- 1 Peer‑led education programmes for young people with type 1 diabetes
- 2 Optimal upper limit and timing for blood glucose measurements after meals for children and young people with type 1 diabetes
- 3 Metformin preparations for children and young people with type 2 diabetes
- 4 Dietary advice based on glycaemic index for children and young people with type 1 diabetes from diagnosis
- 5 Optimal dosage of intravenous insulin for managing diabetic ketoacidosis in children and young people
- 6 Effective resuscitation fluid for managing DKA
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.
What is the effectiveness of education programmes in which young people with type 1 diabetes provide training for their peers?
Training delivered by peers is effective both in healthcare and in other settings. This research should evaluate the engagement of the child or young person with type 1 diabetes and their family members or carers (as appropriate), and outcomes for the child or young person. Outcomes could include their success in achieving their target HbA1c level, engagement with diabetes care and management (for example, attendance at clinic), satisfaction with the education programme, and quality of life. The impact on the young person delivering the training should also be evaluated (this could cover the impact on their diabetes care and the psychosocial impact of providing training for their peers). The research should be conducted using quantitative, qualitative and mixed methods.
2 Optimal upper limit and timing for blood glucose measurements after meals for children and young people with type 1 diabetes
What is the optimal upper limit and timing for blood glucose measurements after meals for children and young people with type 1 diabetes to reach an HbA1c level of 48 mmol/mol (6.5%) without unacceptable hypoglycaemia?
Setting an upper limit for plasma glucose measurements 1–2 hours after meals of less than 8 mmol/litre (rather than the 9 mmol/litre recommended in this guideline) could potentially lead to an improvement in blood glucose management without an unacceptable risk of hypoglycaemia. The evidence reviewed for the guideline did not allow a precise evaluation of the upper limit for the target range, or the timing of blood glucose testing relative to meals. Future research should investigate the HbA1c levels of children and young people with type 1 diabetes who aim for blood glucose measurements after meals slightly lower (to ensure their safety) than 9 mmol/litre, to help decide whether lowering the upper limit is effective in improving long‑term blood glucose management. Outcomes include the child or young person's satisfaction with treatment, their HbA1c levels, rates of hypoglycaemia, the views of their family members or carers (as appropriate), and quality of life.
What is the long‑term comparative clinical and cost effectiveness of different metformin preparations for treating type 2 diabetes in children and young people?
There is high‑quality evidence for the clinical and cost effectiveness of metformin as a treatment for type 2 diabetes from diagnosis in children and young people. However, all of the relevant evidence relates to administration in tablet form and using a standard dosage, despite alternative oral preparations (including solutions and extended‑release tablets) being available and having potential advantages to the standard preparation. Gastrointestinal disorders (for example, nausea, vomiting, diarrhoea, abdominal pain and loss of appetite) are very common with metformin, especially at the start of treatment, and may be reduced or avoided with alternative preparations. Extended‑release tablets and oral solutions may also be easier to swallow, as standard formulation metformin consists of large tablets. Further research would preferably consist of randomised controlled trials. Outcomes should include blood glucose management (preferably using measurement of HbA1c levels) and the child or young person's satisfaction with and adherence to treatment.
4 Dietary advice based on glycaemic index for children and young people with type 1 diabetes from diagnosis
What is the impact of educating children and young people with type 1 diabetes and their family members or carers (as appropriate) about their glycaemic index from diagnosis?
Very little evidence on the effectiveness of dietary advice based on glycaemic index was identified for inclusion in the guideline review, and the evidence that was identified related mostly to twice‑daily insulin regimens. Research is needed to evaluate the effectiveness of teaching children and young people with type 1 diabetes and their family members or carers (as appropriate) about glycaemic index in the context of modern, intensive insulin treatment regimens (insulin pump therapy or multiple daily injections). Important outcomes include success in achieving the target HbA1c level, blood glucose levels after meals, frequency of hypoglycaemia, quality of life, food choices, and the frequency and timing of insulin administration to lower blood glucose levels after meals.
5 Optimal dosage of intravenous insulin for managing diabetic ketoacidosis in children and young people
What is the optimal dosage of intravenous insulin for managing diabetic ketoacidosis (DKA) in children and young people?
The evidence reviewed for the guideline did not allow evaluation of the comparative effectiveness and safety of specific dosages of intravenous insulin, such as 0.025, 0.05 and 0.1 units/kg/hour. The only relevant studies conducted to date have been small retrospective cohort studies with fewer than 100 participants. A large, multi‑centre randomised controlled trial is needed to undertake a comparative study of different dosages. This is because DKA is relatively uncommon and cerebral oedema (a potential adverse consequence of DKA) is rare, and there is a concern that larger dosages are associated with an increased risk of cerebral oedema. Important outcomes include rate of DKA resolution, incidence of hypoglycaemia and incidence of cerebral oedema.
In children and young people with diabetic ketoacidosis, what is the most effective resuscitation fluid (0.9% sodium chloride vs PlasmaLyte 148) for managing DKA?
There was a lack of evidence for the use of PlasmaLyte 148 for DKA. Based on the evidence available, the committee recommended 0.9% sodium chloride as the resuscitation fluid. However, some paediatric units are using PlasmaLyte 148 for initial resuscitation. An adequately powered study is needed to explore the effectiveness of PlasmaLyte 148 as a resuscitation fluid. Important outcomes include incidence of cerebral oedema and mortality.