Update information

November 2016: Recommendations 1.2.115 and 1.3.52 have been amended to add information on when eye screening should begin. Please note the date label of [2015] is unchanged, as this is when the recommendation was written and the evidence last reviewed. The changes made in November 2016 are clarifications of the 2015 wording, not new advice written in 2016, so do not carry a [2016] date.

August 2015: This guideline is an update of NICE guideline CG15 (published July 2004) and replaced the guidance for children and young people.

New recommendations have been added for the diagnosis and management of type 1 and type 2 diabetes in children and young people.


Recommendations are marked as [new 2015], [2015], [2004] or [2004, amended 2015]:

  • [new 2015] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2015] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2004] indicates that the evidence has not been reviewed since 2004

  • [2004, amended 2015] indicates that the evidence has not been reviewed since 2004, but either changes have been made to the recommendation wording that change the meaning or NICE has made editorial changes to the original wording to clarify the action to be taken.

Recommendations from NICE guideline CG15 that have been amended

Recommendations are labelled [2004, amended 2015] if the evidence has not been reviewed but:

  • changes have been made to the recommendation wording that change the meaning or

  • NICE has made editorial changes to the original wording to clarify the action to be taken or

  • the recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

Recommendation in 2004 guideline

Recommendation in current guideline

Reason for change

The diagnosis of type 1 diabetes in children and young people should be based on the criteria specified in the 1999 World Health Organization report on the diagnosis and classification of diabetes mellitus.[a]

The symptoms and signs of type 1 diabetes include: hyperglycaemia (random blood glucose more than 11 mmol/litre), polyuria, polydipsia and weight loss. (1.1.1.1)

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. (1.1.1)

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. (1.1.3)

The WHO updated their report on the diagnosis and classification of diabetes in 2006.

The population has been added to this recommendation for clarification.

In addition, this recommendation has been split into 2 recommendations to make it easier to understand.

'Symptoms and signs' has been replaced with 'characteristics' as the GDG felt this was a more accurate term for the list of conditions in this recommendation.

Excessive tiredness was added at the request of stakeholders commenting on the draft for consultation of the 2015 update as this is a recognised symptom of diabetes.

'Plasma glucose' was added to the second recommendation, to make it clear that diagnosis should be confirmed using the WHO plasma glucose criteria and not their HbA1c criteria.

Children and young people with suspected type 1 diabetes should be offered immediate (same day) referral to a multidisciplinary paediatric diabetes care team that has the competencies needed to confirm diagnosis and to provide immediate care. (1.1.1.2)

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. (1.1.2)

The action was changed from 'offer' to 'refer', as the 2012 NICE guidelines manual used to develop this update has a specific definition of the word 'offer' that was not used when the original 2004 guideline was published.

Consideration should be given to the possibility of other types of diabetes (such as early‑onset type 2 diabetes, other insulin resistance syndromes, maturity‑onset diabetes in the young and molecular/enzymatic abnormalities) in children and young people with suspected type 1 diabetes who:

  • have a strong family history of diabetes

  • are obese at presentation

  • are of black or Asian origin

  • have an insulin requirement of less than 0.5 units/kg body weight/day outside a partial remission phase

  • have no insulin requirement

  • rarely or never produce ketone bodies in the urine (ketonuria) during episodes of hyperglycaemia

  • show evidence of insulin resistance (for example, acanthosis nigricans)

  • have associated features, such as eye disease, deafness, or another systemic illness or syndrome. (1.1.1.3)

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). (1.1.5)

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. (1.1.6)

This recommendation has been split into two, as the Guideline Development Group felt that type 2 diabetes should be considered separately from the rarer conditions now that it is covered in this guideline.

In addition, not all of the factors listed applied to type 2 diabetes or to the rarer conditions. Because of this, the Guideline Development Group felt that separating them into two lists makes it clearer which factors apply to which condition.

In the second recommendation, maturity onset diabetes in the young and molecular/enzymatic abnormalities have been replaced by monogenic diabetes and mitochondrial diabetes to cover diabetes more generally; diabetes in the first year of life has been added to cover neonatal diabetes; the reference to ketone bodies in the urine has been changed to ketone bodies in the blood to mirror the recommendations elsewhere in the guideline; and 'eye' disease' has been replaced with 'optic atrophy and retinitis pigmentosa', as the Guideline Development Group felt that 'eye disease' was not specific enough and could be mistaken for diabetic retinopathy.

Young people with type 1 diabetes should be encouraged to attend clinics on a regular basis (three or four times per year) because regular attendance is associated with good glycaemic control. (1.5.2.1)

Encourage young people with type 1 diabetes to attend clinic 4 times a year because regular contact is associated with optimal blood glucose control. (1.2.3)

The recommended number of contacts has been updated to reflect the Paediatric Diabetes Best Practice Tariff Criteria. In addition, 4 clinic attendances is standard in current clinical practice.

Children and young people with type 1 diabetes and their families should be informed that, as for other children, regular dental examinations[b] and eye examinations (every 2 years) are recommended. (1.3.5.4)

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. (1.2.4)

An explanation has been added to the bullet on eye examination to make it clear this refers to standard eye tests rather than retinopathy monitoring.

In addition, 'recommended' has been changed to 'advised to have' as part of the editorial changes to make this sentence active.

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) how to find information about benefits from government disability support. (1.5.1.4)

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. (1.2.8)

The phrasing has been changed to refer to government disability benefits in general rather than implying that a specific benefit is applicable.

Children and young people with type 1 diabetes wishing to participate in restricted sports (such as scuba diving) should be offered comprehensive advice by their diabetes team. Additional information may be available from local and/or national patient support groups and organisations. (1.2.8.3)

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. (1.2.10)

The reference to restricted sports has been deleted because this is no longer meaningful. The phrasing has been changed to emphasise that the recommendation is about sports that may have particular risks for people with diabetes, and the specific reference to scuba diving has been deleted. The reference to support organisations has been amended to cover sports organisations as well as patient support organisations.

Encourage children and young people with type 1 diabetes not to start smoking. (1.2.9.5)

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. (1.2.13)

A reference to related NICE guidance on prevention of smoking in children and young people has been added.

Offer smoking cessation programmes to children and young people with type 1 diabetes who smoke. (1.2.9.6)

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. (1.2.14)

A reference to related NICE guidance on smoking cessation has been added.

Children and young people with type 1 diabetes and their families should be informed that the Department of Health recommends immunisation against pneumococcal infection for children and young people with diabetes over the age of 2 months. (1.2.11.2)

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. (1.2.17)

This recommendation has been updated to reflect guidance from the Department of Health's Green Book.

Encourage children and young people with type 1 diabetes who are using multiple daily insulin regimens and their family members or carers (as appropriate) to adjust the insulin dose if appropriate after each pre‑meal, bedtime and occasional night‑time blood glucose measurement. (1.2.6.10)

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. (1.2.20)

The reference to the timing of blood glucose measurements has been deleted because the recommendations about blood glucose measurements state the minimum number of times measurements should be made, but not the specific timing of the measurements.

Children and young people with newly diagnosed type 1 diabetes should be informed that they may experience a partial remission phase (or '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 7%. (1.1.3.1)

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%). (1.2.24)

This recommendation has been expanded to include family members or carers (as appropriate), as they may also be involved in the child or young person's treatment.

In addition, the target HbA1c level has been updated to match the new recommendations on HbA1c target levels.

Children and young people with type 1 diabetes using insulin injection regimens should be offered needles that are of an appropriate length for their body fat (short needles are appropriate for children and young people with less body fat; longer needles are appropriate for children and young people with more body fat). (1.2.4.2)

Provide children and young people with type 1 diabetes with insulin injection needles that are of an appropriate length for their body fat. (1.2.26)

The information on what needle length is appropriate for a child has been deleted from this recommendation, as the GDG felt that this was well known and did not need defining in the recommendation.

Children and young people with type 1 diabetes should be offered:

  • annual foot care reviews

  • investigation of the state of injection sites at each clinic visit. (1.3.5.3)

Offer children and young people with type 1 diabetes a review of injection sites at each clinic visit. (1.2.28)

The text on foot care has been removed from this recommendation, as it is covered by the new NICE guideline on diabetic foot care.

Children and young people with type 1 diabetes and their families should be informed that they have the same basic nutritional requirements as other children and young people. The food choices of children and young people should provide sufficient energy and nutrients for optimal growth and development, with total daily energy intake being distributed as follows:

  • carbohydrates – more than 50%

  • protein – 10–15%

  • fat – 30–35%.

The consumption of five portions of fruit and vegetables per day is also recommended. Neonates, infants and pre‑school children require individualised dietary assessment to determine their energy needs. (1.2.7.2)

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. (1.2.36)

The text on total daily energy intake distribution and eating 5 portions of fruit and vegetables per day has been removed from this recommendation, as the 2015 recommendation 1.2.41 covers this.

In addition, the specific energy intake levels were removed, as these are applicable to all children and not just those with type 1 diabetes.

Children and young people with type 1 diabetes should have their height and weight measured and plotted on an appropriate growth chart and their body mass index calculated at each clinic visit. The purpose of measuring and plotting height and weight and calculating body mass index is to check for normal growth and/or significant changes in weight because these may reflect changing glycaemic control. (1.3.5.5)

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. (1.2.45)

This recommendation has been heavily edited for clarity, and the second part of the recommendation has been rewritten to make it easier to follow. The reference to measuring BMI has been deleted because it is not necessary to measure this at every clinic visit.

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 macrovascular disease in the long term. (1.2.8.1)

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. (1.2.47)

The term macrovascular has been changed to cardiovascular to clarify the meaning.

Children and young people with type 1 diabetes and their families should be informed about the effects of exercise on blood glucose levels and about strategies for preventing exercise‑induced hypoglycaemia during and/or after physical activity. (1.2.8.4)

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. (1.2.49)

The term 'exercise‑induced' has been removed from this recommendation, as the GDG felt that the cause of hypoglycaemia did not need stating here. In addition, hyperglycaemia caused by exercise has been added to this recommendation, as this is also a complication that children and young people with type 1 diabetes and their family members or carers (as appropriate) should be aware of.

In addition, this recommendation has been expanded to include family members or carers (as appropriate), as they may also be involved in the child or young person's treatment.

Children and young people with type 1 diabetes should be offered testing of their HbA1c levels two to four times per year (more frequent testing may be appropriate if there is concern about poor glycaemic control). (1.2.6.2)

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). (1.2.71)

The recommended number of measurements has been updated to reflect the Paediatric Diabetes Best Practice Tariff Criteria. In addition, 4 measurements a year is standard in current clinical practice.

Children and young people with type 1 diabetes, their parents and other carers should be informed that they should always have access to an immediate source of carbohydrate (glucose or sucrose) and blood glucose monitoring equipment for immediate confirmation and safe management of hypoglycaemia. (1.3.1.1)

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. (1.2.78)

The type of carbohydrate suitable for safe management of hypoglycaemia has been changed from 'glucose or sucrose' to 'fast‑acting glucose', as the Guideline Development Group felt this was what was recommended in current practice.

Parents and, where appropriate, school nurses and other carers should have access to glucagon for subcutaneous or intramuscular use in an emergency, especially when there is a high risk of severe hypoglycaemia. (1.3.1.6)

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. (1.2.79)

Subcutaneous glucagon has been removed from this recommendation, as the Guideline Development Group did not think this was used in current practice.

The recommendation has been reworded to make it clear that intramuscular glucagon would only be given for severe hypoglycaemia.

In addition, 'have access' has been replaced with 'trained and equipped', as the GDG felt that this was an important point that was left out of the original recommendation.

Children and young people with mild to moderate hypoglycaemia should be treated as follows.

  • Take immediate action.

  • The first line of treatment should be the consumption of rapidly absorbed simple carbohydrate (for example, 10–20 g carbohydrate given by mouth).

  • The simple carbohydrate should raise blood glucose levels within 5–15 minutes.

  • Carbohydrate given in liquid form may be taken more easily.

  • It may be appropriate to give small amounts of rapidly absorbed simple carbohydrate frequently because hypoglycaemia may cause vomiting.

  • As symptoms improve or normoglycaemia is restored additional complex long‑acting carbohydrate should be given orally to maintain blood glucose levels unless a snack or meal is imminent.

  • Additional complex long‑acting carbohydrate is not required for children and young people using continuous subcutaneous insulin infusion.

  • Blood glucose levels should be rechecked within 15 minutes. (1.3.1.4)

Immediately treat mild to moderate hypoglycaemia in children and young people 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. (1.2.80)

This recommendation has been reworded and reordered to make it easier to understand.

In addition, the type of carbohydrate suitable for safe management of hypoglycaemia has been changed from 'glucose or sucrose' to 'fast‑acting glucose', as the Guideline Development Group felt this was what was recommended in current practice. The recommendation also clarifies that administration of fast‑acting glucose should be repeated if hypoglycaemia persists.

Children and young people with severe hypoglycaemia should be treated as follows.

  • In a hospital setting, 10% intravenous glucose should be used when rapid intravenous access is possible (up to 500 mg/kg body weight – 10% glucose is 100 mg/ml).

  • Outside hospital, or where intravenous access is not practicable, intramuscular glucagon or concentrated oral glucose solution (e.g. Hypostop) may be used.

  • Children and young people over 8 years old (or body weight more than 25 kg) should be given 1 mg glucagon.

  • Children under 8 years old (or body weight less than 25 kg) should be given 500 micrograms of glucagon.

  • Blood glucose levels should respond within 10 minutes.

  • As symptoms improve or normoglycaemia is restored, in children and young people who are sufficiently awake, additional complex long‑acting carbohydrate should be given orally to maintain blood glucose levels.

  • Some children and young people may continue to have reduced consciousness for several hours after a severe hypoglycaemic episode, and repeat blood glucose measurements will be required to determine whether further glucose is necessary.

  • Medical assistance should be sought for children and young people whose blood glucose levels fail to respond and those in whom symptoms persist for more than 10 minutes. (1.3.1.5)

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). (1.2.81)

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. (1.2.82)

This recommendation has been reworded, reordered, and split into 2 separate recommendations to make it easier to understand.

The dose for children and young people who weigh 25 kg has been added to the recommendation.

In addition, the action in the section on intramuscular glucagon and concentrated oral glucose solution has changed from 'may be used' to 'Use'. This is because the Guideline Development Group felt that these 2 were the only standard treatment options rather than 2 options out of several, as was suggested by the original wording.

The reference to 'Hypostop' has been changed to 'Glucogel', as the GDG felt that this was the preparation commonly used in clinical practice.

A warning on using oral glucose solution in children with reduced levels of consciousness has been added, as the GDG felt that this is being missed in clinical practice. This is an important safety issue and was alluded to in the 2004 recommendation, but it was not made clear that it applied at this stage. It is vitally important that caution is exercised when giving Glucogel at first presentation, as this is the stage at which reduced conscious level is most likely to occur.

Young people with type 1 diabetes should be informed about the specific effects of alcohol consumption on glycaemic control, particularly the risk of (nocturnal) hypoglycaemia. (1.2.9.1)

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. (1.2.83)

The term 'nocturnal hypoglycaemia' has been changed to 'hypoglycaemia while sleeping', as the Guideline Development Group did not think the original term was common in clinical practice.

Non‑adherence to therapy should be considered in children and young people with type 1 diabetes who have poor glycaemic control, especially in adolescence. (1.4.6.1)

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. (1.2.87)

The action was changed from 'consider' to 'think about', as the 2012 NICE guidelines manual used to develop this update has a specific definition of the word 'consider' that was not used when the original 2004 guideline was published.

Diabetes care teams should be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural problems than other children and young people. (1.4.1.1)

Diabetes teams should be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties. (1.2.94)

This recommendation has been amended, as the original suggested that children and young people with type 1 diabetes have a greater risk of emotional and behavioural problems than all other children and young people, which is not the case.

Young people with 'brittle diabetes' (that is, those who present with frequent episodes of diabetic ketoacidosis over a relatively short time) should have their emotional and psychological well‑being assessed. (1.4.6.3)

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

The term 'brittle diabetes' has been removed from this recommendation, as the GDG felt that this term was no longer commonly used in clinical practice.

Children and young people with type 1 diabetes and their families should be offered timely and ongoing access to mental health professionals because they may experience psychological disturbances (such as anxiety, depression, behavioural and conduct disorders and family conflict) that can impact on the management of diabetes and well‑being. (1.4.7.5)

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. (1.2.98)

The reference to mental health professionals has been amended to clarify that those involved in caring for children and young people with diabetes should be knowledgeable about diabetes. The importance of psychosocial difficulties has also been emphasised by adding this to the recommendation.

Diabetes care teams should be aware that children and young people with type 1 diabetes, in particular young women, have an increased risk of eating disorders. (1.4.3.1)

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. For more guidance on assessing and managing eating disorders, see the NICE guideline on eating disorders. (1.2.107)

A cross‑reference to the NICE guideline on eating disorders has been added for information.

Diabetes care teams should be aware that children and young people with type 1 diabetes who have eating disorders may have associated problems of persistent hyperglycaemia, recurrent hypoglycaemia and/or symptoms associated with gastric paresis. (1.4.3.2)

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. (1.2.108)

The terms 'persistent hyperglycaemia' and 'recurrent hypoglycaemia' have been replaced with the text on poor blood glucose control, covering both hyperglycaemia and hypoglycaemia. This is because the Guideline Development Group felt that these two complications are both indicative of poor blood glucose control, so it would be simpler to use this phrase in the recommendation.

In addition, the phrase 'symptoms associated with gastric paresis' has been changed, as the GDG felt that the use of 'associated' made this recommendation vague. 'gastric paresis' has been changed to 'gastroparesis', as this is the term currently used in practice.

Children and young people with type 1 diabetes in whom eating disorders are identified by their diabetes care team should be offered joint management involving their diabetes care team and child mental health professionals. (1.4.3.3)

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. (1.2.109)

This recommendation has been amended as healthcare professionals outside of the diabetes team (such as GPs) can also identify eating disorders.

Children and young people with type 1 diabetes and their families should be informed that, as for other children, regular dental examinations[b] and eye examinations (every 2 years) are recommended. (1.3.5.4)

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[b]

  • an eye examination by an optician every 2 years. (1.3.3)

An explanation has been added to the bullet on eye examination to make it clear this refers to standard eye tests rather than retinopathy monitoring.

'recommended' has been changed to 'advised to have' as part of the editorial changes to make this sentence active.

In addition, this recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

Children and young people with type 1 diabetes and their families should be offered information about the existence of and means of contacting local and/or national diabetes support groups and organisations, and the potential benefits of membership. This should be done in the time following diagnosis and periodically thereafter. (1.5.1.1)

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. (1.3.5)

NICE has made editorial changes to the original wording to clarify the action to be taken (no change to meaning): a verb has been added, or the verb used has been changed.

In addition, this recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

Children and young people with type 1 diabetes and their families should be advised how to obtain information about benefits in relation to government disability support. (1.5.1.4)

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. (1.3.6)

The word 'possible' has been added, as the benefits available to children and young people with type 2 diabetes can be different to those available to children and young people with type 1 diabetes.

In addition, this recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

Children and young people with type 1 diabetes and their families should be informed that the Department of Health recommends annual immunisation against influenza for children and young people with diabetes over the age of 6 months. (1.2.11.1)

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. (1.3.12)

This recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

In addition, 'over 6 months' has been taken out of this recommendation, as type 2 diabetes normally only occurs in young people or adults, and never in children under 6 months.

Children and young people with type 1 diabetes and their families should be informed that the Department of Health recommends immunisation against pneumococcal infection for children and young people with diabetes over the age of 2 months. (1.2.11.2)

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. (1.3.13)

This recommendation has been updated to reflect guidance from the Department of Health's Green Book.

This recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

In addition, 'over the age of 2 months' has been taken out of this recommendation, as type 2 diabetes normally only occurs in young people or adults, and never in children under 2 months.

Children and young people with type 1 diabetes should have their height and weight measured and plotted on an appropriate growth chart and their body mass index calculated at each clinic visit. The purpose of measuring and plotting height and weight and calculating body mass index is to check for normal growth and/or significant changes in weight because these may reflect changing glycaemic control. (1.3.5.5)

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. (1.3.21)

This recommendation has been heavily edited for clarity, and the second part of the recommendation has been rewritten to make it easier to follow.

In addition, this recommendation originally only applied to type 1 diabetes in children and young people, but has been included in the section of this guideline on type 2 diabetes as it is applicable to this population.

Diabetes care teams should be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural problems than other children and young people. (1.4.1.1)

Diabetes teams should be aware that children and young people with type 2 diabetes have a greater risk of emotional and behavioural difficulties. (1.3.33)

This recommendation has been amended, as the original suggested that children and young people with diabetes have a greater risk of emotional and behavioural problems than all other children and young people, which is not the case.

In addition, this recommendation originally only applied to type 1 diabetes in children and young people, but has been amended to include type 2 diabetes as it is applicable to this population.

Children with type 1 diabetes who are younger than 2 years of age and children and young people who have social or emotional difficulties, or who live a long way from hospital should be offered inpatient initial management. (1.1.2.6)

Offer initial inpatient management to children with diabetes who are aged under 2 years. (1.5.5)

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. (1.5.6)

This recommendation has been split into 2 recommendations to make the differences in care for the 2 populations clearer.

In addition, this recommendation originally only applied to type 1 diabetes in children and young people, but has been amended to include type 2 diabetes as it is applicable to this population.

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. The main changes relate to targets for short‑term blood glucose control and screening for complications. (1.5.2.7)

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. (1.5.13)

The examples of changes at transition have been deleted because those specified in the 2004 recommendation no longer apply to the same extent and there is now much greater harmony generally between the recommendations for children and young people and those for adults.

1.2.3, 1.2.30, 1.2.71, 1.2.87, 1.2.104, 1.2.108, 1.3.40

The terms 'good' and 'satisfactory' have been changed to 'optimal' and the term 'poor' has been changed to 'suboptimal' throughout the recommendations to avoid them appearing judgemental.

1.2.21, 1.2.23

The terms 'preprandial' and 'postprandial' have been changed to 'pre‑meal', 'before meals', and 'after meals' when appropriate, as the GDG felt that these terms are simpler and more commonly used.

1.2.21, 1.2.22, 1.2.23, 1.2.24, 1.2.26, 1.2.40, 1.2.50

These recommendations have been expanded to include family members or carers (as appropriate), as they may also be involved in the child or young person's treatment.

1.2.6, 1.2.22, 1.2.32, 1.2.93, 1.2.96, 1.2.109, 1.4.64, 1.5.7, 1.5.12

NICE has made editorial changes to the original wording to clarify the action to be taken (no change to meaning): a verb has been added, or the verb used has been changed.

1.3.3, 1.3.5, 1.3.6, 1.3.7, 1.3.8, 1.3.9, 1.3.10, 1.3.11, 1.3.12, 1.3.13, 1.3.16, 1.3.21, 1.3.22, 1.3.29, 1.3.30, 1.3.31, 1.3.32, 1.3.33, 1.3.34, 1.3.35, 1.3.36, 1.3.37, 1.3.38, 1.3.40, 1.3.41, 1.5.1, 1.5.2, 1.5.3, 1.5.4, 1.5.5, 1.5.6, 1.5.8, 1.5.9, 1.5.10, 1.5.11, 1.5.12

These recommendations originally only applied to type 1 diabetes in children and young people, but have been included in the section of this guideline on type 2 diabetes as they are applicable to this population.

1.2.52

The term 'blood' has been changed to 'plasma', as this recommendation is referring to a concentration value.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade‑off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of 'the guidelines manual' (January 2009). This does not apply to any recommendations ending [2004] or [2004, amended 2015] (see 'update information' above for details about how recommendations are labelled). In particular, for recommendations labelled [2004] or [2004, amended 2015] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

ISBN: 978-1-4731-1385-5

  • National Institute for Health and Care Excellence (NICE)