gThe dose of standard-release metformin hydrochloride
should be increased gradually to minimise the risk of gastro-
intestinal side-effects.h
There is little experience of the use of other non-insulin
antidiabetic drugs in children, with most evidence
extrapolated from adult studies.
Severalsulfonylureas(such as gliclazide p. 453 ,
glibenclamide p. 453 and tolbutamide p. 453 ) are available
but experience in children is limited; they are not the
recommended choice of treatment in children; therefore
treatment should be initiated by a specialist. The
sulfonylureas may cause hypoglycaemia which may be more
common in children than in adults. Hypoglycaemia is more
likely with long-acting sulfonylureas such as glibenclamide,
which has been associated with severe, prolonged and
sometimes fatal cases—for this reason sulfonylureas are
usually avoided in children.
Treatment of type 2 diabetes
gA target HbA 1 c concentration of 48 mmol/mol ( 6. 5 %)
or lower is ideal to minimise the risk of long-term
complications, however an individualised lowest achievable
target should be agreed with each child and their carers
taking into account factors such as daily activities, individual
life goals, complications, and comorbidities. HbA 1 c
concentrations should be monitored every 3 months.
Note:Consider relaxing the target HbA 1 c level on a case-
by-case basis, with particular consideration for children
where tight blood-glucose control is not appropriate or
poses a high risk of the consequences of hypoglycaemia.
Standard-release metformin hydrochloride is thefirst-line
choice for initial treatment in children and should be offered
from diagnosis, alongside nutrition and lifestyle advice.
If the combination of lifestyle changes and metformin
hydrochloride fails to reduce HbA 1 c to the agreed target
within 3 to 4 months of therapy, addition of a long-acting
insulin or once-daily human isophane insulin p. 457 should
be considered (see also, Insulin p. 447 ).h
gInitiation of insulin should be under specialist
care.l
gMetformin hydrochloride should be continued
alongside insulin, to improve insulin sensitivity. The
combination of metformin hydrochloride and once-daily
insulin is usually an effective treatment for maintaining
glycaemic control in the majority of children for extended
periods of time.
If the combination of basal insulin and metformin does
not achieve the HbA 1 c target (and postprandial
hyperglycaemia persists) addition of prandial rapid- or
short-acting insulin should be initiated and titrated until the
target HbA 1 c is met.hWeight gain may occur and can be
particularly problematic in children with type 2 diabetes
when insulin therapy is initiated, unless there is careful
attention and adherence to dietary measures.gThe
importance of diet and exercise should be emphasised.h
Useful Resources
Diabetes (type and type 2 ) in children and young people:
diagnosis and management. National Institute for Health
and Care Excellence. Clinical guideline NG 18. August 2015
http://www.nice.org.uk/guidance/ng 18.
Diabetic complications
See also
Diabetes p. 445
Type 1 diabetes p. 445
Type 2 diabetes p. 448
Diabetes and cardiovascular disease
Diabetes is a strong risk factor for cardiovascular disease
later in life. Other risk factors for cardiovascular disease
(smoking, hypertension, obesity and hyperlipidaemia)
should be addressed. The use of an ACE inhibitor and of a
lipid-regulating drug can be beneficial in children with
diabetes and a high cardiovascular disease risk. (ACE
inhibitors may also have a role in the management of
diabetic nephropathy).Diabetic nephropathy
Regular review of diabetic children over 12 years of age
should include an annual test for microalbuminuria (the
earliest sign of nephropathy). If reagent strip tests (Micral-
Test II®orMicrobumintest®) are used and prove positive, the
result should be confirmed by laboratory analysis of a urine
sample. Microalbuminuria can occur transiently during
puberty; if it persists (at least 3 positive tests) treatment with
an ACE inhibitor or an angiotensin-II receptor antagonist
under specialist guidance should be considered; to minimise
the risk of renal deterioration, blood pressure should be
carefully controlled.
ACE inhibitors can potentiate the hypoglycaemic effect of
insulin and oral antidiabetic drugs; this effect is more likely
during thefirst weeks of combined treatment and in children
with renal impairment.
See also treatment of hypertension in diabetes.Diabetic neuropathy
Clinical neuropathy is rare in children whose diabetes is well
controlled.Diabetic ketoacidosis
Management
The management of diabetic ketoacidosis involves the
replacement offluid and electrolytes and the administration
of insulin. Guidelines for the Management of Diabetic
Ketoacidosis, published by the British Society of Paediatric
Endocrinology and Diabetes, (available atwww.bsped.org.uk)
should be followed. Clinically well children with mild
ketoacidosis who are dehydrated up to 5 % usually respond to
oral rehydration and subcutaneous insulin. For those who do
not respond, or are clinically unwell, or are dehydrated by
more than 5 %, insulin and replacementfluids are best given
by intravenous infusion.
.To restore circulating volume for children inshock, give
10 mL/kgsodium chloride 0. 9 %as a rapid infusion,
repeat as necessary up to a maximum of 30 mL/kg.
.Furtherfluid should be given by intravenous infusion at a
rate that replaces deficit and provides maintenance over
48 hours; initially usesodium chloride 0. 9 %, changing to
sodium chloride 0. 45 %andglucose 5 %after 12 hours if
response is adequate and plasma-sodium concentration is
stable.
.Includepotassium chloridein thefluids unless anuria is
suspected, adjust according to plasma-potassium
concentration.
.Insulin infusion is necessary to switch off ketogenesis and
reverse acidosis; it should not be started until at least
1 hour after the start of intravenous rehydrationfluids.
.Soluble insulinshould be diluted (andmixed
thoroughly) withsodium chloride 0. 9 %intravenous
infusion to a concentration of 1 unit/mL and infused at a
rate of 0. 1 units/kg/hour.
.Sodium bicarbonateinfusion ( 1. 26 %or 2. 74 %) is rarely
necessary and is used only in cases of extreme acidosis
(blood pH less than 6. 9 ) and shock, since the acid-base
disturbance is normally corrected by treatment with
insulin.BNFC 2018 – 2019 Diabetes mellitus 449
Endocrine system6