Diabetes in children & young people (NICE 2015)
Given the epidemiology of diabetes, most Health Care Professionals spend a significant amount of time treating Type 2 adult patients, often at the expense of a very vulnerable group of patients, specifically young people. The epidemiology of diabetes in this group is also changing as, due to the rise in obesity, it is increasingly common to see a young person with Type 2 diabetes. As a result, it is timely that NICE has published guidance for this group of patients, an update from their original 2004 document. In fact, early in their guidance, the possibility of Type 2 diabetes is raised at time of diagnosis in certain groups including patients of S Asian origin or show signs of insulin resistance (e.g. acanthosis nigricans). There is also increasing recognition of different sub types of diabetes e.g. monogenic with advice around genetic testing and C-peptide measurement. Whilst most children will be managed in secondary care, there are several developments within this guidance which will impact on service delivery. Specifically, this includes enhanced patient (and family) education, a requirement to attend clinic 4 times per year as well as further advice on retinal screening. There is some advice on transition from paediatric to adult care although given the importance of this period, guidance is surprisingly brief especially the potential benefits of psychological services in diabetes care. The lack of recommendations about transition contrasts with the large detailed description on ketoacidosis management, despite DKA guidance being a summary of recommendations from the Joint British Diabetes Societies.
Unsurprisingly, the main sections refer to glycaemic control including targets and drug use. An HbA1c<48mmol/mol (6.5%) is recommended and although an individualised target is suggested, special reference is given to those whose HbA1c is>53mmol/mol. Glycaemic targets have been divided into the management of both T1 and T2 patients. For both, a patient centred approach is advised but a basal bolus regimen is recommended as first line with pump therapy another early option especially if good control is not possible. Obviously dietary modification including carbohydrate counting is required – assuming dietetic services are adequate. As a contrast to T1 management in adults, Metformin is not recommended due to lack of evidence yet the sustained release preparation is considered first line in children with T2 diabetes. Guidelines for this group of patients are the most significant change since 2004 in recognition of their growing number with extensive advice given about lipid, blood pressure and renal complications.
Overall, this new and updated guidance in an important patient group from NICE is welcome however, as ever, the challenge will be its implementation especially those sections where funding and service delivery need addressing.
Dr Mark Freeman