Young people - key issues

Management of diabetes in children and young people “is significantly different and more complex than it is for adults” (Department of Health 2007c, page 2). Adolescence is a time of unique biological challenges to the individual and adolescents with diabetes have health, social and psychological needs which are specific to their age and development. These require consideration when planning care strategies.

Potential problems with this age group include:

Persistent or progressively unsatisfactory metabolic control.
Exploratory (known as risk-taking) behavior.
Recurrent diabetic ketoacidosis (DKA).
Failure to attend clinics.
Family conflict.
Transfer of knowledge/responsibility from parents to young person.
Possible initiation of smoking, alcohol and drug use.

An article published in the BMJ in 2011 discusses a systematic review looking at why some children and young people have diabetic ketoacidosis at diagnosis and the factors that may contribute to this, and is able to draw some conclusions around some of the key factors influencing this. The findings suggest that clinicians in primary and secondary care need to be “particularly alert for diabetic ketoacidosis in children under five years old, those from ethnic minority groups, and those from families with low education level or socioeconomic status". For details see Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review (BMJ 2011;343:bmj.d4092).

Supporting self management

Support and encouragement for the young person and their family is essential for good outcomes and needs to be sensitive to individual needs.

Adolescence is often a time of family conflict. Problems can occur around the transfer of diabetes control as parents try to shift the responsibility of blood glucose management, diet and injecting to their offspring. It is sometimes difficult to trust the adolescent to undertake their own care but this responsibility will ultimately be theirs and they need to learn these skills along with the other lessons required for the transition into adulthood.

Equally, certain developmental goals such as independence from parents, identification and conformity with peers, development of personal identity often clash with the demands of managing diet, injecting and testing for and reacting to blood glucose levels. Concerns about body image may lead to insulin omission and dose manipulation in order to avoid weight gain. Addressing this early on is important because of the potentially serious complications. Sarah's story, told on the BBC website, reflects on a “teenage rebellion” which cost Sarah her sight (Elliott 2006).

Insulin regimens need to be matched with the young person's lifestyle goals. There is a need to establish balance between avoidance of hypoglycaemia and "it won`t happen to me" versus high HbA1c and risk of complications in later life at an age when it is hard to see the importance of addressing risk factors now which will be realised 20 years in the future.

Good education and health behaviours started in adolescents will continue into adult life, for example experimentation with smoking alcohol and drugs is likely to occur and these topics require a considerate, honest and non-judgemental approach.

Complications

30 to 40 per cent of children and young people with Type 1 diabetes will develop
microalbuminuria which can lead to further kidney damage. 25 per cent or more may require laser treatment for retinopathy (Department of Health 2007c).

A care review should be performed at least once per year. This should include blood and urine tests, check on blood pressure, injection site check, foot exam, review of diet, check on height and weight, discussions around physical and psychological well being. The 'My life' section of the Diabetes UK website provides information about managing diabetes specifically aimed at young people, and discusses aspects of treatment and care.

For further information on specific risks and complications see the section within this resource on Complications.

Transition to adult services

Sensitive and planned transition to adult services are essential. Standard 6 of the National Service Framework makes reference to the need for smooth transition from paediatric to adult health services and for this transition to be organised “in partnership with each individual and at an age appropriate to and agreed with them” (Department of Health 2001b, standard 6). Yet many young people continue to experience problems with this transfer (Diabetes UK 2007b). The RCN published guidance in 2007 on good practice in arranging such transitions with a case study illustrating how this is achieved in diabetes care - see Lost in transition: moving young people between child and adult health services (PDF 125.74) [see how to access PDF files].

Role of specialist nurses

The support of multidisciplinary specialist teams in the care of young people with diabetes is important and is highly regarded by young people (Diabetes UK 2007c). The role of specialist nurses working with children and young people with diabetes and the qualifications, skills and education preparation required have been described in some detail in RCN guidance published in 2006. The document also provides guidance on developing specialist services and ways of working - see Specialist nursing services for children and young people with diabetes (PDF 1.4MB).

References

In the text above full details of the bracketed citations and, in many cases, links to the actual documents are available in the reference list within this resource. Go to the Reference list