CLINICAL GUIDELINE FOR THE MANAGEMENT OF CHILDREN
AND YOUNG PEOPLE WITH NEWLY PRESENTING DIABETES
1. Aim/Purpose of this Guideline
1.1. This guideline applies to medical and nursing staff caring for children and
young people presenting with newly diagnosed diabetes.
2. The Guidance
2.1 Children under the age of 16 years with newly diagnosed, or suspected diabetes,
should be seen on the Paediatric Observation Unit on the same day.
 Those aged 16 years, and still in school year 11, can be managed initially
within paediatrics, to allow education of school staff.
2.2 Diabetes is diagnosed by the presence of symptoms of diabetes (polyuria and
polydipsia) and a random laboratory plasma glucose of ≥11.1mmol/l. (1,3,4,5)
 If there are no symptoms, this may be stress-induced hyperglycaemia: see
section 2.7
2.3 Ward nursing staff should:
 perform baseline observations including BP, weight and height the child
and apply topical local anaesthetic cream on arrival
 do capillary blood glucose and blood ketones
 inform a doctor immediately if:
- they are concerned that the patient is ‘unwell’,
- or the patient’s observations meet Paediatric Early Warning Score of
3 or more,
- or blood ketones are >1.5 mmol/l,
- or the patient has any of the symptoms of possible DKA (section
2.4),
- or the patient has a headache: this could represent cerebral
oedema, even if they are not in DKA.
2.4 Consider Diabetic Ketoacidosis (DKA) in any child who is vomiting, or who has
abdominal pain, is drowsy, dehydrated, or is breathing rapidly and deeply
(Kussmaul respirations).
 If DKA is suspected then venous access should be obtained as soon as
possible and bloods taken as per section 2.6.

DKA
-

If DKA is confirmed they should be managed by:
- following the South West DKA Care Pathway (2),
- informing the paediatric registrar and the consultant on call.
is diagnosed by (2):
pH < 7.3 and/or bicarbonate < 15 mmol/l
blood glucose >11 mmol/l
and blood ketones of ≥ 1.5 mmol/L
Clinical Guideline for the management of children and young people with newly presenting diabetes.
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2.5 The majority of children presenting with diabetes will be well. In this situation:
 document a full medical history including:
 medication history (particularly steroid use)
 family history (particularly of diabetes and other autoimmune conditions)
 social history
 school attended
 document a full examination, particularly signs of dehydration
 do fundoscopy to check no cataracts are present (these occur in 0.7%
of children presenting with diabetes secondary to metabolic disturbance).
(7)

plot height and weight on a growth chart.
2.6 Insert an intravenous cannula and take bloods:
 All of these tests (except bedside glucose and ketones) are included in the
‘Paed New Diabetic’ order set on Maxims which is on the right hand side of the
‘Paediatrics’ specialty order page.
Blood test
Blood gas
Adult
Vacutainer *
Paediatric
Bottle
Capillary tube (HDU or lab)
Blood glucose and
ketones
Grey
Yellow
Renal function,
bicarbonate,
immunoglobulins
Gold
Green (Li
hep)
Thyroid function
Gold
Green (Li
hep)
HbA1c
Purple**
Pink
(EDTA)**
FBC
Purple**
Pink
(EDTA)**
GAD and IA2
antibodies***
1 adult Gold bottle (does not
have to be completely full) is
better than multiple
paediatric clear bottles
Special
instructions
Green clinical
chemistry (if
lab gas)
Hand deliver
to lab
N/A
N/A
Green, clinical
chemistry
N/A
Red,
haematology
N/A
Bedside meter
Laboratory glucose
Coeliac screen (anti
TTG)***
Form
If possibility of infection: consider CRP, blood culture and urine MCS
*
**
***
if you want to fill Adult Vacutainers with blood from a syringe, then remove
the lid before putting blood in the bottle (do not put the needle through the lid
and push the blood in otherwise the lid will pop off and spray blood
everywhere).
Fill the EDTA bottle last because EDTA contamination can affect
biochemistry results.
if any queries regarding these tests, contact immunology on ext 3040.
Clinical Guideline for the management of children and young people with newly presenting diabetes.
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2.7 Other causes of hyperglycaemia:
 If there are no symptoms and blood ketones are <0.6 mmol/l, consider stressinduced hyperglycaemia, which is likely to be transitory. In this case, monitor
capillary blood glucose and ketone levels and plan a fasting laboratory plasma
glucose level with HbA1c and GAD and IA2 antibodies. Diabetes is confirmed
by a fasting plasma glucose ≥ 7 mmol/l. An oral glucose tolerance test can also
be considered and can be discussed with the diabetes consultants.(1,3,4,5)
However if the blood ketones rise above 1.5 mmol/l at any point, then
insulin should be started as per section 2.9.
 Consider type 2 diabetes if the child has a long duration of symptoms, is obese,
has a family history of type 2 diabetes, or is of non-white ethnicity. In this case,
examine the child for acanthosis nigricans, which is velvety, hyperpigmented
skin in the body folds eg neck and axillae. Acanthosis is often associated with
insulin resistance, although is not specific to this. However, even if type 2
diabetes is suspected, it is safer to treat initially with insulin as per
section 2.9.
2.8 If the diagnosis of diabetes is confirmed:
 A doctor should explain to the child and parents:
- that the purpose of the admission is to confirm the diagnosis, initiate
treatment and to start to educate them in how to manage diabetes.
- a brief explanation of diabetes. They should be given the Diabetes UK
magazine and the ‘Journey of a Lifetime’ DVD to watch: these should
both be available in the diabetes box in the cupboards in the Paediatric
Observation Treatment Room or Fistral Storeroom.
 Initial management must be discussed with:
- the paediatric registrar
- and the Paediatric Diabetes Specialist Nurses (PDSN): available
between 08.00 and 20.00 hours Monday to Sunday (see contact details
page 5)
 If the child is in DKA:
- Treat as per DKA Care Pathway and inform consultant on call.
 If the child is not in DKA:
- The consultant on call can be informed the following day (weekday or
weekend).
 The PDSN will inform the relevant diabetes consultant of the child’s admission.
2.9 Subcutaneous Insulin Regime
All children, even those with suspected type 2 diabetes, should start on a
Multiple Daily Injection (MDI) insulin regime, which should be prescribed as
follows using the instructions on the PAPER Paediatric Insulin Prescription
Sheet:
A. Lantus Insulin (long-acting)
 For all ages prescribe Lantus Insulin 3ml cartridges via JuniorStar pen.
 If less than 2 years old:
- 0.2 Units/kg/dose once daily at breakfast time (round down to nearest
half unit)
Clinical Guideline for the management of children and young people with newly presenting diabetes.
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
- If admitted after breakfast, but within 6 hours after their usual bedtime,
then give the Lantus at the time of admission and then bring forward
subsequent doses by 2-6 hours a day towards breakfast time.
- If admitted more than 6 hours after their usual bedtime, then the first
dose of Lantus will not be given until breakfast time and Novorapid can
be given as detailed below.
If 2 years old and over:
- Lantus should be given at bedtime.
- between 2 years old and 10 years old: 0.2 units/kg/dose once daily at
bedtime (round down to nearest half unit
- If 10 years old and over: 0.3 units/kg/dose once daily at bedtime (round
down to nearest half unit)
- If admitted at night after their usual bedtime and before breakfast:
 If it is within 6 hours of their normal bedtime, then the Lantus dose
can still be given.
 If it is more than 6 hours after their usual bedtime, then the first
dose of Lantus will not be given until the next bedtime and
Novorapid can be given as detailed below.
B. NovoRapid insulin (Rapid-Acting)
 With Main Meals:
- If less than 10 years: 0.1 units/kg/dose with main meals 3 times a day.
- If 10 years or over: 0.15units/kg/dose with main meals 3 times a day
(round down to nearest half unit)
- This is usually given immediately before eating, but if their appetite is
unpredictable eg toddlers, then it may be given immediately after
eating.
 With Snacks:
- Prescribe quarter the main meal dose to cover all snacks (rounded
down to nearest half unit – if works out to less than 0.5 units then do not
give any Novorapid to cover snacks)
 Novorapid Correction dose:
- should be prescribed to be given if:
 it is more than 2 hours since the last dose of Novorapid
 AND
- blood ketones ≥1.5 mmol/l and blood glucose ≥ 15mmol/l
at ANY TIME
- OR if Blood glucose >20 mmol/l during the day and at
bedtime
- calculated as 0.05 units/kg (rounded down to nearest 0.5 unit).
- repeat blood glucose and ketones levels 2 hours later.
2.10 Ongoing Management in Hospital
The aim of the hospital admission is to provide support and education(1,5) and to turn off
any ketone production and to start aiming for optimal diabetes control. This will be
achieved over the next few weeks. The child and/or carer should be encouraged to
perform blood glucose testing and insulin injections as early as possible.
Clinical Guideline for the management of children and young people with newly presenting diabetes.
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a) Capillary blood glucose should be performed pre-meals, 2 hours after
meals/before snacks, pre-bed, and at 2-3 am and should be recorded on the
Paediatric Insulin Prescription Sheet (Section F on page 4 or on the continuation
sheets). Blood glucose levels will need to be done more often, 2 hourly, if:
 the blood glucose falls to ≤ 5 mmol/l
 or blood glucose rises to ≥ 15 mmol/l OR blood ketones are rising or ≥ 1.5
mmol/l.
 2 hours after a Novorapid Correction dose.
b) Blood ketones should be done:
 if the blood glucose is ≥ 15 mmol/l.
 2 hourly if the previous ketone level was 0.6 mmol/l or above.
c) The diabetes team will see the child and family daily during admission and they will
decide when the child and family are ready for discharge. We are aiming to avoid
hypoglycaemia in hospital and when the child goes home and starts exercising. To
know that the child is safe from developing DKA (ie has a reasonable insulin level to
turn off ketone production), the child needs to have blood ketones < 0.6 mmol/l before
discharge and tolerate their blood glucose between 4 and 20mmol/l.
d) The Paediatric Diabetes Dietitian should be informed of the admission: see contact
details below.
- The child and their family will be seen by the Paediatric Diabetes Dietitian within
2 working days of admission.
- The family should be seen by the Dietitian twice within the first week of
diagnosis. If the family are discharged before their second review they will need
to return to the Paediatric Observation Unit to continue dietetic education.
Please ensure this appointment is arranged before discharge.
e) The PDSN should inform the Paediatric Research Nurses of the admission so that
they can ask the family if they would like to take part in a research study called Address
2: see contact details below.
f) Discharge prescription for pharmacy:
 E-discharge JACS: use the Insulin Treatment protocols as follows:
i.
‘PAEDIATRIC LANTUS & NOVORAPID INSULIN REGIMEN’
ii.

And the ‘PAEDIATRIC DIABETIC ACCESSORIES’. This excepts
Novofine Needles which are not a pharmacy line and are provided by the
PDSN. Need to remember to change Glucagon dose according to weight
(see below).
If JACS is not working and you need to do a handwritten TTO, they should be
prescribed the following:
- Lantus (Glargine) Insulin 3ml cartridges x 1 box of 5
- Novorapid 3ml Penfill cartridges x 1 box of 5
- Glucagon 1mg/ml x 1 GlucaGen HypoKit (second to be prescribed by
GP):
Body weight less than 25kg give 0.5mg PRN
Body weight of 25kg or more give 1mg PRN
- Glucose 40% oral gel x 1 box of 3 tubes (second to be prescribed by GP)
- Glucose 4g tablets x 1 box
Clinical Guideline for the management of children and young people with newly presenting diabetes.
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-
Optium Xceed beta ketone blood test strips x 1 box of 10
Accu-Chek Aviva blood glucose test strips x 2 boxes of 50
Accu-Chek Fastclix Drums x 1 box
Novofine needles 4mm, 1 box of 100 and sharps bin (given by nurses
as non-pharmacy items.
g) The PDSN will arrange an outpatient appointment with the appropriate diabetes
consultant within the next 6 weeks.
Contact details
 Paediatric Diabetes Specialist Nurses: 08.00 – 20.00, daily Monday to Sunday, by pager
via switch for initial diagnosis. Office ext 4567.
 Paediatric Diabetes Consultants
- Dr Katie Mallam: ext 2637 or mobile via switch
- Dr Simon Robertson: ext 2716 or mobile via switch
 Paediatric Dietitians: ext 2409 messages can be left
 Play Specialists for procedure therapy: Bleep 2948
 Paediatric Research Nurses: ext 5138/5139 or contact via Groupwise
Clinical Guideline for the management of children and young people with newly presenting diabetes.
Page 6 of 12
3 Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
Compliance with guidance
Diabetes team (Dr Katie Mallam)
Audit
If any problems identified, or minimum 3 yearly
Diabetes team and Directorate Audit and Guidelines meeting
Audit lead and diabetes team
Required changes to practice will be identified and actioned within
a specified time frame. A lead member of the team will be
identified to take each change forward where appropriate. Lessons
will be shared with all the relevant stakeholders
4 Equality and Diversity
This document complies with the Royal Cornwall Hospitals NHS Trust service Equality
and Diversity statement.
Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Clinical Guideline for the management of children and young people with newly presenting diabetes.
Page 7 of 12
Appendix 1. Governance Information
Document Title
Clinical guideline for the management of
children and young people with newly
presenting diabetes.
Date Issued/Approved:
July 2015
Date Valid From:
July 2015
Date Valid To:
July 2018
Directorate / Department responsible
(author/owner):
Katie Mallam paediatric consultant
Contact details:
01872 252637
Brief summary of contents
Guideline for standardised care of children
and young people with newly presenting
diabetes.
Diabetes
Children
Diagnosis
New
RCHT

Suggested Keywords:
Target Audience
PCH
CFT
KCCG
Executive Director responsible for
Policy:
Date revised:
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Clinical guideline for the management of
children and young people with newly
presenting diabetes. Version 3 Nov 2014
Paediatric Diabetes team
Paediatric consultants
Directorate audit and guidelines
Divisional Manager confirming
approval processes
Name and Post Title of additional
signatories
Not Required
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
Document Library Folder/Sub Folder
Internet & Intranet
Paediatrics
Clinical Guideline for the management of children and young people with newly presenting diabetes.
Page 8 of 12
 Intranet Only
Links to key external standards
(1) NICE Clinical Guideline 15. Type 1
Diabetes: diagnosis, and management
of type 1 diabetes in children, young
people and adults. July 2004
(2) BSPED (British Society of Paediatric
Endocrinology and Diabetes)
Recommended DKA Guidelines 2009
(minor review 2013),
http://www.bsped.org.uk/clinical/docs/DK
AGuideline.pdf, or the Southwest
Diabetes Regional Network Integrated
Care Pathway for Children with Diabetic
Ketoacidosis.
(3) Definition and Diagnosis of Diabetes
Mellitus and Intermediate
Hyperglycaemia. Report of WHO/IDF
Consultation 2006.
(4) ISPAD Clinical Practice Consensus
Guidelines 2009 Compendium. Ragnar
Hanas, Kim C. Donaghue, Georgeanna
Klingensmith, Peter G.F. Swift; Pediatric
Diabetes 2009: 10(Suppl. 12).
(5) Care of the well child newly diagnosed
with Type 1 Diabetes Mellitus, Clinical
Guideline, Association of Children’s
Diabetes Clinicians, December 2012.
Related Documents:
Training Need Identified?
No
Version Control Table
Date
Versio
n No
Summary of Changes
March
2012
V1.0
Initial Issue
October
2013
V2.0
Review and Update
Re format in current template
November
V3.0
2014
Changes Made by
(Name and Job Title)
Dr. Mallam, Dr.
Robertson, Anita
England, Trish Shaw,
Michelle Skews, Pip
Ali- Diabetes Team.
Dr. Mallam- Paediatric
consultant Tabitha
Fergus- Deputy ward
manager
Dr Mallam and
Paediatric Diabetes
Team
Update
Clinical Guideline for the management of children and young people with newly presenting diabetes.
Page 9 of 12
May 2015 V4.0
Update (main changes: reduced Novorapid
snack dose and changed PDSN on call hours)
Dr Mallam and
Paediatric Diabetes
Team
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Clinical Guideline for the management of children and young people with newly presenting diabetes.
Page 10 of 12
Appendix 2. Initial Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to
as policy) (Provide brief description): clinical guideline for the management of children and
young people with newly presenting diabetes.
Directorate and service area: child health Is this a new or existing Policy? Existing
Name of individual completing
Telephone: 01872 252000
assessment: T.Fergus
1. Policy Aim*
To provide clear standardised care for children and young people with
Who is the strategy /
newly presenting diabetes.
policy / proposal /
service function
aimed at?
2. Policy Objectives*
Clear standardised care for children and young people with newly
presenting diabetes.
3. Policy – intended
Outcomes*
Standardised care for children and young people with newly
presenting diabetes.
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
audit
Children, young people and families
no
b) If yes, have these
*groups been
consulted?
C). Please list any
groups who have
been consulted about
this procedure.
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age
Yes
No
X
Rationale for Assessment / Existing Evidence
Clinical Guideline for the management of children and young people with newly presenting diabetes.
Page 11 of 12
Sex (male, female, trans-
X
gender / gender
reassignment)
Race / Ethnic
communities /groups
X
Disability -
X
learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion /
other beliefs
X
Marriage and civil
partnership
X
Pregnancy and maternity
X
Sexual Orientation,
X
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
x
9. If you are not recommending a Full Impact assessment please explain why.
Not required
Signature of policy developer / lead manager / director
T. Fergus
Names and signatures of
members carrying out the
Screening Assessment
Date of completion and submission
July 2015
1.
2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed _____T. Fergus__________
Date ________XXXXXXXXXXXX_______
Clinical Guideline for the management of children and young people with newly presenting diabetes.
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