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Issues and concerns about diabetes in children
PH C
CLINICAL REPORT
SECTION EDITOR
GROWTH AND DEVELOPMENT
Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N A s s i s t a n t t o t h e P re s i d e n t f o r H e a l t h A f f a i r s U n ive r s i t y o f Tex a s a t E l Pa s o
Issues and Concerns About Diabetes in Children
Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N
D
iabetes is much too complex an issue to be covered adequately in one article. The purpose of this article is to provide a brief review of diabetes and its impact on children. This article also explores societal and family issues as external variables that have an impact on the occurrence of type 2 diabetes in children. Throughout the careers of many nurse practitioners, we have known diabetes as a chronic disease with different classifications. Readers may remember the following classifications: juvenile or late-onset diabetes; diabetes insipitus and diabetes mellitus; insulin-dependent or noninsulindependent diabetes (NIDDM); and, more recently, type 1 (children) or type 2 (adult) diabetes. Additional categories of the 1997 classification include other specific types of diabetes and gestational diabetes mellitus. The changes in classifications throughout the years are indicative of attempts to move the understanding of diabetes from that of a disease focused on age or treatment to a conceptualization related to the etiology of the disease in the current classification. The present classification was made by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (1997). A child diagnosed with diabetes at the age of 10 years has a life expectancy of 44 years, whereas persons not affected have a life expectancy of 72 years (National Institute of Diabetes,
304
Digestive, and Kidney Disease [NIDDK], 1995). This fact, coupled with an incidence of diabetes of approximately 100,000 in American children and adolescents, illustrates the magnitude of the problem.
T
he most common
symptoms of type 2 diabetes include the classic symptoms of hyperglycemia, polyuria, polydipsia, polyphagia, weight loss, and fatigue.
Fortunately, whereas diabetes was once considered a “death sentence,” it now is possible for many people to control the disease and lead productive lives. Most health care profession-
als know that one of the ways to have a long life is to have a chronic disease that forces the person to take care of himself or herself. An important issue concerns adaptation to diabetes and the coping strategies used. Grey, Lipman, Cameron, and Thurber (1997) presented research findings documenting that children with diabetes have a higher rate of psychosocial problems such as low self-esteem and worse psychosocial status if metabolic control is poor. They also found that the length of time since diagnosis may influence psychosocial and metabolic adaption, with the longer length of time associated with a worsening of status. As children mature, they are expected to exhibit more self-care. The coping behaviors used most often were found to be diversions, developing selfreliance, solving family problems, and social support (Grey et al., 1997). An important finding in this study was that seeking support from professional and spiritual persons were the least commonly effective coping behaviors. Boys were found to have higher selfworth than girls; however, boys had more difficulty in adjustment and metabolic control than did girls. In this group of 89 children aged 8 to 14 years,
J Pediatr Health Care. (2001). 15, 304-307. Copyright © 2001 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2001/$35.00 + 0
25/8/119346
doi:10.1067/mph.2001.119346
November/December 2001
PH GROWTH AND DEVELOPMENT C there was poorer metabolic adjustment at 1 year, yet psychosocial status and coping behaviors were stable. Avoidance behaviors were associated with poorer adjustment. A study by Razeghi et al. (1998) investigated the efficacy of computermediated communication to enhance self-help in children and adolescents with diabetes. It was found that a computer bulletin board self-help group for children and adolescents was accessed frequently. It was also found that fewer than 10% of the participants in the study dropped out of the group after 1 year. A number of educational efforts have been instituted to help children cope with diabetes. One of these efforts, “Jump Into Action,” found that it was not necessary to train teachers prior to use of the program if sufficient time is given to program implementation (Holcomb et al., 1999). This program was designed for minority students with NIDDM and was found to be more effective than general classroom instruction on nutrition and exercise. Type 2 diabetes is primarily identified as insulin resistance with relative insulin deficiency or primarily an insulin secretory defect with insulin resistance (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). The most common symptoms of type 2 diabetes include the classic symptoms of hyperglycemia, polyuria, polydipsia, polyphagia, weight loss, and fatigue. Type 2 diabetes may be seen in children as young as 8 years, with an average age of diagnosis reported as 13 to 14 years (PinhasHamiel et al., 1996). The early adolescent phase of development (13 to 14 years) includes many issues that adolescents must resolve, including independence and autonomy. Chronic illnesses in general have presented challenges for health care providers who deal with adolescents. A recent excellent article on type 2 diabetes in children and adolescents was published in the July/August 2001 issue of this Journal (Brosnan, Upchurch, & Schreiner, 2001). Today there is global recognition that type 2 diabetes is no longer strictly an adult form of diabetes. Why type 2 diabetes has been identified as affecting young children is not completely understood. During the past 7 years,
JOURNAL OF PEDIATRIC HEALTH CARE
Castiglia
research has taken place regarding a marker for type 2 diabetes called acanthosis nigricans. This condition is characterized by thickened and hyperpigmented skin in the areas of the neck, axilla, and intertriginous folds. It is generally reported to be found in 56% to 92% of overweight children and adolescents with type 2 diabetes (FagotCampagna et al., 2000). It appears that obesity and lack of activity are associated causes. It is also evident that dietary changes related to fat and carbohydrate intake and the number of persons leading a sedentary lifestyle have increased. One need only think of the preponderance of fast food restaurants that entice children and adults to eat double and triple cheeseburgers. The marketing for these foods is often aimed at children, with prizes offered
T
ype 1 diabetes leads
to an inability to use sugar and results in hyperglycemia, ketoacidosis, weight loss, and if untreated, dehydration and coma.
upon purchase. In addition, the cost of fast foods is relatively inexpensive, and of course, the availability of this food cannot be questioned. Furthermore, it is easy to identify how a sedentary lifestyle including Game Boys, computer games, and, of course, television is seductive for children. In the United States, which has so much space for children to play, many parents are afraid to let their children go outside unsupervised because violent crimes against children sometimes occur. Latch-key children are often told to stay inside until a parent comes home from work. By then, it is often too late to go out to skate or play ball.
The answer is not a simple one in today’s society. Perhaps school days need to be longer with time for supervised physical activity. Perhaps children still need to have free time during recess, or perhaps they need a long enough lunch period to be able to go outdoors and play. Perhaps children, like adults, could concentrate better if they had physical breaks built into their school day. Undoubtedly many ideas about strategies exist, but no one in the health care field would say that interventions for dietary and activity changes are not needed. In a society like the United States, a number of isolated attempts have been made to change behaviors harmful to health, yet the basic issues in society that could affect change seem insurmountable. Many families need two salaries. Many women and men want to work outside the home in their careers yet do not seem to be able to afford adequate child care, or, if they can afford it, they cannot find it. Multigenerational families living in close proximity to each other are a rarity. People are living longer, but they have or want to have different lifestyles than did their grandparents. Often they are not interested in staying home to watch their grandchildren because with improved health, they can pursue other activities. Couple all of these familial and social problems with problems of violence in society as a whole. Remember that many of the perpetrators of violence came from homes and societies that contributed to violent acts. Briefly, type 1 diabetes is an absolute insulin deficiency resulting from pancreatic B cell destruction (either immune-mediated or idiopathic). It is the most common endocrine disorder in childhood (Metcalf & Baum, 1991). Type 1 diabetes leads to an inability to use sugar and results in hyperglycemia, ketoacidosis, weight loss, and if untreated, dehydration and coma. The aim of treatment is to balance therapeutic insulin with food intake for children, recognizing that growth and physical activity must also enter the equation. Dietary management, which should be overseen by a dietician, is very important for successful adjustment to diabetes. Carbohydrates affect blood glucose. Unrefined carbohydrates (eg, bread, pasta, and potatoes) should make up 50% of the energy requirement for
November/December 2001
305
PH GROWTH AND DEVELOPMENT C adults and 40% to 45% for children. Refined carbohydrates include sugar, which has an immediate effect of raising blood sugar. Sugar should not be omitted from a child’s diet. An addition of 25 g of sucrose to a healthy diet should not disrupt good glycemic control (Waldron, 1993). The best time to eat sweets is before exercise or after a healthy meal. Fat does not have a direct effect on blood sugar levels. Consuming fat is necessary for adequate energy and to obtain the necessary fat-soluble vitamins and essential fatty acids. Children older than 5 years need 30% to 35% of their dietary intake to contain fat (Magrath & Hartland, 1993). Saturated fats should be reduced by methods such as grilling instead of frying food. Fiber helps slow down the absorption of sugar into the blood. Foods such as fruit, vegetables, peas, baked beans, wholemeal bread, and cereals add fiber to the diet. Protein does not affect blood sugar levels, but all children need about 15% of their diet to consist of protein for energy. Sweeteners have no advantage compared with small quantities of sugar, and the intake of sweeteners should be limited to less than 25 g per day (Waldron, 1993). Diabetic products are not recommended for children because generally they are expensive, do not usually taste very good, and may contain sorbitol, which can have a laxative effect (Richmond, 2000). Dietary control must include obtaining a dietary history, formulating a regular eating plan, balancing carbohydrates with the type of insulin, understanding the peak effect of the insulin, and recognizing the age and life activities of the child (Richmond, 2000). Hypoglycemia is a risk that parents and the child must recognize and treat. In a child, hypoglycemia occurs when the blood glucose level is less than 4 mmol/L. Symptoms include paleness, irritability, change of mood, sweating, dizziness, headache, trembling, blurred vision, fatigue, and/or abdominal pain. The onset is rapid, and when it occurs, the child must be given a fast-acting sugar. This is to be followed by a high-fiber carbohydrate such as a biscuit to maintain the blood sugar level (Richmond, 2000). Hypoglycemia is a major risk for a child with diabetes after exercise; therefore, extra carbohydrates should be included in the diet when exercise occurs.
306
Volume 15 Number 6
Castiglia
When indicated, insulin management is an important component of the treatment and management of diabetes. Insulin has been used in the treatment of diabetes since 1921. At present, approximately 20 different insulins are being produced (Sengewald, 1999). Human insulin became available in the early 1980s; before then, insulin was obtained from the pancreas of beef or pork. Insulin analog (Humalog) has an extremely rapid onset and is administered immediately before or with a meal, which allows meal time flexibility (Sengewald, 1999). Knowing the type of insulin used is very important. Eli Lilly and Company’s brand of insulin from a human source is called Humalin, and Novolin is the brand produced by Novo/Nordick’s Pharmo, Inc. Many patients take a mixture of 2 or 3 types of insulin in one injection. Knowledge of the types of insulin used and the time of injection is important.
S
ymptoms of
hypoglycemia include paleness, irritability, change of mood, sweating, dizziness, headache, trembling, blurred vision, fatigue, and/or abdominal pain.
Although a number of oral medications are available for use with adults, most have not yet been approved for use with children. Metaformin (Glucophage) has been safely tested for 10- to 16-year-olds. The role of other medications is being researched, and sulfonylureas are among those being investigated. The increase in the incidence of type 2 diabetes in children has been a stimulus for more research on medications that are safe for use with children.
CONCLUSION No matter what type of diabetes a child has, type 1 or type 2, parents and children must be informed about all aspects of the illness and its management. The American Diabetic Association and its local branches have information in the form of written materials, and they also offer counseling and nutrition and exercise programs. Nurse practitioners and physicians should avail themselves of these resources. They should also participate in community and school efforts to attempt to cope with what many describe as an “epidemic” of diabetes. Diabetes has always been endemic, especially in persons such as those of Hispanic, AfricanAmerican, or Native Indian descent, but the increase in type 2 diabetes in children has been staggering. Compliance is always an issue for all patients. In childhood, parents take control, and compliance with treatment is usually successful. Problems often emerge during preadolescence and adolescence, when fitting in and being accepted by peers is very important. Being different in any context is not acceptable to the adolescent group mentality. Compliance usually is measured in terms of serum glycosylated hemoglobin (ChbA1c), which indicates long-term blood glucose sugar levels. It is a sensitive test, and if control of the diabetes is poor, the GhbA1c value is high. Values of GhbA1c below 7% indicate good control, and values 9% or higher indicate poor control. Good control can prevent complications of retinopathy, nephropathy, and neuropathy (DCCT Research Group, 1993). Compliance is also affected by the emotions caused by treatment and may include fear, guilt, shame, depression, and anxiety. Kyngus (1999) found that motivation had the strongest statistical connection with compliance and that the support received from parents explains motivation. Much information is available online for parents. One source, http://www. childrenwithdiabetes.com, lists links for resources, including books for parents, adults, and older children. Another resource listed are the many summer camps for children with diabetes. One such camp, Camp Challenge in New Mexico, has scholarships available for children 8 to 13 years of age. It is sponsored by the American Diabetic Asso-
JOURNAL OF PEDIATRIC HEALTH CARE
PH GROWTH AND DEVELOPMENT C ciation. Parents and caregivers are encouraged to avail themselves of all resources that can help them and their child to adjust to this chronic illness.
REFERENCES Brosnan, C. A., Upchurch, S., & Schreiner, B. (2001). Type 2 diabetes in children and adolescents: An emerging disease. Journal of Pediatric Health Care, 15, 187-193. DCCT Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329, 977-986. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. (1997). Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 20, 1183-1197. Fagot-Campagna, A., Pettitt, D. J., Engelgav, M. M., Burrows, N. R., Geiss, L. S., Valdez, R., et
Castiglia
al. (2000). Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective. Journal of Pediatrics, 136, 664-672. Grey, M, Lipman, T., Cameron, M. E., & Thurber, T. W. (1997). Coping behaviors at diagnosis and in adjustment one year later in children with diabetes. Nursing Research, 46, 312-317. Holcomb, J. D., Kingery, P. M., Sherman, L. D., Smith, O. W., Smith, D. W., Cullen, K. W., et al. (1999). Evaluation of a diabetes education program for fifth-grade students. Journal of Health Education, 30, 73-84. Kyngus, H. (1999). A theoretical model of compliance in young diabetics. Journal of Clinical Nursing, 8, 73-80. Magrath, G., & Hartland, B. V. (1993). Dietary recommendations for children and adolescents with diabetes: An implementation paper. British Diabetic Association’s Professional Advisory Committee. Diabetic Medicine, 10, 874-875. Metcalf, M., & Baum, J. (1991). Incidence of insulin dependent diabetes in children under 15 years
in the British Isles during 1988. British Medical Journal, 302, 443-447. National Institute of Diabetes, Digestive, and Kidney Disease. (1995). Diabetes in America (NIH Publication No. 95-1468). Bethesda, MD: Author. Pinhas-Hamiel, O., Dolan, L. M., Daniels, S. R., Standiford, D., Khourg, P. R., & Zietter, P. (1996). Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. Journal of Pediatrics, 128(5 Pt 1), 608-615. Razeghi, S., Renner, C., Shafer, S., Richter, T., Aksungur, A., Meier, S., et al. (1998). Project D: Computer-mediated communication as a tool for self-help in children and adolescents with diabetes. The Diabetes Educator, 24, 577580. Richmond, A. (2000). Childhood diabetes: Dietary aspects. Nursing Standard, 14, 48-52. Sengewald, J. M. (1999). Update on diabetes medications. Journal of Emergency Nursing, 25, 28-30. Waldron, S. (1993). Childhood diabetes: Current dietary management. Current Pediatrics, 3, 138-141.
Pediatric Pearl Fun relief from chicken pox Applying calamine lotion to chicken pox lesions can help reduce the itching and irritation so frequently associated with this childhood illness. To make a game out of it, give the child a small paintbrush and paper cup filled with calamine lotion. Allow the child to paint over the chicken pox lesions and then connect the dots. This method would also work for poison ivy or any other skin lesion for which calamine lotion is helpful. Susan Kulewicz, MS, RN, PNP Former PNP Student at Ohio State University Columbus, Ohio
JOURNAL OF PEDIATRIC HEALTH CARE
November/December 2001
307
CLINICAL REPORT
SECTION EDITOR
GROWTH AND DEVELOPMENT
Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N A s s i s t a n t t o t h e P re s i d e n t f o r H e a l t h A f f a i r s U n ive r s i t y o f Tex a s a t E l Pa s o
Issues and Concerns About Diabetes in Children
Pa t r i c i a T. C a s t i g l i a , P h D, R N , FA A N
D
iabetes is much too complex an issue to be covered adequately in one article. The purpose of this article is to provide a brief review of diabetes and its impact on children. This article also explores societal and family issues as external variables that have an impact on the occurrence of type 2 diabetes in children. Throughout the careers of many nurse practitioners, we have known diabetes as a chronic disease with different classifications. Readers may remember the following classifications: juvenile or late-onset diabetes; diabetes insipitus and diabetes mellitus; insulin-dependent or noninsulindependent diabetes (NIDDM); and, more recently, type 1 (children) or type 2 (adult) diabetes. Additional categories of the 1997 classification include other specific types of diabetes and gestational diabetes mellitus. The changes in classifications throughout the years are indicative of attempts to move the understanding of diabetes from that of a disease focused on age or treatment to a conceptualization related to the etiology of the disease in the current classification. The present classification was made by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (1997). A child diagnosed with diabetes at the age of 10 years has a life expectancy of 44 years, whereas persons not affected have a life expectancy of 72 years (National Institute of Diabetes,
304
Digestive, and Kidney Disease [NIDDK], 1995). This fact, coupled with an incidence of diabetes of approximately 100,000 in American children and adolescents, illustrates the magnitude of the problem.
T
he most common
symptoms of type 2 diabetes include the classic symptoms of hyperglycemia, polyuria, polydipsia, polyphagia, weight loss, and fatigue.
Fortunately, whereas diabetes was once considered a “death sentence,” it now is possible for many people to control the disease and lead productive lives. Most health care profession-
als know that one of the ways to have a long life is to have a chronic disease that forces the person to take care of himself or herself. An important issue concerns adaptation to diabetes and the coping strategies used. Grey, Lipman, Cameron, and Thurber (1997) presented research findings documenting that children with diabetes have a higher rate of psychosocial problems such as low self-esteem and worse psychosocial status if metabolic control is poor. They also found that the length of time since diagnosis may influence psychosocial and metabolic adaption, with the longer length of time associated with a worsening of status. As children mature, they are expected to exhibit more self-care. The coping behaviors used most often were found to be diversions, developing selfreliance, solving family problems, and social support (Grey et al., 1997). An important finding in this study was that seeking support from professional and spiritual persons were the least commonly effective coping behaviors. Boys were found to have higher selfworth than girls; however, boys had more difficulty in adjustment and metabolic control than did girls. In this group of 89 children aged 8 to 14 years,
J Pediatr Health Care. (2001). 15, 304-307. Copyright © 2001 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2001/$35.00 + 0
25/8/119346
doi:10.1067/mph.2001.119346
November/December 2001
PH GROWTH AND DEVELOPMENT C there was poorer metabolic adjustment at 1 year, yet psychosocial status and coping behaviors were stable. Avoidance behaviors were associated with poorer adjustment. A study by Razeghi et al. (1998) investigated the efficacy of computermediated communication to enhance self-help in children and adolescents with diabetes. It was found that a computer bulletin board self-help group for children and adolescents was accessed frequently. It was also found that fewer than 10% of the participants in the study dropped out of the group after 1 year. A number of educational efforts have been instituted to help children cope with diabetes. One of these efforts, “Jump Into Action,” found that it was not necessary to train teachers prior to use of the program if sufficient time is given to program implementation (Holcomb et al., 1999). This program was designed for minority students with NIDDM and was found to be more effective than general classroom instruction on nutrition and exercise. Type 2 diabetes is primarily identified as insulin resistance with relative insulin deficiency or primarily an insulin secretory defect with insulin resistance (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). The most common symptoms of type 2 diabetes include the classic symptoms of hyperglycemia, polyuria, polydipsia, polyphagia, weight loss, and fatigue. Type 2 diabetes may be seen in children as young as 8 years, with an average age of diagnosis reported as 13 to 14 years (PinhasHamiel et al., 1996). The early adolescent phase of development (13 to 14 years) includes many issues that adolescents must resolve, including independence and autonomy. Chronic illnesses in general have presented challenges for health care providers who deal with adolescents. A recent excellent article on type 2 diabetes in children and adolescents was published in the July/August 2001 issue of this Journal (Brosnan, Upchurch, & Schreiner, 2001). Today there is global recognition that type 2 diabetes is no longer strictly an adult form of diabetes. Why type 2 diabetes has been identified as affecting young children is not completely understood. During the past 7 years,
JOURNAL OF PEDIATRIC HEALTH CARE
Castiglia
research has taken place regarding a marker for type 2 diabetes called acanthosis nigricans. This condition is characterized by thickened and hyperpigmented skin in the areas of the neck, axilla, and intertriginous folds. It is generally reported to be found in 56% to 92% of overweight children and adolescents with type 2 diabetes (FagotCampagna et al., 2000). It appears that obesity and lack of activity are associated causes. It is also evident that dietary changes related to fat and carbohydrate intake and the number of persons leading a sedentary lifestyle have increased. One need only think of the preponderance of fast food restaurants that entice children and adults to eat double and triple cheeseburgers. The marketing for these foods is often aimed at children, with prizes offered
T
ype 1 diabetes leads
to an inability to use sugar and results in hyperglycemia, ketoacidosis, weight loss, and if untreated, dehydration and coma.
upon purchase. In addition, the cost of fast foods is relatively inexpensive, and of course, the availability of this food cannot be questioned. Furthermore, it is easy to identify how a sedentary lifestyle including Game Boys, computer games, and, of course, television is seductive for children. In the United States, which has so much space for children to play, many parents are afraid to let their children go outside unsupervised because violent crimes against children sometimes occur. Latch-key children are often told to stay inside until a parent comes home from work. By then, it is often too late to go out to skate or play ball.
The answer is not a simple one in today’s society. Perhaps school days need to be longer with time for supervised physical activity. Perhaps children still need to have free time during recess, or perhaps they need a long enough lunch period to be able to go outdoors and play. Perhaps children, like adults, could concentrate better if they had physical breaks built into their school day. Undoubtedly many ideas about strategies exist, but no one in the health care field would say that interventions for dietary and activity changes are not needed. In a society like the United States, a number of isolated attempts have been made to change behaviors harmful to health, yet the basic issues in society that could affect change seem insurmountable. Many families need two salaries. Many women and men want to work outside the home in their careers yet do not seem to be able to afford adequate child care, or, if they can afford it, they cannot find it. Multigenerational families living in close proximity to each other are a rarity. People are living longer, but they have or want to have different lifestyles than did their grandparents. Often they are not interested in staying home to watch their grandchildren because with improved health, they can pursue other activities. Couple all of these familial and social problems with problems of violence in society as a whole. Remember that many of the perpetrators of violence came from homes and societies that contributed to violent acts. Briefly, type 1 diabetes is an absolute insulin deficiency resulting from pancreatic B cell destruction (either immune-mediated or idiopathic). It is the most common endocrine disorder in childhood (Metcalf & Baum, 1991). Type 1 diabetes leads to an inability to use sugar and results in hyperglycemia, ketoacidosis, weight loss, and if untreated, dehydration and coma. The aim of treatment is to balance therapeutic insulin with food intake for children, recognizing that growth and physical activity must also enter the equation. Dietary management, which should be overseen by a dietician, is very important for successful adjustment to diabetes. Carbohydrates affect blood glucose. Unrefined carbohydrates (eg, bread, pasta, and potatoes) should make up 50% of the energy requirement for
November/December 2001
305
PH GROWTH AND DEVELOPMENT C adults and 40% to 45% for children. Refined carbohydrates include sugar, which has an immediate effect of raising blood sugar. Sugar should not be omitted from a child’s diet. An addition of 25 g of sucrose to a healthy diet should not disrupt good glycemic control (Waldron, 1993). The best time to eat sweets is before exercise or after a healthy meal. Fat does not have a direct effect on blood sugar levels. Consuming fat is necessary for adequate energy and to obtain the necessary fat-soluble vitamins and essential fatty acids. Children older than 5 years need 30% to 35% of their dietary intake to contain fat (Magrath & Hartland, 1993). Saturated fats should be reduced by methods such as grilling instead of frying food. Fiber helps slow down the absorption of sugar into the blood. Foods such as fruit, vegetables, peas, baked beans, wholemeal bread, and cereals add fiber to the diet. Protein does not affect blood sugar levels, but all children need about 15% of their diet to consist of protein for energy. Sweeteners have no advantage compared with small quantities of sugar, and the intake of sweeteners should be limited to less than 25 g per day (Waldron, 1993). Diabetic products are not recommended for children because generally they are expensive, do not usually taste very good, and may contain sorbitol, which can have a laxative effect (Richmond, 2000). Dietary control must include obtaining a dietary history, formulating a regular eating plan, balancing carbohydrates with the type of insulin, understanding the peak effect of the insulin, and recognizing the age and life activities of the child (Richmond, 2000). Hypoglycemia is a risk that parents and the child must recognize and treat. In a child, hypoglycemia occurs when the blood glucose level is less than 4 mmol/L. Symptoms include paleness, irritability, change of mood, sweating, dizziness, headache, trembling, blurred vision, fatigue, and/or abdominal pain. The onset is rapid, and when it occurs, the child must be given a fast-acting sugar. This is to be followed by a high-fiber carbohydrate such as a biscuit to maintain the blood sugar level (Richmond, 2000). Hypoglycemia is a major risk for a child with diabetes after exercise; therefore, extra carbohydrates should be included in the diet when exercise occurs.
306
Volume 15 Number 6
Castiglia
When indicated, insulin management is an important component of the treatment and management of diabetes. Insulin has been used in the treatment of diabetes since 1921. At present, approximately 20 different insulins are being produced (Sengewald, 1999). Human insulin became available in the early 1980s; before then, insulin was obtained from the pancreas of beef or pork. Insulin analog (Humalog) has an extremely rapid onset and is administered immediately before or with a meal, which allows meal time flexibility (Sengewald, 1999). Knowing the type of insulin used is very important. Eli Lilly and Company’s brand of insulin from a human source is called Humalin, and Novolin is the brand produced by Novo/Nordick’s Pharmo, Inc. Many patients take a mixture of 2 or 3 types of insulin in one injection. Knowledge of the types of insulin used and the time of injection is important.
S
ymptoms of
hypoglycemia include paleness, irritability, change of mood, sweating, dizziness, headache, trembling, blurred vision, fatigue, and/or abdominal pain.
Although a number of oral medications are available for use with adults, most have not yet been approved for use with children. Metaformin (Glucophage) has been safely tested for 10- to 16-year-olds. The role of other medications is being researched, and sulfonylureas are among those being investigated. The increase in the incidence of type 2 diabetes in children has been a stimulus for more research on medications that are safe for use with children.
CONCLUSION No matter what type of diabetes a child has, type 1 or type 2, parents and children must be informed about all aspects of the illness and its management. The American Diabetic Association and its local branches have information in the form of written materials, and they also offer counseling and nutrition and exercise programs. Nurse practitioners and physicians should avail themselves of these resources. They should also participate in community and school efforts to attempt to cope with what many describe as an “epidemic” of diabetes. Diabetes has always been endemic, especially in persons such as those of Hispanic, AfricanAmerican, or Native Indian descent, but the increase in type 2 diabetes in children has been staggering. Compliance is always an issue for all patients. In childhood, parents take control, and compliance with treatment is usually successful. Problems often emerge during preadolescence and adolescence, when fitting in and being accepted by peers is very important. Being different in any context is not acceptable to the adolescent group mentality. Compliance usually is measured in terms of serum glycosylated hemoglobin (ChbA1c), which indicates long-term blood glucose sugar levels. It is a sensitive test, and if control of the diabetes is poor, the GhbA1c value is high. Values of GhbA1c below 7% indicate good control, and values 9% or higher indicate poor control. Good control can prevent complications of retinopathy, nephropathy, and neuropathy (DCCT Research Group, 1993). Compliance is also affected by the emotions caused by treatment and may include fear, guilt, shame, depression, and anxiety. Kyngus (1999) found that motivation had the strongest statistical connection with compliance and that the support received from parents explains motivation. Much information is available online for parents. One source, http://www. childrenwithdiabetes.com, lists links for resources, including books for parents, adults, and older children. Another resource listed are the many summer camps for children with diabetes. One such camp, Camp Challenge in New Mexico, has scholarships available for children 8 to 13 years of age. It is sponsored by the American Diabetic Asso-
JOURNAL OF PEDIATRIC HEALTH CARE
PH GROWTH AND DEVELOPMENT C ciation. Parents and caregivers are encouraged to avail themselves of all resources that can help them and their child to adjust to this chronic illness.
REFERENCES Brosnan, C. A., Upchurch, S., & Schreiner, B. (2001). Type 2 diabetes in children and adolescents: An emerging disease. Journal of Pediatric Health Care, 15, 187-193. DCCT Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329, 977-986. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. (1997). Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 20, 1183-1197. Fagot-Campagna, A., Pettitt, D. J., Engelgav, M. M., Burrows, N. R., Geiss, L. S., Valdez, R., et
Castiglia
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in the British Isles during 1988. British Medical Journal, 302, 443-447. National Institute of Diabetes, Digestive, and Kidney Disease. (1995). Diabetes in America (NIH Publication No. 95-1468). Bethesda, MD: Author. Pinhas-Hamiel, O., Dolan, L. M., Daniels, S. R., Standiford, D., Khourg, P. R., & Zietter, P. (1996). Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. Journal of Pediatrics, 128(5 Pt 1), 608-615. Razeghi, S., Renner, C., Shafer, S., Richter, T., Aksungur, A., Meier, S., et al. (1998). Project D: Computer-mediated communication as a tool for self-help in children and adolescents with diabetes. The Diabetes Educator, 24, 577580. Richmond, A. (2000). Childhood diabetes: Dietary aspects. Nursing Standard, 14, 48-52. Sengewald, J. M. (1999). Update on diabetes medications. Journal of Emergency Nursing, 25, 28-30. Waldron, S. (1993). Childhood diabetes: Current dietary management. Current Pediatrics, 3, 138-141.
Pediatric Pearl Fun relief from chicken pox Applying calamine lotion to chicken pox lesions can help reduce the itching and irritation so frequently associated with this childhood illness. To make a game out of it, give the child a small paintbrush and paper cup filled with calamine lotion. Allow the child to paint over the chicken pox lesions and then connect the dots. This method would also work for poison ivy or any other skin lesion for which calamine lotion is helpful. Susan Kulewicz, MS, RN, PNP Former PNP Student at Ohio State University Columbus, Ohio
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