Table 1 Summary of the recommendations with GRADE methodology
Sections | Recommendations | GRADE |
|---|---|---|
Screening and diagnosis | Asymptomatic screening is recommended if there is a high body mass index (BMI > 85th centile) and 1 or more of: first- or second-degree family history of type 2 diabetes, high-risk race/ethnicity, gestational diabetes or insulin resistance (acanthosis nigricans or presence of other metabolic conditions, such as hypertension and hyperlipidaemia, PCOS or SGA) | B |
If a diagnosis is suspected based on clinical symptoms, then a point of care random blood glucose must be performed on the same day and abnormal results discussed with the local diabetes team via locally agreed pathways | D | |
Diagnosis can be made based on fasting glucose, or 2-h glucose concentration during an oral glucose tolerance test (OGTT) or HbA1c. Any of the following are diagnostic of diabetes: | B | |
• HbA1c ≥ 48 mmol/mol (6.5%). Must utilise a laboratory-based, DCCT-aligned, National Glyco-haemoglobin Standardization Program (NGSP) certified methodology that is validated for diagnosis. Do not use HbA1c in patients with haemoglobinopathies, within 3 months of transfusion or with increased red cell turnover | ||
• Fasting plasma glucose (FPG) ≥ 7.0 mmoL/L (126 mg/dL) | ||
• Post OGTT 2-h plasma glucose ≥ 11.1 mmoL/L (200 mg/dL), with 1.75 g/kg (max 75 g) anhydrous glucose dissolved in water | ||
• Symptoms of diabetes(including polyuria, polydipsia and unexplained weight loss) and a random plasma glucose > 11.1 mmol/L (200 mg/dL) | ||
• In the absence of symptoms, hyperglycaemia detected incidentally or under conditions of acute physiologic stress may be transitory and should not be regarded as diagnostic of diabetes. Diagnosis should be confirmed with repeat testing on a different day | ||
OGTT need not be done routinely where HbA1c is ≥ 48 mmol/mol (6.5%) and should not be done where HbA1c is < 6.0% (42 mmol/mol). Those with HbA1c 42–48 mmol/mol (6–6.5%) should be evaluated clinically and clinical judgement used to decide between a repeat HbA1c in 3–6 months or an OGTT | GP | |
HbA1c 42–48 mmol/mol (6–6.5%) is diagnostic of pre-diabetes, the management of this is outside the scope of this guideline | B | |
Once diabetes is diagnosed, the type of diabetes should be diagnosed clinically based on signs and symptoms, biochemical investigations, family history and clinical progression. Monogenic diabetes must be considered, especially where the clinical picture is atypical for type 1 or 2. Where there is diagnostic doubt, the patient should receive appropriate safety netting for the possibility of evolving type 1 diabetes (including blood ketone testing) and be re-evaluated after a short period of time | GP | |
Diabetes autoantibody testing (GAD, IA2 and ZnT8) should be considered in paediatric patients with the clinical diagnosis of T2DM because of the high frequency of islet cell autoimmunity in otherwise “typical” T2DM and where there is diagnostic uncertainty for example where symptomatic or those with lean body weight. Those with diabetes antibodies are more likely to need insulin early | B | |
Glycaemic targets | HbA1c should be measured every 3 months in CYP with T2DM | GP |
HbA1c targets should be individualised, noting the low risk of hypoglycaemia | E | |
Intensify treatment if HbA1c not below 48 mmol/mol (6.5%) at 3 months | B | |
Individualise HbA1c Target after the first 3 months but aim to keep below 48mmol/mol (6.5%) | E | |
Self-monitoring of blood glucose | All patients should be taught to self-manage blood glucose (SMBG) and have the necessary equipment provided | GP |
Frequency of SMBG for CYP with T2DM on basal insulin should be individualised including taking into account the risk of hypoglycaemia, glycaemic target and stage of treatment | GP | |
Those not on insulin should be encouraged to test several times a week consisting of both fasting and post-prandial levels to monitor disease progression, provide data for clinical consultations and predict glycaemic control. Testing may be more intense initially and during periods of changing blood glucose levels (e.g. illness or fasting) but may reduce when levels are stable for several weeks | GP | |
Those on multiple daily injections of insulin should undertake SMBG at least 5 times a day to adjust doses and monitor for hypoglycaemia, similar to CYP with T1DM on MDI | GP | |
Fasting, pre-prandial and post-prandial blood glucose level targets should be set to allow patients to monitor their progress. Fasting and pre-prandial levels should ideally be 3–7 mmol/L (3.9–7 mmol/L if on insulin) and post-prandial should aim to be < 10 mmol/L | GP | |
Continuous glucose monitoring | There is no evidence available to routinely recommend the use of CGMS or FGS in children and young people with type 2 diabetes. Individualised considerations such as learning difficulties or needle phobia may influence management. Brief periods of CGMS/FGS may be indicated during treatment intensification or education | GP |
Structured education | Individualised Structured diabetes education should be provided to CYP with T2DM and their carers at the time of diagnosis, revised soon after diagnosis then annually or more frequently dependent on individual need | GP |
No single structured programme is recommended, with TSDE, Be Healthy For Life and iCAN being examples of existing programmes. (http://main.diabetes.org/dorg/PDFs/Type-2-Diabetes-in-Youth/Type-2-Diabetes-in-Youth.pdf). (portal.bsc.gwu.edu/web/today) | C | |
MDT approach | MDT approach (including dietitian, specialist nurse and psychologist support) to T2DM management in children is key to improving outcomes | D |
A unified approach with consistent team messaging improves outcomes | D | |
T2DM should be managed in the secondary care setting with close integration with primary care. GP primary health team members should be involved in the child’s care in line with the whole family approach, and additional resources such as social prescribing and exercise prescription | D | |
Multi-agency working is important to be included in the MDT approach (such a youth support workers, family support workers, patient advocate, schools, school nurses, social workers) | D | |
Telemedicine could help establish regular contact with the MDT in T2DM patients and their families (including home health monitoring, video clinics, telephone, emails and text support) whilst acknowledging that access may be challenging (including digital poverty) | D | |
Collaboration with an adult diabetes MDT team is essential (ideally young adult service) to enable seamless transition and support with complex cases | GP | |
Weight loss | Weight reduction as part of a strategy to reduce BMI should form part of diabetes management in youth with T2DM as this has been associated with better glycaemic outcomes (Grade C) | C |
CYP with T2DM should be offered a family-based weight loss programme based on a range of personalised diet strategies, physical activity and behavioural intervention to treat obesity (Grade B) | D | |
There is currently insufficient evidence in CYP to recommend specific targets for weight loss to control or reverse T2DM | D | |
• Targets should be at minimum in line with accepted recommendations for the management of obesity. It is important to remember that increasing height in pre-pubertal and pubertal young people results in a reduction in BMI. Targets for weight should be set to reduce weight by 5% in the first 3 months in pre-pubertal and pubertal CYP | ||
• Post-pubertal young people should be advised to aim for 5% weight loss in 3–6 months and 10% weight loss in the 1st year | ||
• In the longer term, CYP should be encouraged to aim to reduce BMI to below 85th centile. Professionals need to be aware of this | ||
Dietary Modifications | An individualised and family-wide approach to dietary modification is essential. A specialised paediatric diabetes dietitian should work together with the family to identify potential diet and lifestyle changes and formulate a plan with SMART (specific, measurable, achievable, relevant, time bound) goals [4,5,6] | B |
Regular follow-up appointments with a specialised paediatric diabetes dietitian are essential to monitor progress and review goals. Additional appointments with the specialised paediatric diabetes dietitian outside the MDT every 4–8 weeks should be considered | GP | |
Families should be encouraged to follow a healthy balanced diet that is rich in wholegrains, vegetables, fruit, low-fat dairy, nuts and seeds and limits fats, oils and sugary foods [7,8,9,10,11,12,13,14] | B | |
Families should be encouraged to consume balanced meals including complex carbohydrate, protein and vegetables to regulate appetite and improve satiety after a meal [15,16,17,18] | B | |
C | ||
If there has been no significant weight loss 6 months after diagnosis while aiming to implement a healthy balanced diet, then alternative approaches can be considered. There is limited evidence in paediatrics that one particular dietary intervention is more successful than another therefore evidence has been extrapolated from adult data. One of the following approaches to promote weight loss can be considered: | ||
• A healthy low-fat diet (limits fat to 30% of energy intake, 45–50% of energy from carbohydrates and 20–25% of energy from protein) [9, 24] | B | |
• A lower carbohydrate diet(limits carbohydrate to 30% of energy intake,45% of energy from fat and 20% of energy from protein) [25] | D | |
• A low-energy diet using either meal replacement products or a guided amount of calories from food at each mealtime that limits energy intake to 800kcal a day for an 8–12 week period (post-pubertal, individualised, adult data). This initial phase is followed by the gradual reintroduction of a healthy balanced diet. This may be a suitable treatment option for young people who are keen to follow a structured plan. Careful consideration should be given to the appropriateness of this option and take in to account life events such as exams, learning to drive and family celebrations [10, 26,27,28,29,30] | C | |
Physical Activity | Physical activity levels recommended for CYP with T2DM are the same as for young people without T2DM across countries (UK, USA, Europe) and the suggestion is for 60 min per day of moderate/vigorous physical activity to improve body composition and insulin sensitivity | B |
For CYP with T2DM, exercise may need to occur in more than one session a day or start with a lesser amount and build up as able | GP | |
Psychological management | CYP must have on-going access to mental health professionals embedded within a diabetes team | GP |
All CYP should be screened for mental health regularly by a team member (at least annually, or more frequently with inadequate diabetes control) including depression and eating disorders | GP | |
• The PedsQLTM Diabetes Module is a specific module of the PedsQLTM freely available for clinical use through registration—https://eprovide.mapi-trust.org/instruments/pediatric-quality-of-life-inventory. It effectively screens for diabetes-related quality of life. PHQ-2 is used for screening for depression | ||
• There is no suitable validated eating disorder questionnaire that adequately screens for binge eating in this population. However, the Adolescent Binge Eating Disorder Questionnaire ADO-BED has been validated in young people with obesity to identify those at risk of binge eating disorder (https://www.medicalhomeportal.org/link/6884) | ||
Pharmacotherapy | Metformin monotherapy is effective in achieving metabolic control in youth with T2DM at least initially after diagnosis | A |
Initial treatment with insulin ± metformin based on metabolic state and ketosis. Metabolically unstable CYP with diabetes being started on s/c or IV insulin | D | |
Once daily basal insulin with a starting dose of 0.25–0.5 units/kg/day. Evidence for HbA1c cut off 69 mmol/mol (8.5%) Maximum dose of basal insulin 1.5 units/kg | C | |
Weaning off insulin after initial treatment | A | |
Evidence for HbA1c cut off 69 mmol/mol (8.5%) | C | |
Addition of insulin if metformin monotherapy fails and beta cell loss | A | |
Prandial insulin and dose | E | |
Liraglutide as an adjunct | B | |
Bariatric surgery | Bariatric surgery in adolescents with BMI > 35 kg/m2 shows clear benefit in remitting T2DM | A |
Surgery should be considered as an option for treatment of obesity-related T2DM for obese CYP who are demonstrating inadequate response to pharmacological treatments within 12–18 months to avoid a reduction in beta-cell mass | GP | |
Bariatric surgery is effective in inducing remission and reducing the progression in diabetic nephropathy and improving hypertension | C | |
Bariatric surgery has been demonstrated to stabilise the progression of diabetic retinopathy (DR) but evidence for long-term resolution of DR is currently not available | D | |
Monitoring of long-term complications post-bariatric surgery in CYPs is required for nutritional deficiencies and metabolic bone health | B | |
There is inadequate data to support bariatric surgery in prepubertal children with obesity-related T2DM with limited data on long-term outcomes | GP | |
Hypertension | Blood pressure should be measured, using an appropriately sized cuff, at every clinic appointment — at least four times per year | D |
Blood pressure readings should be interpreted using a paediatric blood pressure centile chart | B | |
Hypertension is defined as systolic or diastolic pressure equal to or greater than the 95th centile for age and sex on 3 separate occasions. If there is any concern about transient, stress-related, high blood pressure readings (white coat syndrome) ambulatory blood pressure monitoring should be considered | B | |
Increased BMI is a risk factor for developing hypertension and should be measured at every clinic appointment | B | |
Once a diagnosis of hypertension has been made initial treatment should focus on weight reduction, exercise and reducing salt in-take [31] | C | |
If after 6 months blood pressure is still above the 95th centile for age, consider starting an ACE inhibitor [32]—the teratogenic risks of ACE inhibitors should be discussed with female adolescents and steps advised to mitigate against these risks, before starting treatment | ||
• ACE inhibitors are particularly beneficial in young people with diabetes due to their reno-protective effect. Take advice from an adult diabetologist/paediatric nephrologist regarding other options | B | |
• For the Afro-Caribbean population, consideration should be given to other causes of hypertension (refer to hypertension guidelines) but it is likely to be due to metabolic syndrome | ||
• The more common side effects of ACE inhibitors—abnormalities in sodium and potassium can be mitigated against by monitoring electrolytes with a blood test before starting treatment and at 4–6 weeks afterwards. Hypotension—consider a test dose with pre- and post-blood pressure monitoring on a paediatric assessment unit before starting regular treatment | D | |
The aim of treatment should be to reduce blood pressure to less than the 90th centile for age, height and gender | B | |
If ACE inhibitors are not tolerated (the most common side effect, is a dry cough) angiotensin receptor blocker should be used [31] | D | |
If, despite treatment, blood pressure is not lowered below the 90th centile referral to a tertiary hypertension service would be appropriate [31] | D | |
Lipids | Lipid testing should be performed when initial glycaemic control has been achieved or after 3 months of treatment, and annually thereafter | B |
The initial screening lipid profile does not need to be a fasted sample. Use non-HDL-C level for initial screening | A | |
Lipid targets are: | ||
◦ LDL-C < 2.6 mmol/L (100 mg/dL) | ||
◦ HDL-C > 0.91 mmol/L( 35 mg/dL) | ||
◦ Triglycerides < 1.7 mmol/L(150 mg/dl) | ||
◦ Non HDL-C < 3.6 mmol/L (140 mg/dL) | ||
If abnormal profile, initial treatment is by diet modification and improved glycaemic control | A | |
• Limit calories from total fat to 25–30% | ||
• Limit saturated fat to < 7% | ||
• Limit cholesterol to < 200 mg/day | ||
• Avoid trans fats | ||
• For elevated LDL, aim for about 10% calories from monounsaturated fats | ||
• For elevated triglycerides, decrease simple sugar intake and increase dietary n-3 fatty acids in addition to the above changes. (A) [33] | ||
A repeat lipid profile should be performed at 6 months following the dietary intervention and weight management (fasted) | B | |
If repeat fasting LDL-C remains > 3.4 mmol/L (130 mg/dL), treatment with a statin should be commenced. The ideal treatment target is to reduce the LDL-C to < 2.6 mmol/L (100 mg/dL) | B | |
Statins can be used in children over the age of 10 years with type 2 diabetes [34,35,36] | A | |
• High-intensity statins are recommended for the treatment and prevention of cardiovascular disease in patients with T2D. Atorvastatin and rosuvastatin are recommended as can achieve a high-intensity LDL-C lowering effect (> 40%) at lower doses than other statins. They can be prescribed in CYP 10–17 years old (BNFc) | ||
• Statins should be started at the lowest available dosage (atorvastatin 10 mg daily, rosuvastatin 5 mg daily) and increased based on response and side effects | ||
• If LDL-C target levels are not achieved with at least 3 months of compliant use the dose should be increased by 1 increment (usually 10 mg). The dose can be increased by a further increment after a further 3 months or a second agent could be added under the guidance of a lipid specialist (e.g. bile acid sequestrant or cholesterol absorption inhibitor) | B | |
• Liver enzymes should be measured before treatment and repeated within 3 months and at 12 months of starting treatment | ||
• Statins should be used with caution in patients at increased risk of muscle toxicity, including those with a personal or family history of muscular disorders, previous history of muscular toxicity, a high alcohol intake, renal impairment or hypothyroidism. Creatinine kinase concentration should be measured in children before treatment and if unexplained muscle pain occurs. Hypothyroidism should be treated before starting statin treatment. (NICE, BNFc) | B | |
• Statins are teratogenic and contraindicated in pregnancy — caution with use in adolescent girls | ||
If fasting triglycerides are > 5.6 mmol/L (400 mg/dL) or > 11.3 mmol/L (> 1000 mg/dL) non-fasting, there is a risk of developing pancreatitis | C | |
Fibrates can be used in children over the age of 10 years for significant hypertriglyceridaemia | A | |
There are no good RCTs to support the use of omega-3 or fish oils in children or adolescents [37]. Studies have shown benefits in adults in reducing triglyceride levels | A | |
Recommend smoking cessation | B | |
NAFLD | Initial screening with ALT at diagnosis and annually thereafter if normal results | B |
Investigate for NAFLD/NASH and other causes of liver disease if persistently raised ALT (> 2 × ULN) as ALT not specific for NAFLD | C | |
Consider referral to paediatric hepatology/gastroenterology if ALT levels > 3 × ULN despite dietary modifications and improved glycaemic control | A | |
General dietary and lifestyle advice aiming to achieve weight reduction is important however there are currently no specific dietary recommendations shown to reverse or slow the progression of NAFLD | A | |
Management of extrahepatic co-morbidities known to accelerate NAFLD ie insulin resistance and dyslipidaemia is important; however, there are no currently recommended pharmacological treatments specifically for treating NAFLD in children | B | |
Assessment and treatment of co-morbidity (obstructive sleep apnoea, vit D deficiency) | GP | |
Psychological support is important | GP | |
Retinopathy | Diabetic retinopathy screening should start from the age of 12 and annually thereafter, in line with ace advice | B |
Improvement in glycaemic control remains the cornerstone of primary prevention and also mitigates progression once retinopathy has developed | B | |
Adult literature recommends treatment of hypertension and dyslipidaemia in the presence of diabetic retinopathy | B | |
Sudden intensification of glycaemic treatment with a rapid reduction in HbA1c may lead to a rapid progression of retinopathy | B | |
Micro-albuminaemia | Monitoring for albuminuria should commence at the time of diagnosis and annually thereafter by using the early morning spot urine (EMU) for albumin to creatinine ratio (ACR) | B |
An elevated urine ACR of above 3 mg/mmol, should be confirmed by repeating the test on 2 further occasions on different days within a 3- to 6-month period | B | |
For moderately elevated albuminuria (Urine ACR 3–30 mg/mmol), a multidisciplinary team approach should be applied to improve glycaemic control along with targeting other risk factors(smoking, obesity and hypertension) for albuminuria to improve the outcome | B | |
Use an ACE-inhibitor (ACE-I) or angiotensin receptor blocker (ARB), in non-pregnant patients with type 2 diabetes in the following circumstances: | B | |
• For those with moderately increased albuminuria (3–30 mg/mmol) | ||
• For those with severely increased albuminuria (> 30 mg/mmol) | ||
Referral to specialist renal/Kidney care services is recommended for children and young person (CYP) with chronic kidney disease (CKD) in the following circumstances: | B | |
• GFR < 30 ml/min/1.73 m2 and/or consistent finding of significant albuminuria (> 30 mg/mmol) or albumin excretion rate (AER) > 300 mg/24 h | ||
• Significant haematuria | ||
• Renal structural abnormality on ultrasound | ||
Obstructive sleep apnoea | The gold standard diagnostic test is overnight laboratory PSG, which allows for the quantification of episodes of apnoea and hypopnoea per hour of sleep | B |
Clinical signs and symptoms are not always specific. A validated sleep questionnaire may be helpful. Clinicians should have a high index of suspicion for SA | B | |
If symptoms and home sleep monitoring devices are suggestive, the diagnosis of OSA should be made by formal polysomnography and referral to sleep specialist for further management | B |