Dr. K. Kabir,
Management of childhood (age of onset <14 years) is entirely different from that of an adult one. When a diabetic adult can lead a near normal life with self-discipline, common sense and knowledge, the diabetic child must have proper guidance from his attending physician for his normal emotionaland physical development. The child's diabetic control is very much dependent on his emotional and psychological adjustment with his surrounding environment. The concerned physician should be acquainted with certain special aspects of the childhood diabetes for proper guidance,which are discussed below under certain headings.
Diabetes in children progresses through certain definite stages:-
There is no straightforward answer to this question. It depends on three factors:
Despite of the good insulin injection technique, if the child needs more than usual insulin, the question arises "Does the child need that much insulin given to him?"
The Somogyi effect, though rare is essentially a condition of the childhood and adolescent diabetics. The real explanation is not known but Somogyi controlled this" unstable" or " brittle" diabetes only by lowering the insulin dose.
The diabetic diet for the child will be entirely different from that of an adult. The principles in making diet chart for the child is
One should not be too strict to his diet. The child must have enough food to grow normally like other kids. There should be strict restriction to the quality but not to the quantity of the food. He should avoid high sugar content food items like candies, cake, and aerated water jam, jelly, honey jaggery. Outwardly a diabetic child may be full of life, but one should always remember his psychological feeling of daily prick, diet restriction and frequent either urine or blood testing. One should always be sympathetic, if he occasionally breaks his diet.
Carbohydrate intake calculation for the children upto 12 years of age
Boys.....100 + (10x age in years) gm/ day
e.g.For a 8 years old child it is 180 gm/day
It should be as:
Breakfast 40 gms
3 snacks of 20 gms each (midmorning, afternoon and bedtime). There should always room for variation for the child. If a 8 years old child does not want to take40 gm CHO for breakfast (usually it is the rule for children below 8 years) he can have a little less at breakfast and a little more at lunch or at the afternoon snacks at his preference. Of course, his insulin dose is to be adjusted to his meal.
What is meant by good control? Normoglycaemic state is not the only parameter for good control in childhood diabetes. We can say the diabetic child is well controlled if.
If the diabetes is well controlled his health will be unaffected ,properly controlled children grow pretty well. If the child does not grow at the usual rate of 2.2 Kg. per annum or more during puberty there is every possiblity of poor control. Some diabetic children may be obese, it may be either familial or diet breaking or over treatment with insulin.
Emotional adjustment implies that the child is maturing well and developing an understanding of the world. Psychological adjustment refers more to the cast of mind and implies that the child is happy. Whole psychological side of the child is of great importance. If the child is miserable or emotionally immature, his control will be poor and uncontrolled diabetic child is miserable. so a vicious cycle is set up.
It is another problem frequently encountered in diabetic children, and may be due to (a) recurrent infection or (b) poor care at home. It is now well established that recurrent ketoaccidosis has some psychological background.
DCCT has proved that hypoglycaemic attacks are frequent with well controlled diabetic children. In normo-glycaemic state a delayed meal or unexpected exercise will invoke a hypoglycemic attack. On the other hand, frequent severe frequent attacks indicate poor control.
Exercise is a good indicator for the diabetic control. Energetic child means that his control is good. Some children are sedentary by nature, they should be encouraged to take some form of exercise and their control becomes better.
School performance:- Intellectual performanc3eof the diabetic child is normal or slightly. Probably, the disease makes him more conscious than others. Usually the good school performance is not observed with the depressed children; may be because of lack of family supports.
The diabetic child can join any kind of sport provided they are properly educated, such as taking a little extra carbohydrate before participating any sport. They should join the armed forces or drive any vehicle including plane where lives of so many people are at risk. Professional careers are suitable for the diabetic children.
There is no bar to marriage. The diabetic should not choose another diabetic as his life partner where chances of diabetic offspring are more than the non-diabetics.
The uncontrolled diabetic children may suffer from both macro and micro vascular complications . There are, however,certain complications like Mauriac's syndrome in which the child is stunted, with hepatomegaly, rounded face and 'joint contracture' in the fingers, causing them to be slightly bent do occur in the childhood. In the 'joint contracture' it is the tissues round the joint which have tightened, not the joint itself and it has nothing to do with arthritis or Dupuytren's contracture. DCCT has shown that tight control diabetes may prevent or at least delay the long term complication like retinopathy or nephropathy. In conclusion, the diabetic children should be treated with love, affection and gentle care, preferably a separate clinic. Annual residential camps should be organised where children are trained to lead a more disciplined life and exchange a lot of thoughts and share their common sorrows with others.