4Growth and diabetes During childhood and adolescence Physical growthMaturation of organ systemsIncreasing intellectual maturity and understandingPubertyNot affected by diabetes if well controlledPoorly controlled diabetes may causePoor growthDelayed pubertyGrowth during childhood and adolescence is notable for physical growth, maturation of organ systems, increasing understanding and intellectual maturity and changes toward physical, sexual and mental maturity during puberty.If diabetes control is good, the child should grow at the same rate and reach the same size as non-diabetic children in the same community. But if diabetes control is poor, growth may be impaired and puberty may be delayed. Observing the growth of the child with diabetes is therefore an important method of assessing the adequacy of the diabetes care.
5Effects of changes Change Effect Consequence Growth Increasing weight 5Effects of changesChangeEffectConsequenceGrowthIncreasing weightIncreasing dosesPubertyDecreasing insulin sensitivityPsycho-social stressesIncreased dosesMore educationAlcohol and drug useRisk taking behaviourMensesChanges in insulin sensitivityFluctuating insulin needs with increased doses during mensesLifestyleIncreasing activityIncrease food intake / decreased dosesIntellectual maturationIncreased understandingIncreased independenceIncreased autonomyEditing: Fix the size of the background box (AutoShape) after editing the table. The background box is changed by dragging the sides and/or the corners for optimal fit.
7Diabetes at school Safe and supportive school environment The child and adolescent with diabetes has rightsRight to be admitted to schoolRight to receive appropriate careRight to be fully integrated into a school environmentResponsibility of parents and care teamEducating carers (teachers) at schoolSupporting schools and teachersProviding supplies for careDiabetes does not mean that a childs education has to be compromised. But it does mean that a safe and supportive school is crucial.The child with diabetes has rights that includes the right to be admitted to a school despite having diabetes. However, in societies where diabetes has a stigma and where school authorities are anxious about having to be responsible for the child’s diabetes, school attendance is still sometimes denied to children with diabetes. The child has the right to receive appropriate care for diabetes while at school. The child has the right to be fully integrated into the school environment by ensuring his/her safety, involvement in all school activities, attainment of developmental goals, development of self-esteem and acceptance by peers. It is the responsibility of the parent and care team to educate those at school who will be caring for the child with diabetes (teachers and others) on aspects of the child’s care, supporting the school and teachers in their efforts to care for the child with diabetes in school and making sure that there are enough supplies for the care of the child in school, including (where needed) insulin, glucose meters and food in case of hypoglycaemia.
8Educating the people at school Information on diabetes and managementEffect of illnessesHyperglycaemia and ketonesRecognition, treatment and prevention of hypoglycaemiaPractical knowledge and practice in glucose and ketone testing and insulin injectionsEffects of diet and activity on diabetesSocial and psychological impact of diabetesEducation of those at school who will be caring for the child with diabetes (teachers and others) includes information on diabetes and its management. This would include the essential need for insulin, regular meals and snacks and to be able to test blood glucose. The school personnel need education on appropriate management of acute complications (including hypoglycaemia and hyperglycaemia). The effects of illness need to discussed with the school. Practical knowledge and practice in glucose and ketone testing and insulin injections is necessary. Teachers need to understand the effects of diet and activity on diabetes and to include children in activity. An understanding of the social and psychological impact of diabetes may help to integrate the child into the school system.Education must be done by the parents or care team, and not left to the child.
10Diabetes and exercise Common part of children and adolescents lives Encouraged in diabetesBenefits of exercise includeSense of well-beingWeight controlLimit rise in glucose after mealsLowers heart rate and blood pressureLowers blood lipid levelsReduces cardio-vascular riskExercise for children with diabetes is a good thing.Physical exercise is a common part of all children’s lives and should be equally encouraged for those with diabetes. In addition to an improved sense of well-being, exercise may help with weight control, it limits the rise in glucose after meals, keeps the heart rate and blood pressure lower and helps keeps blood lipid levels normal. These factors may reduce cardiovascular risk and may be associated with a lower HbA1c.
11Effect of exercise Hypoglycaemia Hyperglycaemia Ketones Children with diabetes are not able to regulate insulin effects during exercise. Insulin has been injected and is not regulated by the pancreas, and they have impaired glucose counter-regulation (ie. they lack the glucagon response to hypoglycaemia). These factors frequently result in hypoglycaemia during or after activity. Hypoglycaemia is more likely to occur with prolonged or intense activity. Hypoglycaemia may also develop many hours after prolonged activity, if there is a delay in replacing glycogen stores in the liver.However, excessive intake of carbohydrate, decreased insulin doses and the emotional responses to activity and competition may have the reverse effect and result in hyperglycaemia. Excessive sweating and decreased fluid intake may cause dehydration during activity. In the case of poor control and high glucose values, the exaggerated effects of counter-regulatory hormones may cause increased production of ketones.
12Factors affecting glucose response DurationIntensity of activityType of activityMetabolic controlInsulin regimenAbsorption of insulinTiming and type of foodStress and competition involvedDuration: Prolonged activity (>30 minutes) is likely to result in hypoglycaemia. Short periods of activity may cause a transient increase in blood glucose values. Intensity of activity: Low-intensity activity is less likely to cause hypoglycaemia. Moderate and intense activity is more likely to cause hypoglycaemia, especially if prolonged. Type of activity: Anaerobic activity (e.g. sprinting) by its nature lasts for very short periods and may cause an increase in blood glucose values (due to the release of the hormones adrenaline and glucagon). Aerobic activity (e.g. walking, jogging, and swimming) can cause a decrease in blood glucose values, both during and after the activity. Metabolic control: Poor metabolic control often results in high blood glucose values and a low level of circulating insulin. Exercise under these circumstances can cause ketonuria. Type and timing of insulin injections: The most likely time for hypoglycaemia to occur after insulin use depends on the type of insulin. Hypoglycaemia is most likely 2-3 hours after injection of a regular (soluble) insulin (e.g. Actrapid), , or minutes after rapid-acting analogue insulin (NovoRapid). Long-acting insulins (NPH, Monotard) have a much later and more variable peak action. Absorption of insulin: A number of factors affect insulin absorption during activity including: • Choice of injection site: absorption is increased with injections close to muscles that are being exercised, and hypoglycaemia is more likely to occur. Injections away from the active muscle may produce a more consistent effect - eg the abdomen is a good site for injections before running • Ambient temperature: high temperature will increase insulin absorption and low temperature will decrease insulin absorption. Type and timing of food: A meal containing carbohydrate, fats, and protein consumed a few hours before activity will help to prevent hypoglycaemia. Fast-acting foods and fluids used prior to activity can provide the extra energy needed for short-duration activities. These are best given as isotonic drinks. No food, or inadequate food intake prior to activity increases the likelihood of developing hypoglycaemia. Degree of stress/competition involved in the activity: Stress hormones from the adrenal gland will cause an increase in blood glucose. It is not unexpected to have a high glucose level after competitive sport. In many cases this may be followed by late-onset hypoglycaemia, many hours later.
13Managing exercise (1) Very variable effects in different children Monitoring glucose is the keyKnow glucose value before activityMay need snack adjustments (preferably quick carbohydrates)Monitor glucose minutes after the end of the activityWith the large number of variables that can affect blood glucose values during exercise, it is not surprising that activity can produce very variable values in different children. While a few guidelines need to be followed, children may need an individualised way of dealing with activity. The cornerstone of dealing with activity in diabetes is monitoring:The child should know his/her blood glucose value before participating in physical activity. This value will help to determine the food intake that would be required to prevent hypoglycaemiaThe child should have a snack before the activity. For short, high-intensity activity, this snack should preferably be a fluid-based high energy drink. For a long duration of low intensity activity, it should be food that is digested slowly eg fruitActivity should be interrupted about every 30 minutes for an additional snackBlood glucose should be monitored minutes after the end of the activity
14Managing exercise (2) Treat low glucose with additional rapid sugar Sugar cube, coke, honey, sweetsAfter prolonged activity:Additional snack before sleepingHave glucose monitored during the nightDecrease bedtime insulin dose after afternoon or evening exerciseAccurate records of activity, food intake and glucose values to learnA low glucose value should be treated with additional rapidly-digested foodAfter prolonged activity, the child should have an additional snack before sleeping, and should have glucose monitored during the nightAccurate records of activity, food intake and glucose values help the care team to assist with decisions about managing activity.
16Alcohol and drugs Peer pressure to experiment Depend on availability, cost and societal attitudesExperimentation may start in very young childrenChildren and adolescents with diabetes no different from any otherEmpower discussion rather than challenging behaviourRemember that there is peer pressure on adolescents to experiment with alcohol, tobacco and drugsMarijuana, drug and alcohol use may depend upon societal availability, costs and societal attitudes. It is important to remember that experimenting may start in 9-10 year-olds. There is no reason to think that youngsters with diabetes will be different from any other young people. Challenging their behaviour is less important than empowering discussion, encouraging fact-sharing and decision-making for themselves.
17Alcohol drinks Use and abuse not uncommon May cause rapid rise in glucose, i.e. always eat before going to bedEffects on liver correction of hypoglycaemia is impairedFrequent use causes weight gainEmpowerment to deal with peer pressureAlcohol is often associated with being sociable, relaxing and escape, and it decreases social anxiety and day-to-day worries. Abuse of alcohol in mid- to late teens is not uncommon. The carbohydrate content of the alcoholic drink or mixer causes a relatively rapid glucose rise for several hours shortly afterward, and then a decrease. Because of later metabolic effects of alcohol on the liver, that can no longer generate glucose, glycogenolysis is slowed and correction of hypoglycaemia impaired or impossible. So the later effects of alcohol directly contribute to, but do not cause, severe hypoglycaemia, including loss of consciousness and convulsions which are separate from alcohol intoxication per se. Rescue from this condition by glucagon is often impaired. What might have been a mild hypoglycaemic event several hours after alcohol is ingested, could then become a severe hypoglycaemic episode, without any ability of the body to correct the hypoglycaemia because the ‘liver is busy’ Alcohol also provides calories, so frequent alcohol intake also can have an effect on one’s weight. Use empowerment techniques and open-ended non-judgmental questions to help the child deal with peer pressure and to deal appropriately with alcohol use.
18Smoking Similar prevalence of smoking with or without diabetes General risksCardiac diseaseEmphysemaCancersIn people with diabetes, worseCardiovascular diseaseMicro- and macrovascular complicationsHypertensionHyperlipidaemiaStudies report that pre-teens, adolescents and young adults with diabetes smoke at about the same prevalence as those without diabetes, even though there is more contact with healthcare professionals.The general risks of nicotine are an increase risk for cardiovascular disease, emphysema risk and of all cancers, not just lung cancer.The diabetes-specific problems of nicotine are long-term increased risk of cardiovascular disease, micro- and macro-vascular complications, hypertension and hyperlipidemia. The addictive potential for nicotine is no different for those with or without diabetes. These risks need to be brought to the attention of all children with diabetes.
19Marijuana Excessive or frequent use associated with: School and learning difficultiesBehaviour problemsDepressionLow self-esteemAnxietyFamily/peer interactionsSocially deviant behaviourNo major direct effects on diabetesUnless overeating carbohydratesMarijuana is perceived as a mild, non-habituating drug and is almost universally associated with social relaxation and ‘being cool’. Excessive or frequent use correlates with the same list of problems as with excessive or frequent alcohol use: school and learning difficulties, behaviour problems, depression, low self-esteem, anxiety, family/peer interactions and socially deviant behaviour.There are no major direct effects of marijuana use on diabetes. There may be a mild increase in blood glucose after marijuana use
20Other drugs May have Potential for addiction Have psychosocial effects No direct effect on glucose (hypoglycaemia at rave parties)Increase blood glucose levelsDehydration (amphetamine) or water intoxication (ecstasy)Potential for addictionHave psychosocial effectsInterfere with diabetes self-managementSome drugs have direct effects on the heart (amphetamine?)May need psychological interventionOther substances generally either raise blood glucose level (amphetamines, hallucinogens, cocaine) or have no direct effect on blood glucose (barbiturates, heroine, narcotics). Potential for addiction is enormous. May have psychosocial problems usually interfere with diabetes self-management at the time of use and immediately thereafter, and if these substances are in prolonged use, they may move diabetes care issues so far away from reality that dangers increase. During use of these drugs, recognition and treatment of hyperglycaemia and hypoglycaemia become unimportant and nearly impossible.Some substances, particularly the cardiovascular stimulants (the ‘uppers’) also have direct effects on the heart and the circulatory system. When dealing with chronic use of these substances, professional psychological assistance may be required if abuse becomes more and more invasive and interfering with day-to-day function.
22Diabetes and pregnancy Diabetes in pregnancy poses challengesThere are increased risks for both mother and babyAll pregnancies complicated by diabetes should be managed by an experienced teamDiabetes may be existing type 1 diabetes or gestational diabetesDiabetes in pregnancy, especially in a teenage girl, poses particular challenges. Young women with type 1 diabetes have increased risks during pregnancy, which start from conception and continue until after delivery. There are potential complications for both mother and baby. The diabetes may be pre-existing type 1 diabetes or new gestational diabetes. The risks extend to both sets of young women. Therefore all pregnancies complicated by diabetes should be managed by an experienced team and should not be managed at echelon 1-2.
23Risks for mother Hypertension in pregnancy Urinary tract infections Later risk for type 2 diabetesPreterm labourPolyhydramniosMacrosomiaDKAProgression of microvascular complicationsRisks for the mother include and increased risk of hypertension in pregnancy, urinary tract infections, increased risk of later type 2 diabetes following gestational diabetes, preterm labour, polyhydramnios, macrosomia (big baby syndrome)and increased likelihood of caesarean section, DKA which carries a high risk of foetal death and progression of microvascular complications especially eye disease and renal disease in young women with type 1 diabetes
24Poor control late in pregnancy Risks for baby (1)Congenital abnormalitiesSpinalHeartGastro-intestinalLimb abnormalitiesHeart abnormalitiesMacrosomia (big baby syndrome)Obstructed labourIntra-uterine deathPoor control aroundconceptionPoor control late in pregnancyRisks for the baby start before delivery. These risks include congenital abnormalities involving the spine, heart, gastro-intestinal and limb abnormalities. These abnormalities occur if control was poor around conception and affects babies of type 1 pregnancies. Heart abnormalities such as asymmetric septal hyperplasia can occur with poor control later in pregnancy and may affect both type 1 and gestational diabetes.macrosomia or big baby syndrome is a baby that is very large at delivery and increases the need for a cesarean sectionobstructed labour may occur because of the big baby.The ultimate risk for the baby is abortion or intrauterine death.
25Risks for baby (2) Asphyxia Birth trauma at delivery Hypoglycaemia HypocalcaemiaNeonatal jaundiceRespiratory distressPolycythaemiaIncreased later risk of type 2 diabetesDuring and after delivery, risks to the baby include asphyxia andtrauma at delivery including fractured clavicles and upper limbs, Erbs palsy. This usually is the result of macrosomia. Hypoglycaemia, hypocalcaemia, neonatal jaundice, respiratory distress and polycythaemia may all occur in the immediate post delivery period. These risks mean that this is a high risk baby and should be delivered at a facility that is able to deal with these problems in the baby.These babies also face an increased risk of type 2 diabetes in later life.Ideally, effective (tight) blood glucose control is needed from before conception to after delivery.
26Pre-pregnancy planning Unplanned pregnancies hopefully to be avoidedCounsel onAbstinence and contraception (incl. emergency contraception)Effects of diabetes on the pregnancyNeed for tight control of diabetes before and during pregnancyPlanned pregnanciesRisk of progression of mother’s complicationsGenetic implications of diabetesIn the light of these increased risks, unplanned pregnancies should be avoided. Counselling from mid-puberty should include discussion on contraception and the effects of diabetes on the pregnancy and the baby. Abstinence from sexual contact and the use of effective contraception should be part of routine education for all adolescent girls and young women with diabetes. Girls with diabetes should particularly be made aware that poor diabetes control around the time of conception increases the risk of having a baby with congenital abnormality and of miscarriage and late stillbirths. For planned pregnancies, the diabetes should be monitored by an experienced team from pre-conception and throughout the pregnancy. Conception should wait until blood glucose has been well controlled, and young women with diabetes should seek medical care as soon as they are aware of pregnancy. Establishing good control from as early in the pregnancy as possible will reduce risks of the complications listed above.Young women with diabetes should also be made aware that pregnancy may accelerate the progression of their own microvascular complications; particularly eye disease and renal disease. The genetic implications of diabetes should be discussed with the prospective parents, prior to or during the pregnancy.
28Fasting Fasting for Ramadan Insulin required despite the fasting Not compulsory for anyone with illnessSome choose to fastInsulin required despite the fastingNeed to adjust the insulin regimenPractical tips in manualSpecial circumstances need active managementChildren and adults with a medical illness are not required to fast during Ramadan, including diabetes. However, older children, adolescents and adults may choose to observe the Ramadan fast.It is important to remember that insulin is required by the body, both when we are eating and when we are fasting, since glucose is being used by the cells throughout the day. We need more insulin after a meal to deal with the extra glucose from digested food. During fasting, we do not consume food at the usual times, so the insulin doses need to be adjusted so that the body does not receive a large dose of insulin during the daytime when no food is being taken. It is also necessary to increase the amount of insulin given before breaking fast in the evening and before the pre-dawn meal.More practical tips are in the manual to help you support children who want to fast during Ramadan.Fasting for Ramadan is being used as an example of a special circumstance that may arise in the life of a child with diabetes. These special circumstances need active management and children with diabetes need support during these situations.
29QuestionsThese are some of the issues that you need to be aware of as you help children and their families to cope with their diabetes. There are more details of these problems in the manual. Your most important role is support and guide families. Take questions
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