Dr. K. Kabir,
Consultant Diabetologist,
Kolkata.

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.

• Progress of the childhood diabetes
• How much insulin does a child need?
• The diabetic diet of the child
• Diabetic control of the child
• Emotional and psychological adjustment
• Recurrent ketoacidosis
• Hypoglycaemic attack
• Exercise
• Long-term view of the childhood diabetes

Diabetes in children progresses through certain definite stages:-

1. In the first stage: The disease may appear at the very early age. Youngest diabetic child at our clinic was eighteen-month-old baby boy. It deteriorates very rapidly and may be admitted in comatose state. Five years old girl in our series was admitted in coma when it was diagnosed as diabetic ketoacidosis with plasma glucose level over 600mg%. At the discharge, the child is stabilised to the extent, that he is outwardly free from his symptoms of polyurea, polydipsia and lethargy.
2. In the second stage: - There is a period when the child's insulin requirement is less than dose prescribed at the time of discharge from the hospital. This is called "honey-moon period" or "remission period". This stage means that his beta cells are still producing some insulin, but is not sufficient enough to keep the child free from diabetes. Only one dose insulin in the morning is sufficient to lower the blood glucose level under control for the whole day. This period lasts for months or years. In our series, one boy remained free of symptoms for more than four years without even a single dose of insulin. It may quiet suddenly disappear even with trivial infection.
3. In the third stage: Beta cells stop secreting insulin. The blood sugar control is totally dependent on exogenous insulin and the insulin requirement rises.
4. Next stage is puberty: To control of diabetes at this stage is very difficult for a number of both physiological and emotional reasons. The more problems are faced with girls. Insulin requirement is more in adolescence.
5. Usually if diabetes appear at the age of ten or eleven, there may not be the stage of "honey - moon period". Third and fourth stage comes very quickly. Some children never show a clear "honey - moon period".

There is no straightforward answer to this question. It depends on three factors:

• Insulin antagonists
• Insulin resistance and
• Personal idiosyncrasy where cause is not known. Some needs more insulin than others do. With these thoughts in mind the tentative insulin dose scales are as follows.
  • In the honey-moon period ------- It is likely to be 0.5unit pr Kg body weight per day
  • After the honeymoon period. insulin dose is about 1.10 unit per Kg BW per day.
  • During Puberty...... it may be about 1.3 to 1.4 units per Kg BW per day. But on average insulin dose is around 1 unit per Kg BW per day.

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

• The child must be allowed to enjoy his food.
• The diabetic child must be able to fit harmoniously into the family.

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
Lunch 40gms
Dinner 40gms
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 take 40 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.

• He is free of his symptoms of polyurea and polydipsia
• His emotional and psychological development is normal
• He is not easily fatigued with exercise
• He is free of hypoglycaemic attack and if present, they are few and mild in nature

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 performance of 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.

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