Care for Diabetic Children
Insulin
Oral drugs are useless in diabetic children. They are insulin dependent and need insulin, a combination of short/rapid and intermediate acting usually twice a day. During some infection or when the blood glucose level is very high, the child may need a short-acting insulin, three or four times a day. In the beginning, insulin should be injected by an experienced person. A child around ten can inject insulin itself, after some encouragement and instructions. However, parents should supervise, from time to time, the child's technique of insulin injection.
The factors which alter the insulin requirement and the technique of insulin injection have already been discussed. Insulin requirement may often increase around school examinations.
Exercise
Since exercise is an important aspect of the treatment of diabetes, a diabetic child should be encouraged to participate in games, athletics and physical training. Walking, running, skipping are good forms of exercise.
Strenuous exercise can give rise to diabetic ketoacidosis, when diabetes is uncontrolled.
Hypoglycaemia
This problem worries the diabetic child and its parents the most. A child in hypoglycaemia may become unusually quiet, morose, inattentive or naughty and aggressive and may develop nausea and nightmares. Hypoglycaemia at night may give rise to a headache and fatigue the following morning. This may be misinterpreted as a school attendance problem.
The parents, teachers and close friend of a diabetic child should know the warning signals of hypoglycaemia. A diabetic child should carry some glucose and take it dissolved in water at the earliest warning of hypoglycaemia. A diabetic child should always carry diabetes identity card. The child should not be sent home from school while in hypoglycaemia.
Since the physical activities of a child are often erratic, it is wiser to give snacks during a spurt of activities rather than to reduce the dose of insulin. When physical activities are planned, dose of insulin may have to be reduced by 10 per cent, before exercise.
A low blood glucose level at night can give rise to a rebound increase in blood glucose level with glucose in urine the following morning. It is important to recognise this paradoxical increase in the morning blood glucose level. In this case, the dose of evening intermediate acting insulin should be reduced.
Many teenagers overeat in order to ensure against hypoglycaemia. The importance of spacing the meals and snacks in between the main meals, rather than overeating, should be explained to them.
Rapid acting insulin analogues can be given after meals, hence (hey may be used in those children whose food intake is unpredictable.
Monitoring control of diabetes
Self monitoring of blood glucose should be done whenever possible, to achieve good control of diabetes throughout the day, to adjust the balance of insulin, diet and exercise and to confirm OT refute ihe suspicion of hypoglycaemia. The blood glucose readings, insulin dose, exercise, food intake should be tabulated. Some children resent frequent blood glucose tests. Glycated Hb test once in two to three months is valuable.
Regular medical examinations
A diabetic child should be examined at least once in three months and its height and weight should be recorded regularly. A child with well controlled diabetes should grow normally. A record of blood tests, weight, diet, dose of insulin, insulin reactions and any other problems should be maintained. A diabetic child should be vaccinated against infectious diseases such as diphtheria, whooping cough, tetanus, measles, poliomyelitis, hepatitis, typhoid and cholera. It is advisable to give BCG vaccine to a diabetic child. Infection of gums, at the root of the teeth and loss of teeth occur in uncontrolled diabetes. Care of gums and teeth is also essential.
TARGETS FOR PLASMA BLOOD GLUCOSE AND Hb Alc IN CHILDREN
Plasma blood glucose goal range (mg/dl)
| Values by age (years) | Before meal | Bedtime/overnight | Hb A/c |
| Toddlers and | 100-180 | 110-200 | <8.5 |
| preschoolers (< 6) | (but > 7.5%) | ||
| School age (6-12) | 90-180 | 110-180 | <8% |
| Adolescents and young adults (13-19) | 90-130 | 90-150 | < 7.5%* |
* A lower goal of < 7.0% is reasonable if it can be achieved without excessive hypoglycaemia
Complications
Acute complications like diabetic ketocidotic coma and hypoglycaemia have been referred to. Chronic complications like retinopathy and nephropathy are uncommon before puberty. Monitoring for these conditions should be done yearly after onset of puberty or after five years of diabetes. The first eye examination should be obtained once the child is 10 years of age or older and has had diabetes for 3-5 years.
Education
A child with diabetes faces special challenges in the school setting where he/she may be the only pupil receiving insulin, requiring special diet and possibly having insulin reactions. The school life of such a child should be as normal as possible. At the beginning of the academic year, the parents should meet the class teacher to discuss the child's needs, namely timely meals, snacks at the appropriate time, physical activity and prevention and treatment of hypoglycaemia. The teachers may be understandably nervous about a diabetic child. Regular meeting of the teacher and the parents of the child is essential. The Juvenile Diabetes Foundation, Maharashtra chapter has drafted a useful letter to the teachers of diabetic child.
Boarding schools impose additional challenges. Before admitting a diabetic child in such a school, the child's degree of self-reliance and the school's medical facilities should be considered. Roommates must be aware of the child's diabetes and be instructed about dealing with hypoglycaemia.
A well managed diabetic child can have as good a performance in a school or a college as a normal child or a teenager. A career should be planned for a diabetic child. As manual labour is not very suitable for diabetics, good education is necessary for a diabetic child.
Emotional problems
Development of diabetes in a child creates many emotional problems, not only in the child but also in the parents. The child may regard dietary restrictions, insulin injections as a punishment. Admissions to a hospital and separation from parents and other siblings can hurt the child's mind, and make it feel alienated. Parents sometimes panic, feel guilty or become overprotective when diabetes is diagnosed in their child. One parent may blame the other parent for the child's disease. There is no shame in having diabetes. The parents and the child should face the problem squarely.
Overprotection of the child hinders its psychological development. Discipline should be tempered with kindness and understanding. Parents should give the child a sense of responsibility. The child should not be allowed to use diabetes as a means to escape unpleasant situations like school examinations. Many a time, the parents shower all their affection and attention on the diabetic child with the result that the nondiabetic children feel neglected.
Puberty may be delayed if diabetes is uncontrolled. The diabetic child may rebel during adolescence. Willful neglect of diet, manipulation of blood tests, deliberate omission or overdose of insulin are often seen during this period. Occasional lapses in diabetes care during this phase should be tolerated. A diabetic teenager often develops anxiety about future career, job or marriage and needs proper counseling. With proper understanding and right attitudes, a diabetic child can mature normally, physically and psychologically.
Summer camps for diabetic children
Summer camps have proved to be of great value in teaching children to live with diabetes. In these camps, children live with doctors, nurses and dietitians. Besides the usual recreational activities of the camp, the children are taught, self monitoring of blood glucose, diet and technique of insulin injection. These children develop self-reliance and realize that there are many children with diabetes who are successfully coping with their disease. The parents are relieved that the children can look after themselves well. Weekend trips for diabetic children and then-parents have also proved useful.