Evidence categories (Ia-IV) and recommendation grades (A-D) are defined at the end of the "Major Recommendations" field.
In addition to evidence-based recommendations, the guideline development group (GDG) identifies good practice points (GPP) as well as evidence from National Institute for Health and Clinical Excellence (NICE) Technology Appraisals (NICE TA).
Terminology Used in the Guideline
The internationally agreed term "type 1 diabetes" is used in this guideline, rather than "insulin-dependent diabetes mellitus." Similarly, "type 2 diabetes" is used in the guideline, rather than "non-insulin-dependent diabetes mellitus."
The guideline relates to the care of children (people under the age of 11 years) and young people (those aged 11 years or over, but under 18 years). Where appropriate, the following terms are used to refer to specific age groups:
- Neonates (0 weeks or older and younger than 4 weeks)
- Infants (4 weeks or older and younger than 52 weeks)
- Pre-school children (1 year or older and younger than 5 years)
- Primary school children (5 years or older and younger than 11 years)
- Young people (11 years or older and younger than 18 years)
- Adults (18 years or older).
Diagnosis and Initial Management
Diagnosis
D - 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.
GPP - 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.
GPP - 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
GPP - Children and young people with type 1 diabetes should be entered on a population-based, practice-based, and/or clinic-based diabetes register.
Management from Diagnosis
GPP - Children and young people with type 1 diabetes should be offered an ongoing integrated package of care by a multidisciplinary paediatric diabetes care team. To optimise the effectiveness of care and reduce the risk of complications, the diabetes care 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.
GPP - Children and young people with type 1 diabetes and their families should be offered 24-hour access to advice from the diabetes care team.
GPP - Children and young people with type 1 diabetes and their families should be involved in making decisions about the package of care provided by the diabetes care team.
A - At the time of diagnosis, children and young people with type 1 diabetes should be offered home-based or inpatient management according to clinical need, family circumstances and wishes, and residential proximity to inpatient services. Home-based care with support from the local paediatric diabetes care team (including 24-hour telephone access to advice) is safe and as effective as inpatient initial management.
GPP - Children and young people who present with diabetic ketoacidosis should have their diabetic ketoacidosis treated in hospital according to the guidance outlined in this document.
GPP - 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.
GPP - Children and young people with type 1 diabetes and their families should be offered appropriate emotional support following diagnosis, which should be tailored to emotional, social, cultural, and age-dependent needs.
Natural History of Type 1 Diabetes
D - 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 a haemoglobin A1c (HbA1c) level of less than 7%.
A - Children and young people with type 1 diabetes should be informed that the use of multiple daily insulin injection regimens or continuous subcutaneous insulin infusion (or insulin pump therapy) will not prolong the partial remission phase, although these forms of therapy may be appropriate for optimising glycaemic control, especially in young people.
Essential Education at Diagnosis
D - Children and young people with newly diagnosed type 1 diabetes should be offered a structured programme of education covering the aims of insulin therapy, delivery of insulin, self-monitoring of blood glucose, the effects of diet, physical activity, and intercurrent illness on glycaemic control, and the detection and management of hypoglycaemia.
Ongoing Management
Education
GPP - Children and young people with type 1 diabetes and their families should be offered timely and ongoing opportunities to access information about the development, management, and effects of type 1 diabetes. The information provided should be accurate and consistent and it should support informed decision-making.
GPP - Children and young people with type 1 diabetes and their families should be offered opportunities to discuss particular issues and to ask questions at each clinic visit.
GPP - The method of delivering education and content will depend on the individual and should be appropriate for the child's or young person's age, maturity, culture, wishes, and existing knowledge within the family.
GPP - Particular care should be given to communication and the provision of information when children and young people with type 1 diabetes and/or their parents have special needs, such as those associated with physical and sensory disabilities, or difficulties in speaking or reading English.
Insulin Regimens
C - Pre-school and primary school children with type 1 diabetes should be offered the most appropriate individualised regimens to optimise their glycaemic control.
A - Young people with type 1 diabetes should be offered multiple daily injection regimens to help optimise their glycaemic control.
C - Multiple daily injection regimens should be offered only as part of a package of care that involves continuing education, dietary management, instruction on the use of insulin delivery systems and blood glucose monitoring, emotional and behavioural support, and medical, nursing, and dietetic expertise in paediatric diabetes, because this improves glycaemic control.
B - Children and young people using multiple daily injection regimens should be informed that they may experience an initial increase in the risk of hypoglycaemia and short-term weight gain.
C - Children and young people with type 1 diabetes and their families should be informed about strategies for the avoidance and management of hypoglycaemia.
GPP - Young people who do not achieve satisfactory glycaemic control with multiple daily injection regimens should be offered additional support and, if appropriate, alternative insulin therapy (once, twice, or three-times daily mixed insulin regimens or continuous subcutaneous insulin infusion using an insulin pump).
GPP - Young people with type 1 diabetes who have difficulty adhering to multiple daily injection regimens should be offered twice-daily injection regimens.
NICE TA - Continuous subcutaneous insulin infusion (or insulin pump therapy) is recommended as an option for people with type 1 diabetes provided that:
- multiple-dose insulin therapy (including, where appropriate, the use of insulin glargine) has failed;* and
- those receiving the treatment have the commitment and competence to use the therapy effectively
*NICE TA - People for whom multiple-dose therapy has failed are considered to be those for whom it has been impossible to maintain an HBA1c level no greater than 7.5% (or 6.5% in the presence of microalbuminuria or adverse features of the metabolic syndrome) without disabling hypoglycaemia occurring, despite a high level of self care of their diabetes. "Disabling hypoglycaemia," for the purpose of this guidance, means the repeated and unpredicted occurrence of hypoglycaemia requiring third-party assistance that results in continuing anxiety about recurrence and is associated with significant adverse effect on quality of life.
NICE TA - Continuous subcutaneous insulin infusion therapy should be initiated only by a trained specialist team, which should normally comprise a physician with a specialist interest in insulin pump therapy, a diabetes specialist nurse, and a dietitian.
NICE TA - All individuals beginning continuous subcutaneous insulin infusion therapy should be provided with specific training in its use. Ongoing support from a specialist team should be available, particularly in the period immediately following the initiation of continuous subcutaneous insulin infusion. It is recommended that specialist teams should agree a common core of advice appropriate for continuous subcutaneous insulin infusion users.
NICE TA - Established users of continuous subcutaneous insulin infusion therapy should have their insulin management reviewed by their specialist team so that a decision can be made about whether a trial or a switch to multiple-dose insulin incorporating insulin glargine would be appropriate.
Insulin Preparations
GPP - Children and young people with type 1 diabetes should be offered the most appropriate insulin preparations (rapid-acting insulin analogues, short-acting insulins, intermediate-acting insulins, long-acting insulin analogues or biphasic insulins) according to their individual needs and the instructions in the patient information leaflet supplied with the product, with the aim of obtaining an HbA1c level of less than 7.5% without frequent disabling hypoglycaemia and maximising quality of life.
B - Children and young people with type 1 diabetes using multiple daily insulin regimens should be informed that injection of rapid-acting insulin analogues before eating (rather than after eating) reduces post-prandial blood glucose levels and thus helps to optimise blood glucose control.
GPP - For pre-school children with type 1 diabetes it may be appropriate to use rapid-acting insulin analogues shortly after eating (rather than before eating) because food intake can be unpredictable.
GPP - Children and young people with type 1 diabetes who use insulin preparations containing intermediate-acting insulin should be informed that these preparations should be mixed before use according to the instructions in the patient information leaflet supplied with the product.
Methods of Delivering Insulin
GPP - Children and young people with type 1 diabetes should be offered a choice of insulin delivery systems that takes account of their insulin requirements and personal preferences.
GPP - 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).
Non-Insulin Agents (Oral Antidiabetic Drugs)
A - Children and young people with type 1 diabetes should not be offered acarbose or sulphonylureas (glibenclamide, gliclazide, glipizide, tolazamide or glyburide) in combination with insulin because they may increase the risk of hypoglycaemia without improving glycaemic control.
A - Metformin in combination with insulin is suitable for use only within research studies because the effectiveness of this combined treatment in improving glycaemic control is uncertain.
Monitoring Glycaemic Control
A - Children and young people with type 1 diabetes and their families should be informed that the target for long-term glycaemic control is an HbA1c level of less than 7.5% without frequent disabling hypoglycaemia and that their care package should be designed to attempt to achieve this.
D - 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).
D - Current HbA1c measurements should be made available in outpatient clinics because their availability can lead to immediate changes in insulin therapy and/or diet and so reduce the need for follow-up appointments.
A - Children and young people with type 1 diabetes and their families should be informed that aiming to achieve low levels of HbA1c can lead to increased risks of hypoglycaemia and that high levels of HbA1c can lead to increased risks of long-term microvascular complications.
B - Children and young people with HbA1c levels consistently above 9.5% should be offered additional support by their diabetes care teams to help them improve their glycaemic control because they are at increased risk of developing diabetic ketoacidosis and long-term complications.
A - Children and young people with type 1 diabetes should be encouraged to use blood glucose measurements for short-term monitoring of glycaemic control because this is associated with reduced levels of glycated haemoglobin. Urine glucose monitoring is not recommended because it is less effective and is associated with lower patient satisfaction.
D - Children and young people with type 1 diabetes and their families should be informed that the optimal targets for short-term glycaemic control are a pre-prandial blood glucose level of 4 to 8 mmol/L and a post-prandial blood glucose level of less than 10 mmol/L.
C - Children and young people with type 1 diabetes and their families should be encouraged to perform frequent blood glucose monitoring as part of a continuing package of care that includes dietary management, continued education, and regular contact with their diabetes care teams.
GPP - Children and young people with type 1 diabetes and their families should be offered a choice of appropriate equipment for undertaking monitoring of capillary blood glucose to optimise their glycaemic control in response to adjustment of insulin, diet, and exercise.
D - Children and young people using multiple daily injection regimens should be encouraged to adjust their insulin dose if appropriate after each pre-prandial, bedtime, and occasional nighttime blood glucose measurement.
D - Children and young people using twice-daily injection regimens should be encouraged to adjust their insulin dose according to the general trend in pre-prandial, bedtime, and occasional nighttime blood glucose measurements.
GPP - Children and young people with type 1 diabetes who are trying to optimise their glycaemic control and/or have intercurrent illness should be encouraged to measure their blood glucose levels more than four times per day.
GPP - Children and young people with type 1 diabetes and their families should be informed that blood glucose levels should be interpreted in the context of the "whole child," which includes the social, emotional, and physical environment.
B - Children and young people with type 1 diabetes who have persistent problems with hypoglycaemia unawareness or repeated hypoglycaemia or hyperglycaemia should be offered continuous glucose monitoring systems.
B - Children and young people with type 1 diabetes should be offered blood glucose monitors with memories (as opposed to monitors without memories) because these are associated with improved patient satisfaction.
GPP - Children and young people with type 1 diabetes should be encouraged to use a diary in conjunction with a blood glucose monitor because recording food intake and events such as intercurrent illness can help to reduce the frequency of hypoglycaemic episodes.
See the section below titled "Cognitive Disorders" for recommendations about cognitive disorders related to frequent hypoglycaemia.
Diet
C - Children and young people with type 1 diabetes should be offered appropriate dietetic support to help optimise body weight and glycaemic control.
D - 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%
D - 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.
GPP - Children and young people with type 1 diabetes should be encouraged to develop a good working knowledge of nutrition and how it affects their diabetes.
GPP - Children and young people with type 1 diabetes and their families should be informed of the importance of healthy eating in reducing the risk of cardiovascular disease (including foods with a low glycaemic index, fruit and vegetables, and types and amounts of fats), and means of making appropriate nutritional changes in the period after diagnosis and according to need and interest at intervals thereafter.
B - Children and young people with type 1 diabetes should be encouraged to consider eating a bedtime snack. The nutritional composition and timing of all snacks should be discussed with the diabetes care team.
C - Children and young people using multiple daily injection regimens should be offered education about insulin and dietary management as part of their diabetes care package, to enable them to adjust their insulin dose to reflect their carbohydrate intake.
GPP - Children and young people with type 1 diabetes should be offered education about the practical problems associated with fasting and feasting.
Exercise
B - All children and young people, including those with type 1 diabetes, should be encouraged to exercise on a regular basis because this reduces the risks of developing macrovascular disease in the long term.
GPP - Children and young people with type 1 diabetes and their families should be informed that they can participate in all forms of exercise, provided that appropriate attention is given to changes in insulin and dietary management.
GPP - 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 care teams. Additional information may be available from local and/or national patient support groups and organisations.
C - 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.
D - Children and young people with type 1 diabetes should be encouraged to monitor their blood glucose levels before and after exercise so that they can:
- Identify when changes in insulin or food intake are necessary
- Learn the glycaemic response to different exercise conditions
- Be aware of exercise-induced hypoglycaemia
- Be aware that hypoglycaemia may occur several hours after prolonged exercise
D - Children and young people with type 1 diabetes, their parents, and other carers should be informed that additional carbohydrate should be consumed as appropriate to avoid hypoglycaemia and that carbohydrate-based foods should be readily available during and after exercise.
GPP - Children and young people with type 1 diabetes, their parents, and other carers should be informed that additional carbohydrate should be consumed if blood glucose levels are less than 7 mmol/L before exercise is undertaken.
GPP - Children and young people with type 1 diabetes and their families should be informed that changes in their daily exercise patterns may require insulin dose and/or carbohydrate intake to be altered.
GPP - Children and young people with type 1 diabetes, their parents, and other carers should be informed that exercise should be undertaken with caution if blood glucose levels are greater than 17 mmol/L in the presence of ketosis.
Alcohol, Smoking, and Recreational Drugs
C - 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.
GPP - Young people with type 1 diabetes should be offered alcohol education programmes.
GPP - Young people with type 1 diabetes who drink alcohol should be informed 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
B - Children and young people with type 1 diabetes and their families should be informed about general health problems associated with smoking and in particular the risks of developing vascular complications.
GPP - Children and young people with type 1 diabetes should be encouraged not to start smoking.
GPP - Children and young people with type 1 diabetes who smoke should be offered smoking cessation programmes.
GPP - Children and young people with type 1 diabetes and their families should be informed about the general dangers of substance misuse and the possible effects on glycaemic control.
Long-Distance Travel
GPP - Children and young with type 1 diabetes and their families should be offered education about the practical issues related to long-distance travel, such as when best to eat and inject insulin when traveling across time zones.
Immunisation
D - 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.
D - 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.
Complications and Associated Conditions
Hypoglycaemia
D - 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.
D - Children and young people, their parents, schoolteachers, and other carers should be offered education about the recognition and management of hypoglycaemia.
D - Children and young people with type 1 diabetes should be encouraged to wear or carry something that identifies them as having type 1 diabetes (for example, a bracelet).
GPP - 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 to 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.
GPP - 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.
D - 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.
D - Parents and, where appropriate, school nurses and other carers should be offered education on the administration of glucagon.
GPP - Children and young people with type 1 diabetes and their families should be informed 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.
See the section below titled "Cognitive Disorders" for recommendations about cognitive disorders related to frequent hypoglycaemia.
Diabetic Ketoacidosis
D - Children and young people with diabetic ketoacidosis should be treated according to the guidelines published by the British Society for Paediatric Endocrinology and Diabetes.
D - Children and young people with diabetic ketoacidosis should be managed initially in a high-dependency unit or in a high-dependency bed on a children's ward.
D - Children and young people with deteriorating consciousness or suspected cerebral oedema and those who are not responding appropriately to treatment should be managed in a paediatric intensive care unit.
D - Children with diabetic ketoacidosis who are younger than 2 years of age should be managed in a paediatric intensive care unit.
D - Children and young people with a blood pH of less than 7.3 (hydrogen ion concentration of more than 50 nmol/L), but who are clinically well (with no tachycardia, vomiting, drowsiness, abdominal pain, or breathlessness) and less than 5% dehydrated, may respond appropriately to oral rehydration, frequent subcutaneous insulin injections, and monitoring of blood glucose.
Surgery
D - Children and young people with type 1 diabetes should be offered surgery only in centres that have dedicated paediatric facilities for the care of children and young people with diabetes.
D - Careful liaison between surgical, anaesthetic, and diabetes care teams should occur 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.
D - All centres caring for children and young people with type 1 diabetes should have written protocols concerning the safe management of children and young people during surgery. The protocols should be agreed between surgical and anaesthetic staff and the diabetes care team.
Intercurrent Illness
D - Children and young people with type 1 diabetes and their families should be offered clear guidance and protocols ("sick-day rules") for the management of type 1 diabetes during intercurrent illness.
GPP - Children and young people with type 1 diabetes should have short-acting insulin or rapid-acting insulin analogues and blood and/or urine ketone testing strips available for use during intercurrent illness.
Screening for Complications and Associated Conditions
C - Children and young people with type 1 diabetes should be offered screening for:
- C - Coeliac disease at diagnosis
- GPP - and at least every 3 years thereafter until transfer to adult services
- C - Thyroid disease at diagnosis and annually thereafter until transfer to adult services
- C - Retinopathy annually from the age of 12 years
- C - Microalbuminuria annually from the age of 12 years
- C - Blood pressure annually from the age of 12 years
C - Routine screening for elevated blood lipid levels and/or neurological function is not recommended for children and young people with type 1 diabetes.
Children and young people with type 1 diabetes should be offered:
- GPP - Annual foot care reviews
- C - Investigation of the state of injection sites at each clinic visit
D - Children and young people with type 1 diabetes and their families should be informed that, as for other children, regular dental examinations and eye examinations (every 2 years) are recommended.
GPP - 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.
D - Children and young people with type 1 diabetes should have their height and weight measured in a private room.
GPP - The following complications, although rare, should be considered at clinic visits:
- Juvenile cataracts
- Necrobiosis lipoidica
- Addison's disease
Psychological and Social Issues
Emotional and Behavioural Problems
C - 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.
Anxiety and Depression
B - Diabetes care 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.
GPP - Children and young people with type 1 diabetes who have persistently poor glycaemic control should be offered screening for anxiety and depression.
GPP - Children and young people with type 1 diabetes and suspected anxiety and/or depression should be referred promptly to child mental health professionals.
Eating Disorders
C - 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.
C - 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.
GPP - 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.
Cognitive Disorders
C - Parents of pre-school children with type 1 diabetes should be informed that persistent hypoglycaemia, in particular in association with seizures, is associated with a small but definite risk of long-term neurocognitive dysfunction.
GPP - Diabetes care 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.
Behavioural and Conduct Disorders
GPP - Children and young people with type 1 diabetes who have behavioural or conduct disorders, and their families, should be offered access to appropriate health professionals.
Non-Adherence
B - Non-adherence to therapy should be considered in children and young people with type 1 diabetes who have poor glycaemic control, especially in adolescence.
B - Non-adherence to therapy should be considered in children and young people with established type 1 diabetes who present with diabetic ketoacidosis, especially if the diabetic ketoacidosis is recurrent.
GPP - 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.
GPP - The issue of non-adherence to therapy should be raised with children and young people and their families in a sensitive manner.
Psychosocial Support
C - Diabetes care teams should be aware that poor psychosocial support has a negative impact on a variety of outcomes of type 1 diabetes in children and young people, including glycaemic control and self-esteem.
A - Children and young people with type 1 diabetes, especially young people using multiple daily injection regimens, should be offered structured behavioural intervention strategies because these may improve psychological well-being and glycaemic control.
A - Young people with type 1 diabetes should be offered specific support strategies, such as mentoring and self-monitoring of blood glucose levels supported by problem solving, to improve their self-esteem and glycaemic control.
A - Families of children and young people with type 1 diabetes should be offered specific support strategies (such as behavioural family systems therapy) to reduce diabetes-related conflict between family members.
GPP - 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.
GPP - Diabetes care teams should have appropriate access to mental health professionals to support them in the assessment of psychological dysfunction and the delivery of psychosocial support.
Adolescence
B - Diabetes care teams should be aware that adolescence can be a period of worsening glycaemic control, which may in part be due to non-adherence to therapy.
Continuity of Care
Communication between Organisations
GPP - 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.
GPP - Diabetes care teams should liaise regularly with school staff involved in supervising children and young people with type 1 diabetes to offer appropriate diabetes education and practical information.
GPP - Teaching staff should be informed about the potential effects of type 1 diabetes on cognitive function and educational attainment.
GPP - 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.
Transition from Paediatric to Adult Care
D - 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.
GPP - Young people with type 1 diabetes should be allowed sufficient time to familiarise themselves with the practicalities of the transition from paediatric to adult services because this has been shown to improve clinic attendance.
GPP - Specific local protocols should be agreed for transferring young people with type 1 diabetes from paediatric to adult services.
GPP - The age of transfer to the adult service should depend on the individual's physical development and emotional maturity and local circumstances.
D - Transition from the paediatric service should occur at a time of relative stability in the individual's health and should be coordinated with other life transitions.
D - Paediatric diabetes care teams should organise age-banded clinics for young people and young adults jointly with their adult specialty colleagues.
GPP - Young people with type 1 diabetes who are preparing for transition to adult services should be informed that some aspects of diabetes care will change at transition. The main changes relate to targets for short-term glycaemic control and screening for complications.
Definitions:
Source of Evidence
Ia: Systematic review or meta-analysis of randomised controlled trials
Ib: At least one randomised controlled trial
IIa: At least one well-designed controlled study without randomisation
IIb: At least one well-designed quasi-experimental study, such as a cohort study
III: Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case-control studies, and case series
IV: Expert committee reports, opinions and/or clinical experience of respected authorities
Grading of Recommendations
A: Based directly on level I evidence
B: Based directly on level II evidence or extrapolated from level I evidence
C: Based directly on level III evidence or extrapolated from level I or level II evidence
D: Based directly on level IV evidence or extrapolated from level I, level II or level III evidence
GPP: Good practice point based on the view of the Guideline Development Group (GDG)
NICE TA: Recommendation taken from a National Institute for Health and Clinical Excellence (NICE) Technology Appraisal
