Dr Matthew Lockyer explains why GPs should not overlook the NICE guideline on type 1 diabetes in children and young people
We are all aware of a growing epidemic of type 2 diabetes; however, type 1 diabetes is also increasing in incidence, especially among preschool children.1 This is certainly true in my experience, having seen four newly presenting juveniles with diabetes so far this year.
NICE has recently published a two-part guideline on the management of type 1 diabetes. It is composed of one guideline for adult patients (see ‘New guideline aids management of adults with type 1 diabetes’) and another for children and young people. Both are detailed, of high quality, and have good summaries.
GPs will certainly use the adult guideline but may wonder if the guideline for children and young people has relevance for them, as it recommends that care is undertaken by a hospital-based multidisciplinary team rather than in general practice.The new GMS contract acknowledges that the care of children with diabetes under 16 years old is a specialist area and does not include them in the quality and outcomes framework. Despite this, the guideline has several areas of interest for GPs.
The diagnosis of diabetes is often obvious in the older child, but can be more difficult in a baby or toddler. It is vital to be aware of presentation and initial management strategies, both of which are well described in the guideline.
GPs are still often the first port of call for problems, so we must retain an understanding of the ongoing management of the younger diabetes patient as well as an awareness of the signs of emergencies such as hypoglycaemia or diabetic ketoacidosis.
One clear message from the guideline is the wisdom of including diabetes patients of all ages on the practice register, because the requirement to offer pneumonia vaccination and an annual influenza immunisation to diabetes patients applies irrespective of age.
Keeping a general register will also enable GPs to offer shared care in the practice clinic to young adults at the age of 16 years. It will also allow us to record any patients who are using a continuous subcutaneous insulin pump. Although these patients will have access to hospital back-up services, GPs will need to be aware of patients using this system of insulin delivery.
We should also be aware of the possibility of related autoimmune disorders presenting in the young person with diabetes. Coeliac disease and thyroid disease occur sufficiently commonly that screening is recommended, and Addison’s disease is a rare association to keep in mind.
For GPs with an interest in children’s health or diabetes there are many opportunities for supporting secondary care.
The guideline emphasises the importance of psychosocial management of young diabetes patients, and psychology services are rightly considered an essential part of the multidisciplinary diabetes team. The intimate knowledge of family circumstances and the continuity of care gained in general practice can be of great assistance in detecting and managing psychosocial problems as well as in education.
The teenage years are often difficult for young people with diabetes. The guideline recommends a programme of gradual transition to long-term adult care and that young people attend age-banded and joint clinics with adult services. General practice has an important role to play in ensuring that this transition goes smoothly.
- Onkamo P,Vaananen S,Karvonen M,Tuomilehto J. Worldwide increase in incidence of Type I diabetes the analysis of the data on published incidence trends. Diabetologia 1999; 42: 1395-403.