After the completion of clinic in one of Children's National Medical Center's Outpatient sites last week, one of my certified diabetes educators suggested that I specifically delve into the management strategies in the three age groups discussed in the blog about infancy and young children (toddlers), elementary school aged, and adolescents. Today, I will discuss in detail the challenges associated with infants and toddlers and provide helpful suggestions that have proven successful when used by Children's diabetes team.
Infants and young children are often very ill when they first go to their primary care provider or emergency department. Symptoms are often vague: including weight loss, heavier diapers due to increase in urine volume (or lighter- if dehydrated), increased thirst, increased hunger, and increased irritability. By the time they arrive in the medical setting, they are often metabolically compromised and present in diabetic ketoacidosis. As such, most infants and toddlers are then hospitalized either in the pediatric intensive care unit or the medical floor. The first priority is stabilization of acidosis (acids in the blood due to the development of ketones resulting from breakdown of fat and muscle due to the relative lack of insulin), and control of blood sugars. Then the team helps to manage the initial shock and anxiety of family members, including the frightened child who does not understand all that is happening around him. Young children react to the cues of their caregivers. If the parents (or other caregivers) are anxious, frightened, etc., the child will respond accordingly. Therefore, it is essential to develop a relationship with the diabetes care team to assist in the medical management and emotional status of your child.
It is important to try to learn as much information as quickly as possible so your family is empowered and feel more in control. Parents and caregivers need to feel secure in caring for their child safely at home. It is imperative that the diabetes team ensures that you and your child feel "safe" after the appropriate teaching is concluded (survival skills). When the caregivers feel competent, knowing they are only a phone call away from the diabetes healthcare team, the child also will feel reassured. (Note: Knowing the "type" of diabetes is necessary to guide management. In children diagnosed younger than six months of age <and rarely less than 12 months>, Permanent Neonatal Diabetes must be ruled out. For details, see scientific literature including a paper Diagnosis and Treatment of Neonatal Diabetes: a United States Experience in the Pediatric Diabetes journal of which I am one of the authors.)
We also would recommend frequent blood glucose monitoring as well as testing for either urine (it is easier to put cotton balls in diapers to check for ketones as it is hard to squeeze out urine from the diaper) or serum ketones (Precision Extra Beta ketone testing). Some parents test blood sugars using blood from toes. My diabetes educators feel that this may be acceptable in certain cases. Frequent contact with your diabetes team is essential, especially if your infant has received immunizations or is ill. One benefit during this stage of development is that you are in charge.
As the infant grows into "toddlerdom," life changes significantly for all family members. The child becomes somewhat more resistant to usual routines and normal parenting is required with limit setting. Interesting enough, toddlers are often reassured by routine as well. Stay on course with your diabetes management behaviors. A word of advice: feel free to "parent." Just because your child has diabetes (or another chronic illness) does not mean it is time to abandon good parenting skills. Reasonable rules should be in place for all siblings including your child with diabetes. One frequent concern of parents is that they are afraid that they are hurting their child and therefore are worried that the infant/child will hate them. Parents need to check blood sugars quickly without discussion to communicate that there is no choice about this action. We would suggest giving the child choices about other things of which they have some control. Examples include choosing which finger to check and where to give the insulin shot (not in puffy areas).
In regard to mealtimes, set a reasonable amount of time for a meal (15-30 minutes) and then move to a different activity. Not only does this convey the message that the "kitchen is not open for business 24 hours /day," but helps to match the insulin with the carbohydrates in a timely manner. If your child is on basal/bolus therapy it is reasonable to give the rapid acting insulin after the child eats to appropriately match the insulin with the carbs consumed. It is advisable (as taught by child psychologists) to avoid "food wars" as much as possible. Toilet training also may be difficult, especially if your child's blood glucoses are elevated with resulting increased urination and bedwetting. Work with your team to set reasonable blood sugar targets and decrease blood glucose variability. These strategies will help to decrease hyperglycemia and urinary volume and frequency.
Once again, establish routines for your child so he knows what to expect and feel safe. I suggest that your behavior be as matter of fact as possible in order to integrate diabetes management into your child's regular routine (brushing teeth, getting dressed, etc.). Ask behavioral and CDE diabetes team members for support and guidance. They can help. Many psychologists, including the ones at Children's National, conduct research on young children with diabetes to develop better management strategies to help parents cope with diabetes and its ramifications. Trust your parenting instincts and let them guide you as you care for your infant or toddler. And call for support--we will listen.
Published On: March 02, 2009