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Diabetes in children: coping with a lifelong illness

Elizabeth Bragg
MB ChB MRCPCH
Staff Grade Paediatrician
University Hospital Wales
Cardiff

As healthcare practitioners, primary care nurses can help children with diabetes, and their families, by: providing education; providing advice; providing emotional support; being a link to other support organisations; and being aware of practical solutions and ensuring the family gets all the help they are entitled to.

Problems that may arise with a diabetic child
 
Needle phobia
Having diabetes means that a child will probably have to face at least three needles every day of their life, sometimes more. Initially, in a younger child, the parents have to perform the finger prick test to monitor daily blood glucose levels, followed by the subcutaneous insulin injections. Many parents find this difficult initially, since they perceive they are inflicting harm on their child, which is very understandable. It can be helpful to speak to other parents about their feelings at this time.
Children usually decide for themselves when they are ready to self-inject, and are often eager to take over this responsibility. Problems of diabetic control may surface at this time if they are consistently using the same site, which leads to poor insulin absorption. The answer is further education for the child and parental supervision. There is hope for the future, as worldwide research is looking into ways of dealing with injections and blood sampling (see Table 1).

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Toddler tribulations
Many parents who have young children with diabetes are constantly worried because the toddler age group are notorious for showing their independence by refusing to eat meals. This is important because you run the risk of hypoglycaemia if you give an insulin dose and then don't eat. Toddlers are a unique problem in themselves with respect to diabetic control - they have a shorter day than adults, they have periods of intense activity followed by sleep, and they suffer frequent, mild infections.
This all adds up to a difficult management. Once again, parents can be helped by talking to people who have been through the same experience, and practitioners can make sure that parents are in touch with support groups. Education is vital - parents must be informed of the need to monitor a toddler more frequently if needed. Recent developments with human insulin have produced products that act much faster - shortening the amount of time you have to wait between insulin and eating. This means that an injection can be given at the start of the meal, once you know the toddler is going to eat. Many parents will also benefit from advice on behavioural techniques that apply to all toddlers with food refusal.(1,2)

Intercurrent infections
If the child is ill, for instance if they are vomiting and not eating, parents may be tempted to stop insulin on the premise that if they aren't eating they won't need it. However, the hormone regulation systems of the body are complex, and stresses, including infection, increase levels of the secondline hormone, adrenaline. Increased levels of adrenaline lead to increased levels of glucose in the blood, whether or not you're eating. Stopping insulin in an ill child can lead to DKA (diabetic ketoacidosis).
The solution to this problem is to educate the parents and leave them with a clear set of guidelines to follow in case of an intercurrent infection. These are sometimes known as sick-day rules (see Table 2).

[[NIP08_table2_33]]

Sibling behaviour
Many parents find that, when one child is diagnosed as having a chronic illness, their other children experience a variety of difficulties. The spectrum of problems ranges from obvious attention-seeking behaviour to a more subtle dropoff in school performance.
Parents need to be aware that this can happen, and, if the changes are subtle, that the problems might be related to the diagnosis in the diabetic child. Solutions vary with individual children, but include:

  • Discussing the diagnosis with the sibling, to give a full explanation and discover whether they have any fears or worries that haven't been expressed.
  • Trying to maintain normal family life, showing that although the insulin has to be given and the ­monitoring has to be done, family life can ­continue.
  • Advising the parents to try to make time for one-to-one interaction with the sibling. They need to know that although they need less help, they're not loved any less.

Difficulties with control
There are several points in a child's life when insulin control isn't standard. The first is a period when control is too easy, the other two when it becomes more difficult.

Honeymoon period
This occurs just after diabetes has been diagnosed. Even if gaining control was difficult, the child may need very little insulin to keep blood sugar levels in balance. This is probably because the pancreas keeps on producing a little bit of insulin before the islet cells are completely destroyed. It seems a shame to have a child on a regime of injections when they don't appear to be needed, but what we do know is that this period doesn't last. Current advice is to continue with the regime so that parents are prepared for when the honeymoon period is over. Explaining the reasoning to parents can help prevent resentment and misunderstanding during this phase.

Somogyi effect
This happens during sleep, when low blood sugar levels cause a response in the secondline hormones of the body. The firstline hormone (glucagon) doesn't work any more. The secondline hormone (adrenaline) is a weaker increaser of blood sugar, but it does work. The result is that the prebreakfast blood sugar level is raised. The problem arises when parents find a high early morning sugar level, because the instinct is to increase the nighttime insulin dose. What is actually happening is an early morning (3am) hypoglycaemia caused by too much insulin before bed. Increasing the night-time dose can cause a dangerous low at 3am. Explanation will help the parent's understanding, and an overnight stay in hospital to check 3am blood sugar will lead to the correct treatment - a reduction of the nighttime insulin.

Dawn effect
This happens to children who are reaching puberty. As you reach puberty your levels of growth hormone increase. Although this hormone deals with growth it also acts as a thirdline glucose-increasing hormone. Higher levels of growth hormone also lead to a high prebreakfast glucose level. This time it is because the nighttime insulin dose isn't working as well as it was before, and needs to be increased. The 3am blood glucose will help to differentiate between this and the Somogyi effect. Once again a clear explanation to the parents and child will clear up any confusion.

Adolescent aggravations
Adolescence is a time of change, uncertainty (especially with respect to body image) and rebellion. Many children with chronic illnesses find it difficult to continue therapy at this time, and resent the fact that they are different. With diabetes the child can't be as spontaneous as their peers, especially when it comes to fast food.
Having a good relationship with the adolescent is always a help, but is not always possible. If parents are having trouble with communication then a healthcare professional may make the connection. The child is becoming an adult and may not be ready for the heavy responsibility. They need to be made aware that this isn't a choice, and that good education needs to be repeated.
Another problem peculiar to diabetes at this time is self-induced lack of control in adolescent girls who find that if they run their blood sugars high they remain slim. Again they need to be educated about the dangers and long-term complications of this practice.

Conclusion
Management of diabetes is complicated by psycho­social issues. The healthcare provider can alleviate many of the concerns and issues surrounding this condition by performing a few extra tasks:

  • Educate your patient and their family - and see this as an ongoing process.
  • Remember to take a holistic approach and see the child as a member of the family, not just as "a ­diabetic".
  • Be a good listener when they just need someone to talk to.

References

  1. Green C. Toddler taming. Sydney, Australia: Doubleday; 2000.
  2. Food refusal. Available from URL: http://www.well-aware.co.uk/
    cgi/well/condition.pl?id=74&cid=1
  3. Speiser PW. Continuous glucose monitoring in managing diabetes in children. Diab Metab Res Rev 2002;18(4):330-1.
  4. Leoni L, Desai TA. Nanoporous biocapsules for the encapsulation of insulinoma cells: biotransport and biocompatibility consideration. IEEE Trans Biomed Eng 2001;48(11):1335-41.
  5. Insulin sheet transplantation. Available from URL: http://www.isletmedical.com
  6. Lowman AM, et al. Oral delivery of insulin using pH-responsive complexation gels. J Pharm Sci 1999;88:933-7.
  7. Lumelsky N, et al. Differentiation of embryonic stem cells to insulin-secreting structures similar to ­pancreatic islets. Science 2001;293:428.
  8. Cefalu WT, et al. Inhaled human insulin treatment in patients with type 2 diabetes mellitus. Ann Intern Med 2001;134:203-7.
  9. Scollay R. Gene therapy: a brief overview of the past, present, and future. Ann NY Acad Sci 2001;953:26-30.

Resources
Diabetes UK
W:www.diabetes.org.uk
British Dietetic Association
W:www.bda.org.uk
Diabetes News
W:www.diabetesnews.com