Diabetes Type II in Children

 

Diabetes is a long-term condition that can have a major impact on the life of a child or young person, as well as their family or carers. In addition to insulin therapy, diabetes management should include education, support and access to psychological services

Preparations should also be made for the transition from paediatric to adult services, which have a somewhat different model of care and evidence base

Since 2004 type 2 diabetes is being diagnosed with increasing frequency.  Much of the general care for type 2 diabetes is the same as for type 1 diabetes, although the initial management is different

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Diabetes Type II

Education and information

Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis.  Ensure that the programme includes the following core topics:

  • HbA1c monitoring and targets
  • the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control
  • the aims of metformin therapy and possible adverse effects
  • the complications of type 2 diabetes and how to prevent them

Smoking and substance misuse

  1. Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) about general health problems associated with smoking and in particular the risks of developing vascular complications
  2. Offer smoking cessation programmes to children and young people with type 2 diabetes who smoke
  3. Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) about the general dangers of substance misuse and the possible effects on blood glucose control

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Immunisation

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

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Dietary management

At each contact with a child or young person with type 2 diabetes, explain to them and their family members or carers (as appropriate) how healthy eating can help to:

  • reduce hyperglycaemia
  • reduce cardiovascular risk
  • promote weight loss

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

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HbA1C targets and monitoring

  1. Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long-term complications
  2. Measure HbA1c levels every 3 months in children and young people with type 2 diabetes

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Psychological and social support

NOTE:  Diabetes teams should be aware that children and young people with type 2 diabetes have a greater risk of emotional and behavioural difficulties

Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs

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Monitoring of complications

Offer children and young people with type 2 diabetes annual monitoring for:

  • hypertension starting at diagnosis
  • dyslipidaemia starting at diagnosis
  • diabetic retinopathy from 12 years
  • moderately increased albuminuria (albumin:creatinine ratio [ACR] 3–30 mg/mmol; 'microalbuminuria') to detect diabetic kidney disease, starting at diagnosis

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Hypertension

  1. Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that monitoring is important because if hypertension is found, early treatment will reduce the risk of complications
  2. If repeated resting measurements are greater than the 95th percentile for age and sex, confirm hypertension using 24-hour ambulatory blood pressure monitoring before starting antihypertensive therapy

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Dyslipidaemia

  1. When monitoring for dyslipidaemia in children and young people with type 2 diabetes, measure total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol and triglyceride concentrations
  2. Confirm dyslipidaemia using a repeat sample (fasting or non-fasting) before deciding on further management strategies

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Diabetic retinopathy

Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:

  • background retinopathy is often found through monitoring, and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy
  • annual monitoring from 12 years is important because, if significant diabetic retinopathy is found, early treatment will improve the outcome

GPs should refer children with type 2 diabetes to local eye screening services on diagnosis. Begin screening at age 12, and perform this as soon as possible (no later than 3 months after referral date or 12th birthday if referred before age 12)

Consider referring children and young people with type 2 diabetes who are younger than 12 years to an ophthalmologist for retinal examination if blood glucose control is suboptimal

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Diabetic kidney disease

Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:

  • using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria (ACR 3–30 mg/mmol; 'microalbuminuria') is important, as this reduces the risk of false positive results
  • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease
  • annual monitoring (see recommendation 1.3.43) is important because, if diabetic kidney disease is found, early treatment will improve the outcome

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Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio. If the first urine sample of the day is not available, use a random sample, but be aware that this is associated with an increased risk of false positive results

If the initial albumin:creatinine ratio is above 3 mg/mmol but below 30 mg/mmol, confirm the result by repeating the test on 2 further occasions using first urine samples of the day ('early morning urine') before starting further investigation and therapy

Investigate further if the initial albumin:creatinine ratio is 30 mg/mmol or more (proteinuria)

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Transition from Paediatric to Adult Care

  1. Agree specific local protocols for transferring young people with diabetes from paediatric to adult services
  2. Base the decision about the age of transfer to the adult service on the young person's physical development and emotional maturity, and local circumstances

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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