Diabetes in Children (Type 1 and 2)
Scope of this article: This article covers information regarding diabetes in those who are under 18 y/o (children and young people) as per NICE NG18
For diabetes in adults (≥18 y/o), see separate articles:
Types and Pathophysiology
| Type 1 diabetes mellitus (T1DM) | Type 2 diabetes mellitus (T2DM) | |
|---|---|---|
| Key pathophysiology | Autoimmune destruction of pancreatic β-cells → absolute insulin deficiency | Insulin resistance with progressive β-cell dysfunction (and subsequent insulin deficiency) |
Clinical Features and Diagnosis
General Clinical Features
Typical features of diabetes in children and young people:
- Polyuria
- Polydipsia
- Weight loss
- Excessive tiredness
Diabetic ketoacidosis (DKA) is an important first presentation of diabetes in children (mostly due to underlying T1DM)
Step 1 – Confirming Diabetes Mellitus
Confirm diabetes using the standard plasma glucose diagnostic criteria [WHO]
- Symptomatic + 1 abnormal test, or
- Asymptomatic + 2 abnormal tests (same test on different day or 2 different tests on the same day)
| Test | Cut-off value for ‘abnormal test’ |
|---|---|
| Fasting plasma glucose | ≥7.0 mmol/L |
| Random plasma glucose | ≥11.1 mmol/L |
| 2-hour post-oral glucose tolerance test (OGTT) | ≥11.1 mmol/L |
A finger-prick capillary blood glucose can support the initial assessment but should not be used alone to confirm diabetes mellitus. Confirm the diagnosis using laboratory plasma glucose.
HbA1c should not be used to confirm suspected T1DM in children and young people. T1DM can develop rapidly, so HbA1c may not adequately reflect the acute rise in blood glucose.
Step 2 – Determine Type of Diabetes
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 [NICE NG18]
Features suggesting type 2 diabetes [NICE NG18]
- Obesity
- Strong family history of T2DM
- Black / Asian family background
- Features of insulin resistance (e.g. acanthosis nigricans)
- No or little insulin requirement (<0.5 units/kg body weight/day after the partial remission phase)
Features suggesting other types of diabetes (e.g. insulin-resistance syndromes, monogenic or mitochondrial diabetes): [NICE NG18]
- Diabetes in first year of life
- Rarely or never develop ketonaemia during episodes of hyperglycaemia
- Presence of associated features (e.g. optic atrophy, retinitis pigmentosa, deafness, or another systemic illness or syndrome)
Do not routinely measure C-peptide or diabetes-specific autoantibody titres at initial presentation to distinguish type 1 from type 2 diabetes [NICE NG18]
Only consider measuring C-peptide after initial presentation if needed, to distinguish between type 1 diabetes and other types of diabetes [NICE NG18]
- ↓ C-peptide is suggestive of type 1 diabetes
- Rationale: C‑peptide concentrations have better discriminative value the longer the interval between initial presentation and the test
Perform genetic testing if there is atypical disease behaviour, clinical characteristics or family history suggesting monogenic diabetes
Management
Type 1 Diabetes Mellitus (T1DM)
Lifestyle Management
Healthy diet: [NICE NG18]
- Encourage a healthy balanced diet including:
- Low glycaemic index foods
- ≥5 portions of fruit and vegetables/day
- Appropriate types and amounts of fats
- Children with T1DM have the same basic nutritional requirements as other children
- Ensure sufficient energy and nutrients for normal growth and development
Carbohydrate counting education (allows insulin doses to be adjusted according to carbohydrate intake) [NICE NG18]
Exercise: [NICE NG18]
- Encourage regular physical activity
- Children may participate in all forms of exercise with appropriate adjustment of insulin and carbohydrate intake
- Monitor glucose around exercise and be aware that hypoglycaemia can occur during or several hours after exercise
- Take additional carbohydrate when needed to prevent hypoglycaemia and keep carbohydrate-containing food available during and after exercise
Measure height and weight at each clinic visit (abnormal growth or significant weight change may indicate suboptimal glycaemic control) [NICE NG18]
Sick-Day Rules
Sick-day rules in children and adolescents with type 1 diabetes: [ISPAD]
| Changes to insulin therapy | Important rule: NEVER stop insulin (even if the child is ill / vomiting / unable to eat)
Changes to insulin therapy:
|
| Frequent glucose and ketone monitoring |
|
| Maintain hydration | Maintain hydration by giving small, frequent sips every 5-10 min (target ~4-6 mL/kg/hour)
Monitor fluid intake, urine output and check body weight every 4-6 hours (ongoing weight loss indicates worsening dehydration) |
| When to seek medical attention | Seek urgent medical review / emergency hospital transfer if ANY of the following:
|
Blood Glucose Monitoring
Day-to-Day Glucose Monitoring
Monitoring method: [NICE NG18]
- Offer real-time continuous glucose monitoring (CGM)
- If the patient is using CGM, capillary glucose testing is still needed, but less often
- In those who are NOT using CGM → at least 5 capillary blood glucose tests per day
Blood glucose target: [NICE NG18]
- On waking: 4-7 mmol/L
- Before meals: 4-7 mmol/L
- After meals: 5-9 mmol/L
- When driving: ≥5 mmol/L
Long-Term Glycaemic Monitoring
Test of choice for long-term glycaemic monitoring: HbA1c [NICE NG18]
- Target: ≤48 mmol/mol (6.5%)
- Measure HbA1c 4 times per year (more frequent if blood glucose management is difficult)
- Agree an individualised lowest achievable target, taking into account hypoglycaemia risk, activities, comorbidities and circumstances
Do not confuse tests used to diagnose vs glucose monitoring in T1DM:
- Diagnosis → plasma glucose
- Daily control → capillary glucose / continuous glucose monitoring
- Long-term control → HbA1c
If glycaemic targets are difficult to achieve, consider and assess for:
- Non-adherence (non-adherence is common in children and young people)
- Insulin regimen
- Monitoring techniques / device use
- Diet and activity
- Psychosocial factors
Pharmacological Management
Mainstay of management: insulin therapy [NICE NG18]
- 1st line: multiple daily injection basal-bolus insulin regimen
- 2nd line (if multiple daily injections not appropriate): insulin pump (continuous subcutaneous insulin infusion)
Partial remission phase (a “honeymoon period”) when starting to use insulin
After starting insulin, some children with newly diagnosed T1DM enter a temporary partial remission phase due to residual pancreatic β-cell function
- Insulin requirements temporarily decrease
- A low insulin requirement of around ≤0.5 units/kg/day may be sufficient to maintain HbA1c <48 mmol/mol (6.5%)
- Insulin should not be stopped, even during the remission phase
Do not routinely add oral glucose-lowering medicines, including metformin, to insulin therapy in children and young people with T1DM [NICE NG18]
Hypoglycaemia Management
Patients with T1DM and their family / carer should always have access to fast-acting glucose and glucose-monitoring equipment [NICE NG18]
Management of hypoglycaemia: [NICE NG18]
| Hypoglycaemia severity | Management |
|---|---|
| Mild to moderate | Give 10-20 g oral fast-acting glucose
Recheck blood glucose within 15 minutes
|
| Severe (impaired consciousness / seizure or unable to safely take oral treatment) | In hospital + IV access available:
Outside hospital OR rapid IV access unavailable:
Seek medical help if glucose/symptoms do not improve within 10 minutes |
Alcohol use and hypoglycaemia in T1DM: [NICE NG18]
- Alcohol increases hypoglycaemia risk, including overnight
- Eat carbohydrate before and after drinking + monitor glucose
- Alcohol-related severe hypoglycaemia may respond poorly to glucagon → IV glucose may be required
Long-Term Complication Screening
Monitoring for complications and associated conditions: [NICE NG18]
| Condition | When / how to screen |
|---|---|
| Thyroid disease | At diagnosis, then annually until transfer to adult services |
| Diabetic kidney disease | Urine ACR annually from age 12 |
| Hypertension | BP annually from age 12 |
| Diabetic retinopathy | Refer for screening from age 12 (also see the Diabetic Retinopathy article) |
| Coeliac disease | Test at diagnosis (also see the Coeliac Disease article) |
Routine health checks (recommended similarly to children without diabetes): [NICE NG18]
- Regular dental examinations / oral health reviews
- Eye examination by an optician at least every 2 years
Monitoring schedule (presented in an alternative format):
- At diagnosis: thyroid + coeliac
- Every year: thyroid
- From 12 y/o every year: eyes + kidneys + BP
T1DM and T2DM share screening for complications caused by chronic hyperglycaemia, such as nephropathy, retinopathy and hypertension
Thyroid disease and coeliac disease are specifically associated with the autoimmune nature of T1DM, rather than being complications of hyperglycaemia, so they are only part of the routine screening for T1DM, but not T2DM
Type 2 Diabetes Mellitus (T2DM)
Lifestyle Management
Follow the same general healthy eating principles as for T1DM above
Lifestyle management in T2DM places additional emphasis on: [NICE NG18]
- Weight management
- Increasing physical activity (esp. in those who are overweight or obese)
Explain that diet, increased physical activity and reducing excess body weight can improve glycaemic control and may contribute to remission
Blood Glucose Monitoring
Day-to-day monitoring: [NICE NG18]
- Provide capillary blood glucose monitoring equipment at diagnosis (individualise testing frequency)
- Continuous glucose monitoring is NOT routinely offered to all patients with T2DM
- Consider real-time continuous glucose monitoring if the patient requires insulin therapy
- Offer real-time continuous glucose monitoring if capillary monitoring cannot be performed effectively / the child would otherwise need very frequent capillary testing / recurrent or severe hypoglycaemia
Long-term glycaemic monitoring: [NICE NG18]
- HbA1c target: ≤48 mmol/mol (6.5%)
- Measure every 3 months
Pharmacological Management
There are 2 main pathways:
- Standard pathway (most patients)
- Marked hyperglycaemia (HbA1c ≥69 mmol/mol / 8.5%) or insulin deficiency (suggested by ketosis, but without DKA)
1. Standard Pathway
| Step 1: ALL patients at diagnosis | Metformin monotherapy (+ lifestyle management)
Review glucose monitoring data 4 weeks after diagnosis, then at least every 3 months |
| Step 2: if above target* | If >10 y/o → dual therapy
Alternative: consider adding SGLT-2 inhibitor (empagliflozin) |
| Step 3: if still above target* | Triple therapy: add insulin to metformin PLUS liraglutide / dulaglutide / empagliflozin |
*Above target is defined as any of:
|
|
Marked Hyperglycaemia / Insulin Deficiency Pathway
| Step 1: ALL patients at diagnosis | Dual therapy of metformin PLUS insulin (+ lifestyle management)
|
| Step 2: reassess glycaemic control based on target | If within target* → gradually reduce insulin with the aim of stopping it
If above target*:
|
| Step 3: if above target with insulin therapy* | Increase insulin |
*Above target is defined as any of:
|
|
Key difference in management principle from T1DM
- In T1DM, insulin is required lifelong because of absolute insulin deficiency
- In T2DM, insulin started at diagnosis for marked hyperglycaemia or ketosis may be temporary and can be gradually withdrawn if glycaemic targets are achieved
Long-Term Complication Screening
From diagnosis, annually: [NICE NG18]
- Blood pressure → screen for hypertension
- Lipid profile → screen for dyslipidaemia
- Urine ACR → screen for diabetic kidney disease
From 12 y/o: [NICE NG18]
- Diabetic retinopathy screening (also see the Diabetic Retinopathy article)
T1DM and T2DM share screening for complications caused by chronic hyperglycaemia, such as nephropathy, retinopathy and hypertension
Thyroid disease and coeliac disease are specifically associated with the autoimmune nature of T1DM, rather than being complications of hyperglycaemia, so they are only part of the routine screening for T1DM, but not T2DM