Your growing child will have different reactions to diabetes at different ages. Young children passively but not happily accept the insulin shots, whereas young adults want to take charge of their condition. The following sections describe what you can expect from children with T1DM at different ages.
Missing the initial diagnosis of T1DM in an infant up to 18 months of age is ' easy to do because the child can't tell you what's wrong. You may not notice that diapers have to be changed more often because of excessive urination, and the baby's nausea and vomiting may be ascribed to a stomach problem. Call your doctor immediately to get a diagnosis if you suspect that your baby has T1DM; Chapter 2 has more information on typical symptoms.
The infant up to 18 months of age with T1DM is completely under the care of his parent (usually the mother). He'll resist his shots and his glucose tests but must clearly understand that they're essential. This is something you have to insist upon even though the child can't understand the reason.
It's better for the baby's neurological system to allow his blood glucose to be a little higher. A blood glucose between 150 and 200 mg/dl (8.3 to 11.1 mmol/L) is a good target to shoot for. Chapter 7 has full details on measuring and monitoring blood glucose.
The toddler who is 18 months to 3 years old is at the stage of beginning to test his parents, establishing himself as a separate human being. He's starting to learn to control his environment (by toilet training, for example). With diabetes, he may refuse shots, refuse to eat enough and at the right time, and generally make it difficult for you to manage the disease. You have to set limits and be firm, know when to insist when the item is essential (like taking insulin) and when to give in so that the child can have some victories as well (like allowing the child a piece of birthday cake).
Use of very short-acting insulin like lispro (see Chapter 10) is very helpful in toddlers because the child's eating habits tend to be irregular and you can give the insulin just as the child begins to eat.
Children between 3 and 6 years
The child between ages 3 and 6 is still home and tests your limitations even more than a toddler. But at last he can tell you when he has symptoms of hypoglycemia (see Chapter 4). At this age, the child is wondering what he did to deserve diabetes when all his friends don't have it. Get the child involved with food preparation so that he feels he plays a part in his care.
As your child gets closer to 6 years old, think about enrolling him in a diabetes camp or a children's diabetes group. There he'll be surrounded by kids like him and will realize that everyone has similar concerns and limitations. It turns out that diabetes isn't a punishment after all but something to be managed. (For information on camps for children with T1DM go to the Web site of the American Diabetes Association at www.diabetes.org/community programs-and-localevents/diabetescamps.jsp.)
Don't try to teach your young child about the complications of diabetes yet. He doesn't possess the skills or knowledge to manage his disease and will simply be frightened.
As the child begins school between 6 and 12 years of age, he wants to know more. This is the time for you and the child to go to a diabetes education program and to sit down together with a dietitian to work out the best diet to promote continued growth and good diabetic control. It's also the time to hand over some of the control (don't give up control of the insulin just yet), especially because you're not at school to monitor the child all the time. Establish that the school has food that's healthy for your child and also has a program where knowledgeable people are available to help him in the event of hypoglycemia. This is mandated by law. Your child should have access to immediate sources of glucose and permission to take them if necessary as well as the right to go to the bathroom when required. You also want to be sure that one parent is always available and reachable in case of an emergency. (Check out Chapter 14 for more information about adjusting to school with type 1 diabetes.)
Diabetes camp is a valuable place for your child to go at this age because he can make friends with other children with diabetes and also can learn more about his condition. In addition, nutrition is especially important as the child is growing rapidly (see Chapter 8). Snacks between meals will smooth out the glucose control.
When the child reaches age 13 to 15 and officially becomes a teenager, he's extremely curious and wants to know about everything, including his diabetes. Another trip together to a diabetes education program and the dietitian isn't overdoing it at all. He's probably forgotten a lot of information since his last visit, and there's usually some new and hopeful information that you can both learn from the program. At this age, involving both parents in diabetes education and treatment is even better than just one parent.
It's time to give up more and more control while still overseeing the way your child is managing his diabetes. Continuing attendance at diabetes camp confirms that he's doing the right things and reinforces the notion that diabetes can be associated with fun.
This and the following stage may be a very difficult time in terms of trying to keep good glucose control because of the production of large amounts of growth hormone, which tends to raise blood glucose. Don't expect perfection, and make sure your child doesn't either! Maintaining reasonable good diabetic control, allowing the average blood glucose to be a little higher (to avoid hypoglycemia), and knowing that after your child grows out of the teen years he can achieve tighter control will get you through these stages with your sanity intact.
The stage of puberty, from age 15 to 19, with all the new and powerful hormones (especially the sex hormones) may prove to be the most difficult time of all to manage T1DM. All the problems of attraction to and being attractive for a significant other seem to get in the way. Who wants his girlfriend to know that he has a chronic disease? Your child also has a lot of buddies of the same sex that he wants to impress. Telling them he can't eat this or that or that he has to take a shot several times a day or must leave for a regular doctor's appointment hardly makes a good impression.
In this age range, teenagers want to see the doctor on their own. They want to know that their diabetes won't prevent them from doing whatever they want in life. Teenagers also need their friends to know about diabetes and to help them when needed. This may be difficult for the teenager who really doesn't want anyone to know about his disease, but it's essential.
This is the stage when girls, especially, are highly conscious of their weight and may skip insulin shots in order to lose weight. Skipping insulin will show up in the hemoglobin A1c (see Chapter 7). If this level starts to rise as the child is losing weight, you need to step in to deal with the problem; see Chapter 8 for details.
Despite the difficulty of achieving excellent glucose control, this also is the point at which you really need to emphasize the importance of tight blood glucose control for two reasons: Tight control beginning now will help to prevent diabetic complications later on; and your young adult is preparing to go off to college, where you'll have little or no control over what happens. If he has developed good habits of eating, insulin administration, and so forth, these habits are likely to continue when he's on his own.
Be sure to discuss alcohol use and sexual activity before your teenager leaves the nest. Make sure he understands that overdoing it with alcohol provides many empty calories and can lead to hypoglycemia (see Chapter 12). In addition, be certain that your daughter is aware of the danger of pregnancy when diabetes isn't well-controlled (see Chapter 16) and that children of either sex are aware of sexually transmitted diseases. You may not be comfortable talking about these subjects with your child, but think how you'll feel if they suffer the consequences of ignorance.
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