Diabetes and the Growing Child

Programme 1 2 3 4 5 6 Effects of growth on diabetes School issues Fasting Pregnancy Smoking, alcohol and drugs Exercise School issues

Effects of growth on diabetes

Growth and diabetes During childhood and adolescence Physical growth Maturation of organ systems Increasing intellectual maturity and understanding Puberty Not affected by diabetes if well controlled Poorly controlled diabetes may cause Poor growth Delayed puberty Growth 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.

Effects of changes Change Effect Consequence Growth Increasing weight 5 Effects of changes Change Effect Consequence Growth Increasing weight Increasing doses Puberty Decreasing insulin sensitivity Psycho-social stresses Increased doses More education Alcohol and drug use Risk taking behaviour Menses Changes in insulin sensitivity Fluctuating insulin needs with increased doses during menses Lifestyle Increasing activity Increase food intake / decreased doses Intellectual maturation Increased understanding Increased independence Increased autonomy Editing: 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.

School issues

Diabetes at school Safe and supportive school environment The child and adolescent with diabetes has rights Right to be admitted to school Right to receive appropriate care Right to be fully integrated into a school environment Responsibility of parents and care team Educating carers (teachers) at school Supporting schools and teachers Providing supplies for care Diabetes 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.  

Educating the people at school Information on diabetes and management Effect of illnesses Hyperglycaemia and ketones Recognition, treatment and prevention of hypoglycaemia Practical knowledge and practice in glucose and ketone testing and insulin injections Effects of diet and activity on diabetes Social and psychological impact of diabetes Education 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.   

Exercise

Diabetes and exercise Common part of children and adolescents lives Encouraged in diabetes Benefits of exercise include Sense of well-being Weight control Limit rise in glucose after meals Lowers heart rate and blood pressure Lowers blood lipid levels Reduces cardio-vascular risk Exercise 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.

Effect 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.

Factors affecting glucose response Duration Intensity of activity Type of activity Metabolic control Insulin regimen Absorption of insulin Timing and type of food Stress and competition involved Duration: 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 40-90 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.

Managing exercise (1) Very variable effects in different children Monitoring glucose is the key Know glucose value before activity May need snack adjustments (preferably quick carbohydrates) Monitor glucose 30-60 minutes after the end of the activity With 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 hypoglycaemia The 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 fruit Activity should be interrupted about every 30 minutes for an additional snack Blood glucose should be monitored 30-60 minutes after the end of the activity

Managing exercise (2) Treat low glucose with additional rapid sugar Sugar cube, coke, honey, sweets After prolonged activity: Additional snack before sleeping Have glucose monitored during the night Decrease bedtime insulin dose after afternoon or evening exercise Accurate records of activity, food intake and glucose values to learn A low glucose value should be treated with additional rapidly-digested food After prolonged activity, the child should have an additional snack before sleeping, and should have glucose monitored during the night Accurate records of activity, food intake and glucose values help the care team to assist with decisions about managing activity.

Smoking, alcohol and drugs

Alcohol and drugs Peer pressure to experiment Depend on availability, cost and societal attitudes Experimentation may start in very young children Children and adolescents with diabetes no different from any other Empower discussion rather than challenging behaviour Remember that there is peer pressure on adolescents to experiment with alcohol, tobacco and drugs   Marijuana, 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.

Alcohol drinks Use and abuse not uncommon May cause rapid rise in glucose, i.e. always eat before going to bed Effects on liver correction of hypoglycaemia is impaired Frequent use causes weight gain Empowerment to deal with peer pressure Alcohol 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.

Smoking Similar prevalence of smoking with or without diabetes General risks Cardiac disease Emphysema Cancers In people with diabetes, worse Cardiovascular disease Micro- and macrovascular complications Hypertension Hyperlipidaemia Studies 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.

Marijuana Excessive or frequent use associated with: School and learning difficulties Behaviour problems Depression Low self-esteem Anxiety Family/peer interactions Socially deviant behaviour No major direct effects on diabetes Unless overeating carbohydrates Marijuana 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

Other drugs May have Potential for addiction Have psychosocial effects No direct effect on glucose (hypoglycaemia at rave parties) Increase blood glucose levels Dehydration (amphetamine) or water intoxication (ecstasy) Potential for addiction Have psychosocial effects Interfere with diabetes self-management Some drugs have direct effects on the heart (amphetamine?) May need psychological intervention Other 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.

Pregnancy

Diabetes and pregnancy Diabetes in pregnancy poses challenges There are increased risks for both mother and baby All pregnancies complicated by diabetes should be managed by an experienced team Diabetes may be existing type 1 diabetes or gestational diabetes Diabetes 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.

Risks for mother Hypertension in pregnancy Urinary tract infections Later risk for type 2 diabetes Preterm labour Polyhydramnios Macrosomia DKA Progression of microvascular complications Risks 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

Poor control late in pregnancy Risks for baby (1) Congenital abnormalities Spinal Heart Gastro-intestinal Limb abnormalities Heart abnormalities Macrosomia (big baby syndrome) Obstructed labour Intra-uterine death Poor control around conception Poor control late in pregnancy Risks 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 section obstructed labour may occur because of the big baby. The ultimate risk for the baby is abortion or intrauterine death.

Risks for baby (2) Asphyxia Birth trauma at delivery Hypoglycaemia Hypocalcaemia Neonatal jaundice Respiratory distress Polycythaemia Increased later risk of type 2 diabetes During and after delivery, risks to the baby include asphyxia and trauma 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.

Pre-pregnancy planning Unplanned pregnancies hopefully to be avoided Counsel on Abstinence and contraception (incl. emergency contraception) Effects of diabetes on the pregnancy Need for tight control of diabetes before and during pregnancy Planned pregnancies Risk of progression of mother’s complications Genetic implications of diabetes In 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.

Fasting

Fasting Fasting for Ramadan Insulin required despite the fasting Not compulsory for anyone with illness Some choose to fast Insulin required despite the fasting Need to adjust the insulin regimen Practical tips in manual Special circumstances need active management Children 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.

Questions These 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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