1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

Blood glucose and plasma glucose

This guideline refers frequently to circulating glucose concentrations as 'blood glucose'. A lot of the evidence linking specific circulating glucose concentrations with particular outcomes uses 'plasma' rather than 'blood' glucose. In addition, patient‑held glucose meters and monitoring systems are all calibrated to plasma glucose equivalents. However, the term 'blood glucose monitoring' is in very common use, so in this guideline we use the term 'blood glucose', except when referring to specific concentration values.

1.1 Diagnosis

1.1.1 Be aware that the characteristics of type 1 diabetes in children and young people include:

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

  • polyuria

  • polydipsia

  • weight loss

  • excessive tiredness. [2004, amended 2015]

1.1.2 Refer children and young people with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care. [2004, amended 2015]

1.1.3 Confirm type 1 diabetes in children and young people using the plasma glucose criteria specified in the World Health Organization's 2006 report on the diagnosis and classification of diabetes mellitus. [2004, amended 2015]

1.1.4 When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there are strong indications of type 2 diabetes, monogenic or mitochondrial diabetes (see recommendations 1.1.5 and 1.1.6). [new 2015]

1.1.5 Think about the possibility of type 2 diabetes in children and young people with suspected diabetes who:

  • have a strong family history of type 2 diabetes

  • are obese at presentation

  • are of black or Asian family origin

  • have no insulin requirement, or have an insulin requirement of less than 0.5 units/kg body weight/day after the partial remission phase

  • show evidence of insulin resistance (for example, acanthosis nigricans). [2004, amended 2015]

1.1.6 Think about the possibility of types of diabetes other than types 1 or 2 (such as other insulin resistance syndromes, or monogenic or mitochondrial diabetes) in children and young people with suspected diabetes who have any of the following features:

  • diabetes in the first year of life

  • rarely or never develop ketone bodies in the blood (ketonaemia) during episodes of hyperglycaemia

  • associated features, such as optic atrophy, retinitis pigmentosa, deafness, or another systemic illness or syndrome. [2004, amended 2015]

1.1.7 Do not measure C‑peptide and/or diabetes‑specific autoantibody titres at initial presentation to distinguish type 1 diabetes from type 2 diabetes. [new 2015]

1.1.8 Consider measuring C‑peptide after initial presentation if there is difficulty distinguishing type 1 diabetes from other types of diabetes. Be aware that C‑peptide concentrations have better discriminative value the longer the interval between initial presentation and the test. [new 2015]

1.1.9 Perform genetic testing if atypical disease behaviour, clinical characteristics or family history suggest monogenic diabetes. [new 2015]

1.2 Type 1 diabetes

Education and information for children and young people with type 1 diabetes

1.2.1 Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis. Ensure that the programme includes the following core topics:

  • insulin therapy, including its aims, how it works, its mode of delivery and dosage adjustment

  • blood glucose monitoring, including targets for blood glucose control (blood glucose and HbA1c levels)

  • the effects of diet, physical activity and intercurrent illness on blood glucose control

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

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

1.2.2 Tailor the education programme to each child or young person with type 1 diabetes and their family members or carers (as appropriate), taking account of issues such as:

  • personal preferences

  • emotional wellbeing

  • age and maturity

  • cultural considerations

  • existing knowledge

  • current and future social circumstances

  • life goals. [new 2015]

1.2.3 Encourage young people with type 1 diabetes to attend clinic 4 times a year because regular contact is associated with optimal blood glucose control. [2004, amended 2015]

1.2.4 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that like others they are advised to have:

  • regular dental examinations (see the NICE guideline on dental recall)

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

1.2.5 Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to discuss any concerns and raise any questions they have with their diabetes team. [new 2015]

1.2.6 Give children and young people with type 1 diabetes and their family members or carers (as appropriate) information about local and/or national diabetes support groups and organisations, and the potential benefits of membership. Give this information after diagnosis and regularly afterwards. [2004, amended 2015]

1.2.7 Encourage children and young people with type 1 diabetes to wear or carry something that identifies them as having type 1 diabetes (for example, a bracelet). [2004]

1.2.8 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) how to find information about government disability benefits. [2004, amended 2015]

1.2.9 Take particular care when communicating with and providing information to children and young people with type 1 diabetes if they and/or their family members or carers (as appropriate) have, for example, physical and sensory disabilities, or difficulties speaking or reading English. [2004]

1.2.10 Children and young people with type 1 diabetes wishing to participate in sports that may have particular risks for people with diabetes should be offered comprehensive advice by their diabetes team. Additional information may be available from local and/or national support groups and organisations, including sports organisations. [2004, amended 2015]

1.2.11 Offer education for children and young people with type 1 diabetes and their family members or carers (as appropriate) about the practical issues related to long‑distance travel, such as when best to eat and inject insulin when travelling across time zones. [2004]

Smoking and substance misuse

1.2.12 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about general health problems associated with smoking and in particular the risks of developing vascular complications. [2004]

1.2.13 Encourage children and young people with type 1 diabetes not to start smoking. See also the NICE guidelines on preventing the uptake of smoking by children and young people and school-based interventions to prevent smoking. [2004, amended 2015]

1.2.14 Offer smoking cessation programmes to children and young people with type 1 diabetes who smoke. See also the NICE guidelines on brief interventions and referral for smoking cessation, smoking cessation services, harm reduction approaches to smoking, and smoking cessation in secondary care. [2004, amended 2015]

1.2.15 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about the general dangers of substance misuse and the possible effects on blood glucose control. [2004]

Immunisation

1.2.16 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends annual immunisation against influenza for children and young people with diabetes over the age of 6 months. [2004]

1.2.17 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends immunisation against pneumococcal infection for children and young people with diabetes who need insulin or oral hypoglycaemic medicines. [2004, amended 2015]

Insulin therapy for children and young people with type 1 diabetes

While the insulin regimen should be individualised for each patient, there are 3 basic types of insulin regimen.

Multiple daily injection basal–bolus insulin regimens: injections of short‑acting insulin or rapid‑acting insulin analogue before meals, together with 1 or more separate daily injections of intermediate‑acting insulin or long‑acting insulin analogue.

Continuous subcutaneous insulin infusion (insulin pump therapy): a programmable pump and insulin storage device that gives a regular or continuous amount of insulin (usually a rapid‑acting insulin analogue or short‑acting insulin) by a subcutaneous needle or cannula.

One, two or three insulin injections per day: these are usually injections of short‑acting insulin or rapid‑acting insulin analogue mixed with intermediate‑acting insulin.

1.2.18 Take into account the personal and family circumstances of the child or young person with type 1 diabetes and discuss their personal preferences with them and their family members or carers (as appropriate) when choosing an insulin regimen. [new 2015]

1.2.19 Offer children and young people with type 1 diabetes multiple daily injection basal–bolus insulin regimens from diagnosis. If a multiple daily injection regimen is not appropriate for a child or young person with type 1 diabetes, consider continuous subcutaneous insulin infusion (CSII or insulin pump) therapy as recommended in continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (NICE technology appraisal guidance 151). [new 2015]

1.2.20 Encourage children and young people with type 1 diabetes who are using multiple daily insulin injection regimens and their family members or carers (as appropriate) to adjust the insulin dose if appropriate after each blood glucose measurement. [2004, amended 2015]

1.2.21 Explain to children and young people with type 1 diabetes using multiple daily insulin injection regimens and their family members or carers (as appropriate) that injecting rapid‑acting insulin analogues before eating (rather than after eating) reduces blood glucose levels after meals and helps to optimise blood glucose control. [2004, amended 2015]

1.2.22 Provide all children and young people with type 1 diabetes who are starting continuous subcutaneous insulin infusion (CSII or insulin pump) therapy and their family members or carers (as appropriate) with specific training in its use. Provide ongoing support from a specialist team, particularly in the period immediately after starting continuous subcutaneous insulin infusion. Specialist teams should agree a common core of advice for continuous subcutaneous insulin infusion users. [2004, amended 2015]

1.2.23 Encourage children and young people with type 1 diabetes who are using twice‑daily injection regimens and their family members or carers (as appropriate) to adjust the insulin dose according to the general trend in pre‑meal, bedtime and occasional night‑time blood glucose. [2004, amended 2015]

1.2.24 Explain to children and young people with newly diagnosed type 1 diabetes and their family members or carers (as appropriate) that they may experience a partial remission phase (a 'honeymoon period') during which a low dosage of insulin (0.5 units/kg body weight/day) may be sufficient to maintain an HbA1c level of less than 48 mmol/mol (6.5%). [2004, amended 2015]

1.2.25 Offer children and young people with type 1 diabetes a choice of insulin delivery systems that takes account of their insulin requirements and personal preferences. [2004]

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

1.2.27 Provide children and young people with type 1 diabetes and their family members or carers (as appropriate) with suitable containers for collecting used needles and other sharps. Arrangements should be available for the suitable disposal of these containers. See also section 1.1.4 of the NICE guideline on infection control. [new 2015]

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

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

1.2.30 If a child or young person with type 1 diabetes does not have optimal blood glucose control (see recommendations 1.2.54 and 1.2.67):

  • offer appropriate additional support such as increased contact frequency with their diabetes team, and

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

Oral medicines for children and young people with type 1 diabetes

1.2.31 Metformin in combination with insulin is suitable for use only within research studies because the effectiveness of this combined treatment in improving blood glucose control is uncertain. [2004]

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

Dietary management for children and young people with type 1 diabetes

1.2.33 Support children and young people with type 1 diabetes and their family members or carers (as appropriate) to develop a good working knowledge of nutrition and how it affects their diabetes. [new 2015]

1.2.34 Explain regularly to children and young people with type 1 diabetes and their family members or carers (as appropriate) how healthy eating (including eating foods with a low glycaemic index, fruit and vegetables, and appropriate types and amounts of fats) can reduce their risk of cardiovascular disease, and support them to adjust their food choices accordingly. [new 2015]

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

1.2.36 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that children and young people with type 1 diabetes have the same basic nutritional requirements as other children and young people. Children and young people's food should provide sufficient energy and nutrients for optimal growth and development. [2004, amended 2015]

1.2.37 Offer level 3 carbohydrate‑counting[3] education from diagnosis to children and young people with type 1 diabetes who are using a multiple daily insulin injection regimen or continuous subcutaneous insulin infusion (CSII or insulin pump) therapy, and to their family members or carers (as appropriate), and repeat the offer at intervals thereafter. [new 2015]

1.2.38 Offer children and young people with type 1 diabetes who are changing their insulin regimen, and their family members or carers (as appropriate), dietary advice tailored to the new treatment. [new 2015]

1.2.39 Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) education about the practical problems associated with fasting and feasting. [2004, amended 2015]

1.2.40 Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to discuss the nutritional composition and timing of snacks with their diabetes team. [new 2015]

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

1.2.42 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that a low glycaemic index diet may help to improve blood glucose control and reduce the risk of hyperglycaemic episodes. [new 2015]

1.2.43 Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) advice and education to promote a low glycaemic index diet. [new 2015]

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

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

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

Exercise for children and young people with type 1 diabetes

1.2.47 Encourage all children and young people, including those with type 1 diabetes, to exercise on a regular basis because this reduces the risks of developing cardiovascular disease in the long term. [2004, amended 2015]

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

1.2.49 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about the effects of exercise on blood glucose levels and about strategies for avoiding hypo‑ or hyperglycaemia during or after physical activity. [2004, amended 2015]

1.2.50 Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to monitor blood glucose levels before and after exercise so that they can:

  • identify when changes in insulin or food intake are necessary

  • learn the blood glucose response to different exercise conditions

  • be aware of exercise‑induced hypoglycaemia

  • be aware that hypoglycaemia may occur several hours after prolonged exercise. [2004, amended 2015]

1.2.51 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that additional carbohydrate should be consumed as appropriate to avoid hypoglycaemia and that carbohydrate‑based foods should be readily available during and after exercise. [2004]

1.2.52 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that additional carbohydrate should be consumed if plasma glucose levels are less than 7 mmol/litre before exercise is undertaken. [2004, amended 2015]

1.2.53 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that changes in daily exercise patterns may require insulin dose and/or carbohydrate intake to be altered. [2004]

Blood glucose and HbA1c targets and monitoring for children and young people with type 1 diabetes

Blood glucose targets

1.2.54 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the optimal target ranges for short‑term plasma glucose control are:

  • fasting plasma glucose level of 4–7 mmol/litre on waking

  • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day

  • a plasma glucose level of 5–9 mmol/litre after meals

  • a plasma glucose level of at least 5 mmol/litre when driving[4] . [new 2015]

1.2.55 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that achieving and maintaining blood glucose levels towards the lower end of the target optimal ranges will help them to achieve the lowest attainable HbA1c. [new 2015]

1.2.56 Ensure that children and young people with type 1 diabetes do not experience problematic hypoglycaemia or undue emotional distress when achieving, or attempting to achieve, blood glucose and HbA1c targets. [new 2015]

1.2.57 Be aware that there may be conflict between children and young people with type 1 diabetes and their family members or carers about blood glucose and HbA1c targets, and that an agreed compromise may be needed. [new 2015]

Blood glucose monitoring

1.2.58 Advise children and young people with type 1 diabetes and their family members or carers (as appropriate) to routinely perform at least 5 capillary blood glucose tests per day. [new 2015]

1.2.59 Advise children and young people with type 1 diabetes and their family members or carers (as appropriate) that more frequent testing is often needed (for example with physical activity and during intercurrent illness), and ensure they have enough test strips for this. [new 2015]

1.2.60 Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) a choice of equipment for monitoring capillary blood glucose, so they can optimise their blood glucose control in response to adjustment of insulin, diet and exercise. [2004]

1.2.61 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that blood glucose levels should be interpreted in the context of the 'whole child', which includes the social, emotional and physical environment. [2004]

1.2.62 Offer ongoing real‑time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have:

  • frequent severe hypoglycaemia or

  • impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety) or

  • inability to recognise, or communicate about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities). [new 2015]

1.2.63 Consider ongoing real‑time continuous glucose monitoring for:

  • neonates, infants and pre‑school children

  • children and young people who undertake high levels of physical activity (for example, sport at a regional, national or international level)

  • children and young people who have comorbidities (for example anorexia nervosa) or who are receiving treatments (for example corticosteroids) that can make blood glucose control difficult. [new 2015]

1.2.64 Consider intermittent (real‑time or retrospective) continuous glucose monitoring to help improve blood glucose control in children and young people who continue to have hyperglycaemia despite insulin adjustment and additional support. [new 2015]

HbA1c targets and monitoring

1.2.65 Use methods to measure HbA1c that have been calibrated according to International Federation of Clinical Chemistry (IFCC) standardisation. [new 2015]

1.2.66 Explain the benefits of safely achieving and maintaining the lowest attainable HbA1c to children and young people with type 1 diabetes and their family members or carers (as appropriate). [new 2015]

1.2.67 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long‑term complications. [new 2015]

1.2.68 Explain to children and young people with type 1 diabetes who have an HbA1c level above the ideal target of 48 mmol/mol (6.5%) and their family members or carers (as appropriate) that any reduction in HbA1c level reduces the risk of long‑term complications. [new 2015]

1.2.69 Agree an individualised lowest achievable HbA1c target with each child or young person with type 1 diabetes and their family members or carers (as appropriate), taking into account factors such as daily activities, individual life goals, complications, comorbidities and the risk of hypoglycaemia. [new 2015]

1.2.70 Support children and young people with type 1 diabetes and their family members or carers (as appropriate) to safely achieve and maintain their individual agreed HbA1c target level. [new 2015]

1.2.71 Offer children and young people with type 1 diabetes measurement of their HbA1c level 4 times a year (more frequent testing may be appropriate if there is concern about suboptimal blood glucose control). [2004, amended 2015]

1.2.72 Diabetes services should document the proportion of children and young people with type 1 diabetes in a service who achieve an HbA1c level of 53 mmol/mol (7%) or lower. [new 2015]

Hyperglycaemia, blood ketone monitoring and intercurrent illness in children and young people with type 1 diabetes

1.2.73 Provide each child and young person with type 1 diabetes and their family members or carers (as appropriate) with clear 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 seek further advice or help.

    Revisit the advice with the child or young person and their family members or carers (as appropriate) at least annually. [new 2015]

1.2.74 Offer children and young people with type 1 diabetes blood ketone testing strips and a meter, and advise them and their family members or carers (as appropriate) to test for ketonaemia if they are ill or have hyperglycaemia. [new 2015]

1.2.75 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that it is important to ensure that blood ketone testing strips are not used after the specified ('use‑by') date. [new 2015]

Hypoglycaemia in children and young people with type 1 diabetes

1.2.76 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about strategies for avoiding and managing hypoglycaemia. [2004]

1.2.77 Offer education for children and young people with type 1 diabetes, their family members, carers, and schoolteachers about recognising and managing hypoglycaemia. [2004]

1.2.78 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that they should always have access to an immediate source of fast‑acting glucose and blood glucose monitoring equipment for immediate confirmation and safe management of hypoglycaemia. [2004, amended 2015]

1.2.79 Family members or carers and, where appropriate, school nurses and other carers should be trained and equipped to give intramuscular glucagon for severe hypoglycaemia in an emergency. [2004, amended 2015]

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

  • Give fast‑acting glucose (for example, 10–20 g) by mouth (liquid carbohydrate may be taken more easily 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 5–15 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

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

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

1.2.82 Treat severe hypoglycaemia in children and young people with type 1 diabetes who are not in hospital or who do not have rapid intravenous access available as follows.

  • 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 as this could be dangerous.

  • If using intramuscular glucagon:

    • give children and young people over 8 years old (or who weigh 25 kg or more) 1 mg glucagon.

    • give children under 8 years old (or who weigh less than 25 kg) 500 micrograms of glucagon.

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

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

  • Recheck the 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]

1.2.83 Explain to young people with type 1 diabetes the effects of alcohol consumption on blood glucose control, and in particular that there is an increased risk of hypoglycaemia including hypoglycaemia while sleeping. [2004, amended 2015]

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

  • eat food containing carbohydrate before and after drinking

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

1.2.85 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that when alcohol causes or contributes to the development of hypoglycaemia, glucagon may be ineffective in treating the hypoglycaemia and intravenous glucose will be required. [2004]

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

Difficulties with maintaining optimal blood glucose control in children and young people with type 1 diabetes

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

1.2.88 Be aware that adolescence can be a period of worsening blood glucose control in young people with type 1 diabetes, which may in part be due to non‑adherence to therapy. [2004]

1.2.89 Raise the issue of non‑adherence to therapy with children and young people with type 1 diabetes and their family members or carers (as appropriate) in a sensitive manner. [2004]

1.2.90 Be aware of the possible negative psychological impact of setting targets that may be difficult for some children and young people with type 1 diabetes to achieve and maintain. [new 2015]

Surgery for children and young people with type 1 diabetes

1.2.91 Offer surgery to children and young people with type 1 diabetes only in centres that have dedicated paediatric facilities for caring for children and young people with diabetes. [2004]

1.2.92 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]

1.2.93 Ensure that there is careful liaison between surgical, anaesthetic and diabetes teams before children and young people with type 1 diabetes are admitted to hospital for elective surgery and as soon as possible after admission for emergency surgery. [2004, amended 2015]

Psychological and social issues in children and young people with type 1 diabetes

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

1.2.95 Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age‑dependent needs. [2004]

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

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

1.2.98 Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes 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]

1.2.99 For the treatment of depression and antisocial behaviour and conduct disorders in children and young people with type 1 diabetes see the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people. [new 2015]

1.2.100 Diabetes teams should have appropriate access to mental health professionals to support them in psychological assessment and the delivery of psychosocial support. [2004]

1.2.101 Offer children and young people with type 1 diabetes who have behavioural or conduct disorders, and their family members or carers (as appropriate), access to appropriate mental health professionals. [2004]

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

1.2.103 Consider a programme of behavioural intervention therapy or behavioural techniques for children and young people with type 1 diabetes in whom there are concerns about psychological wellbeing in order to improve:

  • 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 control in children and young people with high HbA1c levels (HbA1c above 69 mmol/mol [8.5%]) – for example, multisystemic therapy. [new 2015]

1.2.104 Offer screening for anxiety and depression to children and young people with type 1 diabetes who have persistently suboptimal blood glucose control. [2004]

1.2.105 Diabetes teams should be aware that children and young people with type 1 diabetes may develop anxiety and/or depression, particularly when difficulties in self‑management arise in young people and children who have had type 1 diabetes for a long time. [2004]

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

1.2.107 Diabetes teams should be aware that children and young people with type 1 diabetes, in particular young women, have an increased risk of eating disorders. See also the NICE guideline on eating disorders. [2004, amended 2015]

1.2.108 Be aware that children and young people with type 1 diabetes who have eating disorders may have associated difficulties with:

  • suboptimal blood glucose control (both hyperglycaemia and hypoglycaemia)

  • symptoms of gastroparesis. [2004, amended 2015]

1.2.109 For children and young people with type 1 diabetes in whom eating disorders are identified, offer joint management involving their diabetes team and child mental health professionals. [2004, amended 2015]

Monitoring for complications and associated conditions of type 1 diabetes

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

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

  • diabetic retinopathy annually from 12 years

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

  • hypertension annually from 12 years. [new 2015]

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

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

1.2.113 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]

1.2.114 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) the importance of annual monitoring from 12 years for diabetic retinopathy and diabetic kidney disease. [new 2015]

Diabetic retinopathy in children and young people with type 1 diabetes

1.2.115 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that:

  • monitoring for diabetic retinopathy begins at 12 years (see recommendation 1.2.110) because diabetic retinopathy that needs treatment is extremely rare in children and young people under 12

  • background retinopathy is often found through monitoring, and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy

  • annual monitoring from 12 years is important because, if significant diabetic retinopathy is found, early treatment will improve the outcome. [new 2015]

Diabetic kidney disease in children and young people with type 1 diabetes

1.2.116 Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that:

  • monitoring for moderately increased albuminuria (ACR 3–30 mg/mmol; 'microalbuminuria') to detect diabetic kidney disease begins at 12 years (see recommendation 1.2.110) because diabetic kidney disease in children and young people under 12 is extremely rare

  • using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria is important, as this reduces the risk of false positive results

  • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease

  • annual monitoring from 12 years is important because, if diabetic kidney disease is found, early treatment will improve the outcome. [new 2015]

1.2.117 Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio. If the first urine sample of the day is not available, use a random sample, but be aware that this is associated with an increased risk of false positive results. [new 2015]

1.2.118 If the initial albumin:creatinine ratio is above 3 mg/mmol but below 30 mg/mmol, confirm the result by repeating the test on 2 further occasions using first urine samples of the day ('early morning urine') before starting further investigation and therapy. [new 2015]

1.2.119 Investigate further if the initial albumin:creatinine ratio is 30 mg/mmol or more (proteinuria). [new 2015]

1.3 Type 2 diabetes

Education and information for children and young people with type 2 diabetes

1.3.1 Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis. Ensure that the programme includes the following core topics:

  • HbA1c monitoring and targets

  • the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control

  • the aims of metformin therapy and possible adverse effects

  • the complications of type 2 diabetes and how to prevent them. [new 2015]

1.3.2 Tailor the education programme to each child or young person with type 2 diabetes and their family members or carers (as appropriate), taking account of issues such as:

  • personal preferences

  • emotional wellbeing

  • age and maturity

  • cultural considerations

  • existing knowledge

  • current and future social circumstances

  • life goals. [new 2015]

1.3.3 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that like others they are advised to have:

  • regular dental examinations (see the NICE guideline on dental recall)

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

1.3.4 Encourage children and young people with type 2 diabetes and their family members or carers (as appropriate) to discuss any concerns and raise any questions they have with their diabetes team. [new 2015]

1.3.5 Give children and young people with type 2 diabetes and their family members or carers (as appropriate) information about local and/or national diabetes support groups and organisations, and the potential benefits of membership. Give this information after diagnosis and regularly afterwards. [2004, amended 2015]

1.3.6 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) how to find information about possible government disability benefits. [2004, amended 2015]

1.3.7 Take particular care when communicating with and providing information to children and young people with type 2 diabetes if they and/or their family members or carers (as appropriate) have, for example, physical and sensory disabilities, or difficulties speaking or reading English. [2004, amended 2015]

Smoking and substance misuse

1.3.8 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) about general health problems associated with smoking and in particular the risks of developing vascular complications. [2004, amended 2015]

1.3.9 Encourage children and young people with type 2 diabetes not to start smoking. See also the NICE guidelines on preventing the uptake of smoking by children and young people and school-based interventions to prevent smoking. [2004, amended 2015]

1.3.10 Offer smoking cessation programmes to children and young people with type 2 diabetes who smoke. See also the NICE guidelines on brief interventions and referral for smoking cessation, smoking cessation services, harm reduction approaches to smoking, and smoking cessation in secondary care. [2004, amended 2015]

1.3.11 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) about the general dangers of substance misuse and the possible effects on blood glucose control. [2004, amended 2015]

Immunisation

1.3.12 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends annual immunisation against influenza for children and young people with diabetes. [2004, amended 2015]

1.3.13 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends immunisation against pneumococcal infection for children and young people with diabetes who need insulin or oral hypoglycaemic medicines. [2004, amended 2015]

Dietary management for children and young people with type 2 diabetes

1.3.14 At each contact with a child or young person with type 2 diabetes who is overweight or obese, advise them and their family members or carers (as appropriate) about the benefits of physical activity and weight loss, and provide support towards achieving this. See also the NICE guidelines on maintaining a healthy weight and managing obesity. [new 2015]

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

1.3.16 At each contact with a child or young person with type 2 diabetes, explain to them and their family members or carers (as appropriate) how healthy eating can help to:

  • reduce hyperglycaemia

  • reduce cardiovascular risk

  • promote weight loss (see recommendation 1.3.14). [new 2015]

1.3.17 Provide dietary advice to children and young people with type 2 diabetes and their family members or carers (as appropriate) in a sensitive manner, taking into account the difficulties that many people encounter with weight reduction, and emphasise the additional advantages of healthy eating for blood glucose control and avoiding complications. [new 2015]

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

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

1.3.20 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 BMI.

    Check for normal growth and/or significant changes in weight because these may reflect changes in blood glucose control. [2004, amended 2015]

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

Metformin

1.3.22 Offer standard‑release metformin from diagnosis to children and young people with type 2 diabetes. [new 2015]

HbA1c targets and monitoring for children and young people with type 2 diabetes

1.3.23 Use methods to measure HbA1c that have been calibrated according to International Federation of Clinical Chemistry (IFCC) standardisation. [new 2015]

1.3.24 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long‑term complications. [new 2015]

1.3.25 Explain to children and young people with type 2 diabetes who have an HbA1c level above the ideal target of 48 mmol/mol (6.5%) and their family members or carers (as appropriate) that any reduction in HbA1c level reduces the risk of long‑term complications. [new 2015]

1.3.26 Explain the benefits of safely achieving and maintaining the lowest attainable HbA1c to children and young people with type 2 diabetes and their family members or carers (as appropriate). [new 2015]

1.3.27 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. [new 2015]

1.3.28 Measure HbA1c levels every 3 months in children and young people with type 2 diabetes. [new 2015]

1.3.29 Support children and young people with type 2 diabetes and their family members or carers (as appropriate) to safely achieve and maintain their individual agreed HbA1c target level. [new 2015]

1.3.30 Diabetes services should document the proportion of children and young people with type 2 diabetes in a service who achieve an HbA1c level of 53 mmol/mol (7%) or lower. [new 2015]

Surgery for children and young people with type 2 diabetes

1.3.31 Offer surgery to children and young people with type 2 diabetes only in centres that have dedicated paediatric facilities for caring for children and young people with diabetes. [2004, amended 2015]

1.3.32 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]

Psychological and social issues in children and young people with type 2 diabetes

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

1.3.34 Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age‑dependent needs. [2004, amended 2015]

1.3.35 Be aware that children and young people with type 2 diabetes have an increased risk of psychological conditions (for example anxiety, depression, behavioural and conduct disorders) and complex social factors (for example family conflict) that can affect their wellbeing and diabetes management. See also the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people. [new 2015]

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

1.3.37 Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes 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]

1.3.38 For the treatment of depression and antisocial behaviour and conduct disorders in children and young people with type 2 diabetes see the NICE guidelines on depression in children and young people and antisocial behaviour and conduct disorders in children and young people. [new 2015]

1.3.39 Diabetes teams should have appropriate access to mental health professionals to support them in psychological assessment and the delivery of psychosocial support. [2004, amended 2015]

1.3.40 Offer screening for anxiety and depression to children and young people with type 2 diabetes who have persistently suboptimal blood glucose control. [2004, amended 2015]

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

1.3.42 Ensure that children and young people with type 2 diabetes and their family members or carers (as appropriate) have timely and ongoing access to mental health services when needed. [new 2015]

Monitoring for complications and associated conditions of type 2 diabetes

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

  • hypertension starting at diagnosis

  • dyslipidaemia starting at diagnosis

  • diabetic retinopathy from 12 years

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

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

1.3.45 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) the importance of annual monitoring for hypertension, dyslipidaemia, diabetic retinopathy and diabetic kidney disease. [new 2015]

Hypertension in children and young people with type 2 diabetes

1.3.46 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that monitoring (see recommendation 1.3.43) is important because if hypertension is found, early treatment will reduce the risk of complications. [new 2015]

1.3.47 Use a cuff large enough for the child or young person with type 2 diabetes when measuring blood pressure. [new 2015]

1.3.48 If repeated resting measurements are greater than the 95th percentile for age and sex, confirm hypertension using 24‑hour ambulatory blood pressure monitoring before starting antihypertensive therapy. [new 2015]

Dyslipidaemia in children and young people with type 2 diabetes

1.3.49 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that monitoring (see recommendation 1.3.43) is important because if dyslipidaemia is found, early treatment will reduce the risk of complications. [new 2015]

1.3.50 When monitoring for dyslipidaemia in children and young people with type 2 diabetes, measure total cholesterol, high‑density lipoprotein (HDL) cholesterol, non‑HDL cholesterol and triglyceride concentrations. [new 2015]

1.3.51 Confirm dyslipidaemia using a repeat sample (fasting or non‑fasting) before deciding on further management strategies. [new 2015]

Diabetic retinopathy in children and young people with type 2 diabetes

1.3.52 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:

  • background retinopathy is often found through monitoring (see recommendation 1.3.43), and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy

  • annual monitoring from 12 years is important because, if significant diabetic retinopathy is found, early treatment will improve the outcome. [new 2015]

1.3.53 Consider referring children and young people with type 2 diabetes who are younger than 12 years to an ophthalmologist for retinal examination if blood glucose control is suboptimal. [new 2015]

Diabetic kidney disease in children and young people with type 2 diabetes

1.3.54 Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:

  • using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria (ACR 3–30 mg/mmol; 'microalbuminuria') is important, as this reduces the risk of false positive results

  • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease

  • annual monitoring (see recommendation 1.3.43) is important because, if diabetic kidney disease is found, early treatment will improve the outcome. [new 2015]

1.3.55 Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio. If the first urine sample of the day is not available, use a random sample, but be aware that this is associated with an increased risk of false positive results. [new 2015]

1.3.56 If the initial albumin:creatinine ratio is above 3 mg/mmol but below 30 mg/mmol, confirm the result by repeating the test on 2 further occasions using first urine samples of the day ('early morning urine') before starting further investigation and therapy. [new 2015]

1.3.57 Investigate further if the initial albumin:creatinine ratio is 30 mg/mmol or more (proteinuria). [new 2015]

1.4 Diabetic ketoacidosis

Recognition, referral and diagnosis

1.4.1 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 the following:

  • nausea or vomiting

  • abdominal pain

  • hyperventilation

  • dehydration

  • reduced level of consciousness. [new 2015]

1.4.2 If the plasma glucose level is above 11 mmol/litre in a child or young person without known diabetes, and they have symptoms that suggest diabetic ketoacidosis (DKA) (see recommendation 1.4.1), suspect DKA and immediately send them to a hospital with acute paediatric facilities. [new 2015]

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

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

  • nausea or vomiting

  • abdominal pain

  • hyperventilation

  • dehydration

  • reduced level of consciousness. [new 2015]

1.4.5 When DKA is suspected in a child or young person with known diabetes (see recommendation 1.4.4) measure the blood ketones (beta‑hydroxybutyrate), using a near‑patient method if available. If the level is elevated, immediately send them to a hospital with acute paediatric facilities. [new 2015]

1.4.6 When DKA is suspected in a child or young person with known diabetes (see recommendation 1.4.4) and it is not possible to measure the blood ketones (beta‑hydroxybutyrate) using a near‑patient method, immediately send them to a hospital with acute paediatric facilities. [new 2015]

1.4.7 If DKA is suspected or confirmed in a child or young person, explain to them and to their family members or carers (as appropriate) that DKA is a serious matter that needs urgent hospital assessment. [new 2015]

1.4.8 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. [new 2015]

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

  • acidosis (indicated by blood pH below 7.3 or plasma bicarbonate below 18 mmol/litre) and

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

1.4.10 Diagnose severe DKA in children and young people with DKA who have a blood pH below 7.1. [new 2015]

Initial management of diabetic ketoacidosis

1.4.11 Inform the responsible senior clinician once a diagnosis of DKA in a child or young person is made. [new 2015]

1.4.12 Explain to the child or young person with DKA and to their family members or carers (as appropriate) about their condition and the care that they may need. [new 2015]

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

  • level of consciousness

  • vital signs (heart rate, blood pressure, temperature, respiratory rate [look for Kussmaul breathing])

  • history of nausea or vomiting

  • clinical evidence of dehydration

  • body weight. [new 2015]

1.4.14 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 [new 2015]

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

1.4.16 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. [new 2015]

1.4.17 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 (indicated by a blood pH below 7.1). [new 2015]

1.4.18 Think about inserting a nasogastric tube if a child or young person with DKA has a reduced level of consciousness and is vomiting, to reduce the risk of aspiration. [new 2015]

1.4.19 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. [new 2015]

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

1.4.21 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. [new 2015]

Fluid and insulin therapy

1.4.22 Treat DKA with oral fluids and subcutaneous insulin only if the child or young person is alert, not nauseated or vomiting, and not clinically dehydrated. [new 2015]

1.4.23 If DKA is treated with oral fluids and subcutaneous insulin, ensure that the child or young person is recovering by monitoring for resolution of ketonaemia and acidosis. [new 2015]

1.4.24 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. [new 2015]

1.4.25 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. [new 2015]

1.4.26 Do not give an intravenous fluid bolus to children and young people with mild or moderate DKA (indicated by a blood pH of 7.1 or above). [new 2015]

1.4.27 Do not routinely give an intravenous fluid bolus to a child or young person with severe DKA (indicated by a blood pH below 7.1). [new 2015]

1.4.28 Do not give more than one intravenous fluid bolus of 10 ml/kg 0.9% sodium chloride to a child or young person with severe DKA (indicated by a blood pH below 7.1) without discussion with the responsible senior paediatrician. [new 2015]

1.4.29 In children and young people with DKA, calculate their total fluid requirement for the first 48 hours by adding the estimated fluid deficit (see recommendation 1.4.30) to the fluid maintenance requirement (see recommendation 1.4.31). [new 2015]

1.4.30 When calculating the fluid requirement for children and young people with DKA, assume:

  • a 5% fluid deficit in mild to moderate DKA (indicated by a blood pH of 7.1 or above)

  • a 10% fluid deficit in severe DKA (indicated by a blood pH below 7.1). [new 2015]

1.4.31 Calculate the maintenance fluid requirement for children and young people with DKA using the following 'reduced volume' rules:

  • if they weigh less than 10 kg, give 2 ml/kg/hour

  • if they weigh between 10 and 40 kg, give 1 ml/kg/hour

  • if they weigh more than 40 kg, give a fixed volume of 40 ml/hour.

    These are lower than standard fluid maintenance volumes because large fluid volumes are associated with an increased risk of cerebral oedema. [new 2015]

1.4.32 Aim to replace the fluid deficit evenly over the first 48 hours in children and young people with DKA, because faster rehydration is associated with an increased risk of cerebral oedema. [new 2015]

1.4.33 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. [new 2015]

1.4.34 Ensure that all fluids (except any initial bolus) administered to children and young people with DKA contain 40 mmol/litre potassium chloride, unless they have renal failure. [new 2015]

1.4.35 If more than 20 ml/kg of fluid has been given by intravenous bolus to a child or young person with DKA, subtract any additional bolus volumes from the total fluid calculation for the 48‑hour period. [new 2015]

1.4.36 Do not give intravenous sodium bicarbonate to children and young people with DKA. [new 2015]

1.4.37 Think about inserting a urinary catheter if it is not possible to accurately measure urine output for a child or young person with DKA. [new 2015]

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

1.4.39 Start an intravenous insulin infusion 1–2 hours after beginning intravenous fluid therapy in children and young people with DKA. [new 2015]

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

1.4.41 If a child or young person with DKA is using insulin pump therapy, disconnect the pump when starting intravenous insulin therapy. [new 2015]

1.4.42 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 the onset of DKA. [new 2015]

1.4.43 Change fluids to 0.9% sodium chloride with 5% glucose and 40 mmol/litre potassium chloride once the plasma glucose concentration falls below 14 mmol/litre in children and young people with DKA. [new 2015]

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

  • increase the glucose concentration of the intravenous fluid infusion, and

  • if there is persisting ketosis, continue to give insulin at a dosage of least 0.05 units/kg/hour. [new 2015]

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

1.4.46 Think about stopping intravenous fluid therapy for DKA in a child or young person if ketosis is resolving, they are alert, and they can take oral fluids without nausea or vomiting. [new 2015]

1.4.47 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. [new 2015]

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

1.4.49 For a child or young person with DKA who is using insulin pump therapy, 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. [new 2015]

Monitoring during therapy

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

  • capillary blood glucose

  • vital signs (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). [new 2015]

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

  • children under 2 years with DKA

  • children and young people with severe DKA (indicated by a blood pH below 7.1).

    This is because these children and young people are at increased risk of cerebral oedema. [new 2015]

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

1.4.53 Ensure that healthcare professionals performing the monitoring described in recommendations 1.4.50, 1.4.51 and 1.4.52 know what to look for and when to seek advice. [new 2015]

1.4.54 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. [new 2015]

1.4.55 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 (indicated by a blood pH below 7.1)

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

1.4.56 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. [new 2015]

1.4.57 Update the child and young person with DKA and their family members or carers (as appropriate) regularly about their progress. [new 2015]

Complications of diabetic ketoacidosis

Cerebral oedema

1.4.58 Immediately assess children and young people with DKA for suspected cerebral oedema if they have any of these early manifestations:

  • headache

  • agitation or irritability

  • unexpected fall in heart rate

  • increased blood pressure. [new 2015]

1.4.59 If cerebral oedema is suspected in a child or young person with DKA, treat immediately with 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). [new 2015]

1.4.60 Immediately treat for 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) if a child or young person with DKA develops any of these signs:

  • deterioration in level of consciousness

  • abnormalities of breathing pattern, for example respiratory pauses

  • oculomotor palsies

  • pupillary inequality or dilatation. [new 2015]

1.4.61 After starting treatment for cerebral oedema with mannitol or hypertonic sodium chloride in a child or young person with DKA, immediately seek specialist advice on further management, including which care setting would be best. [new 2015]

Hypokalaemia

1.4.62 If a child or young person with DKA develops hypokalaemia (potassium below 3 mmol/litre):

  • think about temporarily suspending the insulin infusion

  • discuss hypokalaemia management urgently with a paediatric critical care specialist, because a central venous catheter is needed for intravenous administration of potassium solutions above 40 mmol/litre. [new 2015]

Venous thromboembolic disease

1.4.63 Be aware of the increased risk of venous thromboembolism in children and young people with DKA, especially those with central venous catheters. [new 2015]

Avoiding future episodes of diabetic ketoacidosis

1.4.64 After a child or young person with known diabetes has recovered from an episode of DKA, discuss with them and their family members or carers (if appropriate) the factors that may have led to the episode. [new 2015]

1.4.65 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 the DKA is recurrent. [2004, amended 2015]

1.4.66 Advise children and young people who have had an episode of DKA and their family members or carers (if appropriate) how to reduce the risk of future episodes. In particular, advise them of the importance of managing intercurrent illnesses. [new 2015]

1.5 Service provision

1.5.1 Offer children and young people with diabetes an ongoing integrated package of care provided by a multidisciplinary paediatric diabetes team. To optimise the effectiveness of care and reduce the risk of complications, the diabetes team should include members with appropriate training in clinical, educational, dietetic, lifestyle, mental health and foot care aspects of diabetes for children and young people. [2004, amended 2015]

1.5.2 Offer children and young people with diabetes and their family members or carers (as appropriate) 24‑hour access to advice from their diabetes team. [2004, amended 2015]

1.5.3 Involve children and young people with diabetes and their family members or carers (as appropriate) in making decisions about the package of care provided by their diabetes team. [2004, amended 2015]

1.5.4 At diagnosis, offer children and young people with diabetes home‑based or inpatient management according to clinical need, family circumstances and wishes. Explain that home‑based care with support from the local paediatric diabetes team (including 24‑hour telephone access) is safe and as effective as inpatient initial management. [2004, amended 2015]

1.5.5 Offer initial inpatient management to children with diabetes who are aged under 2 years. [2004, amended 2015]

1.5.6 Think about initial inpatient management for children and young people with diabetes if there are social or emotional factors that would make home‑based management inappropriate, or if they live a long distance from the hospital. [2004, amended 2015]

1.5.7 Diabetes teams should liaise regularly with school staff supervising children and young people with type 1 diabetes to provide appropriate diabetes education and practical information. [2004, amended 2015]

1.5.8 Record the details of children and young people with diabetes on a population‑based, practice‑based or clinic‑based diabetes register. [2004, amended 2015]

Transition from paediatric to adult care

1.5.9 Allow sufficient time for young people with diabetes to familiarise themselves with the practicalities of the transition from paediatric to adult services because this improves clinic attendance. [2004, amended 2015]

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

1.5.11 Base the decision about the age of transfer to the adult service on the young person's physical development and emotional maturity, and local circumstances. [2004, amended 2015]

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

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



[3] Level 3 carbohydrate counting is defined as carbohydrate counting with adjustment of insulin dosage according to an insulin:carbohydrate ratio.

[4] For further details about driving, see the DVLA guidance for people with insulin-treated diabetes.

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