Information for parents of kids aged 2-4 years

A child aged 2 - 4 years with or without diabetes

 •Wants to be in control, wants to "do", to be in charge
• Achieves tasks, repeats them, gradually becoming more competent
• Daydreams and uses magic and pretend-play in their day-to-day life
• May have an imaginary 'friend' who is very real to them and with whom they have long conversations!
• Develops language skills
• Constantly asks "why?.. why?"
• Develops a range of gestures to express themselves
• 'Reads' you like a book!
• Throws (and recovers from) tantrums more easily
• Thinks in 'black and white', right or wrong, good or bad
• Has you as parent or carer as their main attachment
• Is self-centred, happily playing with a toy alone, then gradually learning to share toys
• May have to gradually learn to share the love of their parents when a brother or sister joins the family

 

When a 2-4 year old is diagnosed with diabetes

• It is difficult for your child to understand what has happened and that a needle helps them to stay healthy. They may see the injections as a punishment. You may be able to simply explain to your child that diabetes just happened - "Johnny got asthma, it's nobody's fault, you didn't catch it"
• A will of their own is already developing so your toddler may resist finger pricks and injections. Again you may explain - "Injections are medicine, you don't have to go back to hospital"
• Painful procedures are frightening to toddlers and pre-schoolers so these should be performed quickly and treated as routine. Prolonging the agony only makes things worse for you and your child
• Your child may gradually be taught about hypo symptoms. From about 4 years old, during a hypo, you can draw their attention to the way they are feeling so that they begin to recognise their symptoms and ask for help
• You may gradually encourage your child to learn about the right foods to be eaten and give them some choices, but...
• Concept of time is not understood, so your child will not be able to connect times with insulin and food

Living with diabetes

Parent's responsibility and coping from day to day
• Play, such as allowing your child to give pretend needles to a doll or soft toy, gives the toddler a chance to act out their feelings and lays some groundwork for their future involvement in diabetes related tasks
• As your child approaches four or five and asks why?, try to make your answer concise and encourage small tasks, one at a time, to fit in with your answers. They may push the button on the meter, choose which finger to be pricked or a site for their injection. But do not give in to the same spot being used all the time!
• At times when you are tired and overwhelmed with it all, remember that your child will eventually become independent, however need you to help along the way
• Give lots of hugs and kisses after any diabetes related procedure

Pre-school
• You will probably be very reluctant to let your child out of your sight but for you and your child's sake it is a good time to give your child a chance to spread their wings (and you a chance to spread yours)
• To take this huge step you must feel comfortable that your child will be safe as well as happy
• Ask your educator to visit the pre-school to talk to the staff so they in turn will feel comfortable with the situation. They are usually most helpful and only too happy to assist
• It is helpful to the staff if you provide one or two hypo kits for them to store in a prominent place. Remember to restock hypo kits regularly
• A photograph of your child placed in the staff room and details of hypo symptoms is advisable. An emergency action poster next to the photo as a reminder is a good idea. 
• Your child should wear some type of diabetes identifi¬cation chain or bracelet. This habit is a good one to encourage at a young age as it may encourage them to maintain that habit as they get older
• The pre-school staff don’t usually mind you going at lunchtime to check your child's blood glucose level (BGL) especially when newly diagnosed

If you don’t have access to an educator, add some handy hints of your own for your child's teacher:
• If the teacher is unsure if it's a hypo, they will do more harm than good withholding treatment than treating unnecessarily
• The teacher should not be afraid to re-treat the hypo if your child is not feeling better. The teacher should not send the child alone to obtain treatment
• The teacher should stay with your child until fully recovered

For more information about managing diabetes at pre-school click here.

To care for your child you must care for yourself
diabetes takes a lot of time and energy so it's normal to feel frustrated and tired from the constant daily demands of management. Your emotions may change and recur (perhaps frequently) - guilt, frustration, helplessness, sadness, anger ... and elation when all goes according to plan!
• Try and talk to someone who may understand.
• Share your feelings with your partner, a friend or relative, support groups, your doctor, other health professionals such as a social worker or psychologist
• Share diabetes-related tasks with your partner or supportive family and friends
• Keep in touch with your educator as ongoing education can help you and your child at different stages
• Don't be afraid to ask your health professional team for support and guidance.
• Encourage relatives or friends to attend education sessions and/or support groups to learn more about diabetes so that they may in turn give you support
• Find some time for yourself. It's a worthwhile investment for the daily demands of parenting

What does any child do with food at this age?

Being a toddler means that they are learning to be independent and a person in their own right. It also means learning the boundaries of this independence. Eating food... how much, what, when and where is a way in which a child at this stage explores the boundaries of behaviour and rules. As a parent, try to help your child understand what is reasonable.

Refuses food
A toddler (like many adults) will choose foods because they like them, not because the foods are healthy. Toddlers also learn very quickly that refusing one food will mean they will get their favourite, so try not to fall into the trap of providing less nutritious alternatives.

Much of the stress of food refusal can be eased if you keep calm. Keep food preparation simple, so if it does end up on the floor or on the wall, you don't feel you have wasted time.

The love/hate relationship with food that often occurs with toddlers is quite normal. Likes and dislikes of food can change on a daily basis. There is no logic in their actions, so don't be tempted to bribe. Meeting demands for a favourite cup or plate is reasonable, but preparing special, separate meals is not. If the same food is eaten for three days in a row there is no reason to be concerned as you'll notice that over the next week or two, the range will broaden.

Has a fickle appetite
At this age it is very common for appetite to vary from day to day and meal to meal. Snacks are important, so try to offer healthy choices such as fresh fruit pieces, yoghurt, triangle or finger sandwiches and pikelets.

Drinking too much milk or juice can be contribute to poor appetite. To prevent this, it's very important to wean toddlers from a bottle to a cup from 18 months onwards. This helps decrease the amount of fluid taken and leaves more room for solids. As a guide, toddlers only need 600mL milk and up to 200mL of juice per day. It’s also a good idea to avoid giving drinks just before a meal or snack as this can reduce appetite. Anaemia and tooth decay can result if fluids are chosen in place of food, particularly from a bottle.

If you are worried that your child doesn't seem to be eating anything, try recording all the food and fluid taken over the day - you may well be surprised. Young children can nibble away at food over the day and take in quite a considerable amount. It’s therefore important that snacks are nutritious.

Sometimes the variety may be limited to two or three choices such as cheese sandwiches and bananas, but if the foods are nutritious there's no need to worry. Try introducing new foods a little at a time and often during the day. The problem may resolve itself over the next week or so. Toddlers are learning about their likes and dislikes and testing them out.

Begins to share family foods
At this stage, seating your child at the table is an important social event. Your child can enjoy many (if not all) of the meals that the rest of the family eats, such as stews, casseroles, mild curries, bolognaise sauce and pasta. Food may have to be cut into smaller pieces, but cooking two meals is not necessary. If there are siblings at the dinner table, offering praise for eating well can also encourage positive eating habits in your toddler.

Sometimes midday and evening meals may need to be served earlier than the rest of the family. Smaller children can't wait as long as older children or adults. Their attention span is shorter, they may lose interest in eating and they also may become very grumpy if a meal is delayed too long.

After the age of two, low fat dairy foods can slowly be introduced into your child's diet. Before this age, it is difficult for children to consume adequate amounts of energy for their requirements and regular or full cream dairy products are needed.

Some fats which can be limited at this stage are:
• Processed meats (such as devon and salami)
• Sausages
• Fried foods (such as battered fish and chips)
• High fat snack foods like crisps, corn chips
• Creamed and chocolate-coated biscuits
• Pastries
• Chicken skin and visible fat on meat

In addition, more fibre rich foods can also be encouraged, such as wholemeal breads and crackers and high fibre cereals.

Riding the food merry-go-round ... of diabetes

Erratic eating and avoiding hypos
Food fads, fussy eating, variable likes and dislikes and tantrums are common in toddlers – with or without diabetes! For the parent of a child with diabetes, these food behaviours are often an additional source of stress. In particular fears about hypoglycaemia are common.

Although many parents worry that their child is not eating enough, the rate of growth usually slows around this age, so a reduction in food intake is common. A grazing style eating pattern with regular carbohydrate choices is encouraged.

Children of this age are very aware of parental stress, so where possible try to remain calm about your child’s mealtime behaviours. It’s important to keep food choices simple and offer the choice between one or two foods. Resist the temptation to offer treats if your child refuses to eat. Try to offer a nutritious alternative instead. Avoid bribes, force-feeding or following your child around the house trying to coax them to eat. Sometimes a simple plate of finger food without fuss is enough to encourage your child to eat.

Keep encouraging healthy food choices. You may find that changing from a bottle to a cup also helps encourage appetite at meal times. Offering meals and snacks ahead of time or giving insulin after meals may also help reduce stress and avoid some of the problems that may arise with food

There's more to meals than food
Carbohydrate foods often become the focus for parents and children with diabetes – and for obvious reasons. Remember, for overall good nutrition and appropriate growth and development, other foods are equally as important. So don’t forget about vegetables, lean meats and other protein foods.

It may be tempting to resort to any carbohydrate food such as sweets or juice to prevent hypos but this is not a nutritious habit to encourage. Try to encourage a variety of food choices instead. Note: 200mL of juice a day is ample and remember that water is the best everyday drink.

The importance of a flexible insulin regimen
If you are having difficulties with amount and timing of your child’s food intake, discuss possible variations to the insulin regimen with your child's diabetes doctor or educator. If your child is refusing to eat and their BGLs are not low, it may be OK to wait a short time before offering the meal again. It may also be possible to give insulin after the meal or adjust the dose to prevent hypos. Talk to your diabetes team about possible changes to your child’s insulin plan - it is preferable adjust insulin dosage rather than to force-feed the toddler who refuses to eat.

Source: http://www.diabeteskidsandteens.com.au/parents_and_carers_2.html

Diabetes in Children: An Emerging Epidemic

Type 2 diabetes used to be called "adult-onset diabetes" for a reason -- it occurred in middle-aged adults primarily and rarely, if ever, in children. But within the last decade, a serious change in diabetes trends made the description "adult-onset" no longer applicable, because adult-onset diabetes is becoming increasingly common in children.

 

An estimated 3,700 Americans under 20 are diagnosed with what is now more commonly referred to as simply "type 2" diabetes every year, according to the U.S. Centers for Disease Control and Prevention (CDC).
Because type 2 diabetes in this young of an age group is such a new phenomenon, no one knows for sure just what health toll the disease will take, but given its long list of associated risks, which are dangerous enough when they first begin in your 50s or 60s, it could be significant.

Heart Attacks and Kidney Problems in Their 20s and 30s?
Diabetes is known to quadruple your risk of having a heart attack or stroke. It's the leading cause of blindness and kidney failure in the United States. It also significantly increases your risk of high blood pressure, nervous system damage, gum disease and lower-limb amputations.
These statistics are primarily for people who develop diabetes in their middle-age years and beyond, and it stands to reason that the longer a person has diabetes, the worse the complications may become. So it's possible that a generation of children with diabetes could be facing a slew of formerly "adult" diseases, like high blood pressure and heart disease, while they're still in their youth.

No One Knows How Many Kids are at Risk
Under 4,000 new diagnoses of type 2 diabetes in kids under 20 each year may not seem like that high of a number, but it's likely that a far greater number of American youth are teetering on the edge of a diabetes diagnosis than initially meets the eye.
Estimates of undiagnosed diabetes are unavailable for children, but consider this: already, 24 million Americans have diabetes, but one-quarter of them do not know they have it. An estimated 57 million also have pre-diabetes, a stepping-stone to the actual disease, and again many do not know it. This is because symptoms often develop slowly, sometimes over a period years, and may be easy to miss. Some people also have no symptoms at all.
Given that more than twice the number of U.S. adults that have diabetes are suffering from "silent" pre-diabetes, it's likely that an untold number of U.S. kids also have pre-diabetes and are only months or years away from a full-blown diabetes diagnosis.
Further, the number of children with diabetes is growing at an alarming rate. In one nationwide study of children's hospital discharge records from 1997, 2000 and 2003, rates of hospitalizations for type 2 diabetes increased 200 percent.

Is Obesity to Blame?
Childhood obesity has more than tripled in the last three decades. According to the latest statistics from the CDC, "The prevalence of obesity among children aged 6 to 11 years increased from 6.5% in 1980 to 19.6% in 2008. The prevalence of obesity among adolescents aged 12 to 19 years increased from 5.0% to 18.1%."

As in adults, excess weight in kids increases their risk of related complications ranging from heart disease and cancer to type 2 diabetes. Disease development does not occur overnight, of course, which means that kids who are overweight today may develop diabetes 10 years or so down the line, when they reach their teen years or enter young adulthood.
Further, overweight or obese kids are more likely to become overweight or obese adults, so those who escape a diabetes diagnosis in their youth are still at increased risk as adults, assuming they're still overweight. And adding to the vicious cycle is the fact that babies born to women with type 2 diabetes are at an increased risk of type 2 diabetes as well, which suggests the diabetes trend among youth may soon start to skyrocket even higher.

Prevention and Early Intervention are Key
Children are at risk of type 2 diabetes for many of the same reasons as adults, with poor diet that is focused on soda, sweets and refined processed junk and fast foods, and lack of exercise among the top culprits. Not only will this increase your child's risk of becoming overweight or obese, but it can also lead to diabetes directly.

As a parent, you can therefore play an important role in helping your child to avoid this potentially deadly disease by instilling, and modeling, healthy lifestyle choices. Among them, try:

• Eating dinner as a family.Sitting down to a healthy, balanced meal each night is one of the best ways to get your kids to eat right. Limit soda, fast food and other junk foods.
• Encouraging physical activity.Young kids shouldn't have to set aside special time to "exercise" -- they should be getting plenty of physical activity naturally by playing outdoors with friends, riding bikes with the family or taking the dog for a walk.
• Avoiding rewarding your kids with food.This sets them up to use food (and typically unhealthy foods) to satisfy their emotional needs.
• Limiting TV and video game time.This will not only cut down on the number of junk-food advertisements your child sees, but it will also help to discourage sedentary behavior. If all else fails, at least give active video games a try.

If your child has already been diagnosed with type 2 diabetes or is showing signs of high blood sugar levels, early intervention is key. A knowledgeable health care practitioner can help guide you on how to prevent, manage and ultimately reverse diabetes using lifestyle interventions along with identifying the unique underlying causes of the condition in your child.
Reference
1. ABC News March 23, 2007, Findings presented at the 2007 annual meeting of the Pediatric Academic Societies, in Toronto

The Functional Endocrinology Center of Colorado provides hope to patients with Type II Diabetes and Hypothyroidism by providing alternative paths to care. Founded by Dr. Brandon Credeur, DC, and Dr. Heather Credeur, DC, the center is located at 4155 E Jewell Ave, Ste 1018, Denver, CO 80222, 303-302-0933, http://www.drcredeur.com.

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