  Check for normal growth or significant changes in weight because these may reflect changes in blood glucose levels. [2004, amended 2015]

Provide arrangements for weighing children and young people with type 2 diabetes that respect their privacy. [2004, amended 2015]

Refer children and young people with suspected type 2 diabetes to a multidisciplinary paediatric diabetes team for specialist review to:

• confirm diagnosis and

• provide immediate and continuing care. [2023]

Offer children and young people with type 2 diabetes:

• advice and support on dietary management (see recommendations 1.3.15 to 1.3.22)

• a metformin monotherapy formulation in line with their own preferences

• equipment for capillary blood glucose monitoring.
  
  See also recommendation 1.3.84 on screening for diabetic retinopathy.
  
  In May 2023, the use of formulations other than standard-release metformin was off-label. See NICE's information on prescribing medicines. (2015, updated 2023)

In addition, offer children and young people with type 2 diabetes:

• insulin if their HbA1c level is 69 mmol/mol (8.5%) or more

• basal-bolus insulin if they have ketosis but not diabetic ketoacidosis (DKA).
  
  If the child or young person with type 2 diabetes exhibits signs and symptoms of DKA, see section 1.4 on DKA. [2023]

Four weeks after diagnosing type 2 diabetes and starting metformin in a child or young person, review data from glucose monitoring and, if needed, change treatment (see recommendations on adding liraglutide, dulaglutide, or empagliflozin for people on metformin only or for people on metformin and insulin). [2023]

Review treatment for children and young people with type 2 diabetes, as needed, at least every 3 months. Assess glucose trends using available data from glucose monitoring and HbA1c measurements. [2023]

If HbA1c monitoring cannot be used because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose levels using one of the following:

• glucose profiles

• total glycated haemoglobin estimation (if abnormal haemoglobins)

• fructosamine estimation. [2023]

Adjust the frequency of capillary blood glucose monitoring based on the person's treatment and whether they are using CGM. Ensure they have enough test strips for capillary blood glucose monitoring. [2023]

For children and young people with type 2 diabetes who have been on insulin therapy from diagnosis, gradually reduce with the aim of stopping insulin therapy if they have achieved:

• an HbA1c level of 48 mmol/mol (6.5%) or less or

• a plasma glucose level of 4 mmol/litre to 7 mmol/litre, on 4 or more days a week, when fasting or before meals or

• a plasma glucose level of 5 mmol/litre to 9 mmol/litre, on 4 or more days a week, 2 hours after meals.
  
  See also recommendations on insulin therapy for children and young people with type 2 diabetes in this guideline. [2023]

When insulin therapy is appropriate (as per the recommendations about prescribing insulin at diagnosis or when to subsequently add insulin in this guideline), discuss the choice of insulin regimen with the child or young person and their family:

• explain the advantages and disadvantages of the different options and whether only basal or a combination of basal and meal-time insulin is required

• discuss their personal circumstances and preferences

• help them make an informed decision between the options that are available to them. [2023]

Provide children and young people with type 2 diabetes insulin injection needles that are the right length for their body fat. [2023]

Provide children and young people with type 2 diabetes and their families or carers with:

• suitable containers for collecting used needles and other sharps

• a way to safely get rid of these containers.
  
  See also the section on safe use and disposal of sharps in the NICE guideline on healthcare-associated infections. [2023]

Offer children and young people with type 2 diabetes a review of injection sites at each clinic visit. [2023]

If a child or young person with type 2 diabetes does not have optimal blood glucose levels (see recommendations 1.3.31 on HbA1c target and 1.3.48 for HbA1c and plasma glucose targets), offer additional support, such as more contact with their diabetes team. [2023]

Ensure that the paediatric diabetes team updates the child or young person's school healthcare plan as soon as treatment changes in a way that affects the school's involvement, and annually. [2023]

For recommendations about involving children and young people, and their family and carers, in making decisions about treatment, see:

• recommendation 1.5.4 (2015) on service provision in this guideline

• sections 1.2 to 1.4 in NICE's guideline on shared decision making.

Only offer surgery in centres that have dedicated paediatric facilities for children and young people with diabetes. [2004, amended 2015]

All centres caring for children and young people with type 2 diabetes should have written protocols on safe surgery for children and young people. The protocols should be agreed between surgical and anaesthetic staff and the diabetes team. [2004, amended 2015]

Be aware that children and young people with type 2 diabetes have a greater risk of emotional and behavioural difficulties. [2004, amended 2015]

Offer children and young people with type 2 diabetes and their families or carers emotional support after diagnosis, and tailor this to their emotional, social, cultural and age‑dependent needs. [2004, amended 2015]

Be aware that children and young people with type 2 diabetes have an increased risk of psychological conditions (for example, anxiety, depression, and behavioural and conduct disorders) and complex social factors (for example, family conflict), and these can affect their wellbeing and diabetes management. [2015]

Be aware that a lack of adequate psychosocial support for children and young people with type 2 diabetes has a negative effect on various outcomes (including blood glucose management) and can also reduce their self‑esteem. [2004, amended 2015]

Offer children and young people with type 2 diabetes and their families or carers timely and ongoing access to mental health professionals with an understanding of diabetes. This is because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders, and family conflict) or psychosocial difficulties that can impact on the management of diabetes and wellbeing. [2004, amended 2015]

See the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people for guidance on managing these conditions. [2015]

Diabetes teams should have access to mental health professionals to support them in psychological assessment and providing psychosocial support. [2004, amended 2015]

Offer assessment for anxiety and depression to children and young people with type 2 diabetes who have persistent difficulty with blood glucose management. [2004, amended 2015]

Refer children and young people with type 2 diabetes and suspected anxiety or depression promptly to child mental health professionals. [2004, amended 2015]

Ensure that children and young people with type 2 diabetes and their families or carers have timely and ongoing access to mental health services when needed. [2015]

Offer children and young people with type 2 diabetes annual monitoring for:

• hypertension, starting at diagnosis

• dyslipidaemia, starting at diagnosis

• moderately increased albuminuria (albumin to creatinine ratio [ACR] 3 mg/mmol to 30 mg/mmol) to detect diabetic kidney disease, starting at diagnosis. [2015]

Explain to children and young people with type 2 diabetes and their families or carers the importance of annual monitoring for hypertension, dyslipidaemia and diabetic kidney disease. [2015]

Refer children and young people with type 2 diabetes for diabetic retinopathy screening from 12 years, in line with NHS England's diabetic eye screening programme. [2015]

For guidance on managing foot problems in children and young people with type 2 diabetes, see the NICE guideline on diabetic foot problems. [2015]

Measure capillary blood glucose at presentation in children and young people without known diabetes who have:

• increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and any of

• nausea, vomiting, abdominal pain, hyperventilation, dehydration or reduced level of consciousness. [2015]

For children or young people without known diabetes who have a plasma glucose level above 11 mmol/litre and symptoms that suggest diabetic ketoacidosis (DKA; see recommendation 1.4.1), suspect DKA and immediately send them to a hospital with acute paediatric facilities. [2015]

Be aware that children and young people taking insulin for diabetes may develop DKA with normal blood glucose levels. [2015]

Suspect DKA even if the blood glucose is normal in a child or young person with known diabetes and any of the following:

• nausea or vomiting

• abdominal pain

• hyperventilation

• dehydration

• reduced level of consciousness. [2015]

When DKA is suspected in a child or young person with known diabetes, measure their blood ketones (beta‑hydroxybutyrate), using a near‑patient method if available. Immediately send them to a hospital with acute paediatric facilities if:

• their blood ketones are elevated

• a near-patient method for measuring their blood ketones is not available. [2015]

If DKA is suspected or confirmed in a child or young person, explain to them and to their families or carers that DKA is serious and that they need urgent hospital assessment. [2015]

When a child or young person with suspected or known DKA arrives at hospital, measure their:

• capillary blood glucose

• capillary blood ketones (beta‑hydroxybutyrate) if near‑patient testing is available, or urine ketones if it is not

• capillary or venous pH and bicarbonate. [2015]

Diagnose DKA in children and young people with diabetes who have:

• hyperglycaemia (plasma glucose more than 11 mmol/litre) and

• acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 15 mmol/litre) and

• ketonaemia (indicated by blood beta‑hydroxybutyrate above 3 mmol/litre) or ketonuria (++ and above on the standard strip marking scale). [2015]

Diagnose DKA severity as follows:

• mild DKA if blood pH is below 7.3 or plasma bicarbonate is below 15 mmol/litre

• moderate DKA if blood pH is below 7.2 or plasma bicarbonate is below 10 mmol/litre

• severe DKA if blood pH is below 7.1 or plasma bicarbonate is below 5 mmol/litre. [2015]

Inform the responsible senior clinician when a child or young person is diagnosed with DKA. [2015]

Explain to the child or young person and their families or carers what DKA is, and what care that they may need. [2015]

When DKA is diagnosed in a child or young person in hospital, record their:

• level of consciousness

• heart rate, blood pressure, temperature, respiratory rate (look for Kussmaul breathing)

• history of nausea or vomiting

• clinical evidence of dehydration

• body weight. [2015]

When DKA is diagnosed in a child or young person in hospital, measure and record the capillary or venous:

• pH and pCO₂

• plasma sodium, potassium, urea and creatinine

• plasma bicarbonate. [2015]

Consider a near‑patient blood ketone (beta‑hydroxybutyrate) testing method for rapid diagnosis and monitoring of DKA in children and young people in hospital. [2015]

Children and young people with DKA should be cared for in a facility that can provide the level of monitoring and care for DKA specified in section 1.4 of this guideline. [2015]

Children and young people with DKA should be cared for with one‑to‑one nursing either on a high‑dependency unit (preferably a paediatric unit) or on a general paediatric ward, if:

• they are younger than 2 years or

• they have severe DKA (blood pH below 7.1). [2015]

Think about inserting a nasogastric tube if a child or young person with DKA has a reduced level of consciousness and is vomiting. [2015]

Seek urgent anaesthetic review and discuss with a paediatric critical care specialist if a child or young person with DKA cannot protect their airway because they have a reduced level of consciousness. [2015]

Discuss the use of inotropes with a paediatric critical care specialist if a child or young person with DKA is in hypotensive shock. [2015]

Think about sepsis in a child or young person with DKA who has any of the following:

• fever or hypothermia

• hypotension

• refractory acidosis

• lactic acidosis. [2015]

Treat DKA with intravenous fluids and intravenous insulin if the child or young person is not alert, is nauseated or vomiting, or is clinically dehydrated. [2020]

Do not give oral fluids to a child or young person who is receiving intravenous fluids for DKA unless ketosis is resolving, they are alert, and they are not nauseated or vomiting. [2020]

For children and young people with DKA who are clinically dehydrated but not in shock:

• give an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride over 30 minutes

• discuss with the responsible senior paediatrician before giving more than one intravenous bolus of 10 ml/kg 0.9% sodium chloride

• only consider giving a second 10 ml/kg 0.9% sodium chloride intravenous bolus if needed to improve tissue perfusion, and only after reassessing their clinical status

• when calculating the total fluid requirement, subtract these initial bolus volumes from the total fluid deficit. [2020]

For children and young people who have signs of shock, that is weak, thready (low-volume) pulse and hypotension, give an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride as soon as possible. When calculating the total fluid requirement, do not subtract this fluid bolus from the total fluid deficit. [2020]

Be aware that:

• shock is rare in children and young people with DKA

• prolonged capillary refill, tachycardia and tachypnoea are common in children with moderate-to-severe DKA, but this does not mean the child or young person is in shock (these are signs of vasoconstriction caused by metabolic acidosis and hypocapnia). [2020]

Calculate the total fluid requirement for the first 48 hours in children and young people with DKA by adding the estimated fluid deficit to the fluid maintenance requirement:

• For the fluid deficit:

  • in mild-to-moderate DKA (blood pH 7.1 or above), assume 5% dehydration (so a 10 kg child needs 500 ml)

  • in severe DKA (blood pH below 7.1), assume 10% dehydration

  • aim to replace the deficit evenly over the first 48 hours, but in critically ill children and young people, discuss the fluid regimen early with the senior paediatrician or paediatric intensivist (or both) because the risk of cerebral oedema is higher.

• For the fluid maintenance requirement, use the Holliday–Segar formula:

  • give 100 ml/kg for the first 10 kg of weight

  • give 50 ml/kg for the second 10 kg of weight

  • give 20 ml/kg for every kg after this

  • use a maximum weight of 75 kg in the calculation.
    
    When calculating the total fluid requirement, subtract any initial bolus volumes from the total fluid deficit (unless the child or young person is in shock). [2020]

Use 0.9% sodium chloride without added glucose for both rehydration and maintenance fluid in children and young people with DKA, until the plasma glucose concentration is below 14 mmol/litre. [2020]

Be aware that some children and young people with DKA may develop hyperchloremic acidosis, but this resolves on its own over time and specific management is not needed. [2020]

Include 40 mmol/litre (or 20 mmol/500 ml) potassium chloride in all fluids (except the initial intravenous boluses) given to children and young people with DKA, unless they have anuria or their potassium level is above the normal range. Do not delay potassium replacement, because hypokalaemia can occur once the insulin infusion starts. [2020]

For children and young people with potassium levels above the normal range, only add 40 mmol/litre (or 20 mmol/500 ml) potassium chloride to their intravenous fluids if:

• their potassium is less than 5.5 mmol/litre or

• they have a history of passing urine. [2020]

For children and young people with DKA who have hypokalaemia at presentation, include potassium chloride in intravenous fluids before starting the insulin infusion. [2020]

Monitor sodium levels throughout DKA treatment and calculate the corrected sodium initially to identify if the child or young person has hyponatraemia. [2020]

When monitoring serum sodium levels in children and young people with DKA, be aware that:

• serum sodium should rise as DKA is treated as blood glucose falls

• falling serum sodium is a sign of possible cerebral oedema

• a rapid and ongoing rise in serum sodium concentration may also be a sign of cerebral oedema, caused by the loss of free water in the urine. [2020]

Do not give intravenous sodium bicarbonate to children and young people with DKA unless:

• they have compromised cardiac contractility, caused by life-threatening hyperkalaemia or severe acidosis and

• you have discussed with the paediatric intensivist. [2020]

Do not give children and young people with DKA additional intravenous fluid to replace urinary losses. [2015]

Start an intravenous insulin infusion 1 to 2 hours after beginning intravenous fluid therapy in children and young people with DKA. If a child or young person with DKA is using an insulin pump, disconnect the pump when starting intravenous insulin therapy. [2015]

When treating DKA with intravenous insulin in children and young people, use a soluble insulin infusion at a dosage between 0.05 units/kg/hour and 0.1 units/kg/hour. Do not give bolus doses of intravenous insulin. [2015]

In discussion with a diabetes specialist, think about continuing subcutaneous basal insulin in a child or young person who was using a basal insulin before DKA started. [2015]

When the plasma glucose concentration falls below 14 mmol/litre in children and young people with DKA, change fluids to 0.9% sodium chloride with 5% glucose and 40 mmol/litre (or 20 mmol/500 ml) potassium chloride. [2020]

If a child or young person's plasma glucose falls below 6 mmol/litre during DKA treatment:

• increase the glucose concentration of the intravenous fluid infusion and

• if they have persisting ketosis, continue to give insulin at a dosage of least 0.05 units/kg/hour. [2020]

If the blood beta‑hydroxybutyrate level is not falling within 6 to 8 hours in a child or young person with DKA, think about increasing the insulin dosage to 0.1 units/kg/hour or more. [2015]

Think about stopping intravenous fluid therapy for DKA in a child or young person if:

• ketosis is resolving and their blood pH has reached 7.3 and

• they are alert and

• they can take oral fluids without nausea or vomiting.
  
  Discuss with the responsible senior paediatrician before stopping intravenous fluid therapy and changing to oral fluids for DKA in a child or young person if they still have mild acidosis or ketosis. [2020]

Do not change from intravenous insulin to subcutaneous insulin in a child or young person with DKA until ketosis is resolving, they are alert, and they can take oral fluids without nausea or vomiting. [2015]

Start subcutaneous insulin in a child or young person with DKA at least 30 minutes before stopping intravenous insulin. [2015]

For a child or young person with DKA who is using an insulin pump, restart the pump at least 60 minutes before stopping intravenous insulin. Change the insulin cartridge and infusion set and insert the cannula into a new subcutaneous site. [2015]

Monitor and record the following at least hourly in children and young people with DKA:

• capillary blood glucose

• heart rate, blood pressure, temperature, respiratory rate (look for Kussmaul breathing)

• fluid balance, with fluid input and output charts

• level of consciousness (using the modified Glasgow Coma Scale). [2015]

Monitor and record the level of consciousness (using the modified Glasgow Coma Scale) and heart rate (to detect bradycardia) every 30 minutes in:

• children under 2 years with DKA

• children and young people with severe DKA (blood pH below 7.1).
  
  This is because these children and young people are at an increased risk of cerebral oedema. [2015]

Monitor children and young people having intravenous therapy for DKA using continuous electrocardiogram (ECG) to detect signs of hypokalaemia (including ST‑segment depression and prominent U‑waves). [2015]

Ensure that healthcare professionals performing the monitoring described in recommendations 1.4.46, 1.4.47 and 1.4.48 know what to look for and when to seek advice. [2015]

At 2 hours after starting treatment, and then at least every 4 hours, carry out and record the results of the following blood tests in children and young people with DKA:

• glucose (laboratory measurement)

• blood pH and pCO₂

• plasma sodium, potassium and urea

• beta‑hydroxybutyrate. [2015]

A doctor involved in the care of the child or young person with DKA should review them face‑to‑face at diagnosis and then at least every 4 hours, and more frequently if:

• they are aged under 2 years

• they have severe DKA (blood pH below 7.1)

• there are any other reasons for special concern. [2015]

At each face‑to‑face review of children and young people with DKA, assess the following:

• clinical status, including vital signs and neurological status

• results of blood investigations

• ECG trace

• cumulative fluid balance record. [2015]

Update the child and young person with DKA and their families or carers regularly about their progress. [2015]

After a child or young person with known diabetes has recovered from an episode of DKA, discuss what may have led to the episode with them and their families or carers. [2015]

Think about the possibility of non‑adherence to therapy in children and young people with established type 1 diabetes who present with DKA, especially if they have had multiple episodes of DKA. [2004, amended 2015]

Advise children and young people who have had DKA and their families or carers how to reduce the risk of future episodes. In particular, explain the importance of managing intercurrent illnesses. [2015]

Give young people with diabetes enough time to understand how transition from paediatric to adult services will work, because this improves clinic attendance. [2004, amended 2015]

Agree specific local protocols for transferring young people with diabetes from paediatric to adult services. [2004, amended 2015]

Base the decision on when a young person should transfer to the adult service on their physical development and emotional maturity, and on local circumstances. [2004, amended 2015]

Ensure that transition from the paediatric service occurs at a time of relative stability in the young person's health, and that it is coordinated with other life transitions. [2004, amended 2015]

Explain to young people with type 1 diabetes who are preparing for transition to adult services that some aspects of diabetes care will change. [2004, amended 2015]