Support, planning key to managing toddlers with type 1 diabetes
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NEW ORLEANS — Managing type 1 diabetes is complicated for any adult adjusting to the diagnosis, but the challenges are compounded when parents learn that their young toddler or preschooler has the disease.
Finicky eating, growth spurts, a growing need for independence, the typical toddler tantrums — the unique situations facing the parents and caregivers of young children with type 1 diabetes can seem daunting by any standard, said Sheila Dennehy, RN, MSN, CDE, of Winthrop Pediatric Associates in Mineola, New York. For these parents and caregivers, increased support and guidance are required to help them navigate what can be a confusing and frightening new reality.
“Just think, you have a young toddler with limited understanding, who is unable to effectively verbalize their needs and feelings,” said Dennehy, speaking during a presentation here on managing type 1 diabetes in preschoolers and toddlers. “Add their erratic activity, finicky eating patterns, small body frame and erratic sleeping patterns. Couple that with parents who are new to the parenting game ... add a newborn to that and throw in a diagnosis of type 1 diabetes, and this can wreak havoc on any family situation.”
Know the risks
There are several steps parents and caregivers can take to better manage a disease that requires multiple checks of blood glucose, careful carbohydrate and calorie measurements and multiple, daily injections in children who don’t have a full understanding of what is happening to them or why, Dennehy said. Still, parents need to be mindful of the challenges ahead of them.
“Finicky eating, growth spurts, and often, the refusal to eat can all make consistent timing and amounts of meals nearly impossible,” Dennehy said. “Insulin requirements vary and will require dose changes week to week. There is a need for naps, which can be unplanned, and overnight periods of long sleep, which make the toddler vulnerable to hypoglycemia. The toddler has limited ability to communicate and therefore may not report symptoms of hypoglycemia.”
In addition, toddlers are prone to rapid dehydration, especially during illness, Dennehy said. They often have a degree of hypoglycemic unawareness and require more frequent blood glucose monitoring, so parents and caregivers must be vigilant for changes resulting from hypoglycemia.
Blood glucose testing, finger sticks, injections, pump site insertion and glucose sensors, all done multiple times throughout the day and week, and at night, can lead to feelings of mistrust between the toddler and caregiver at a vulnerable time, Dennehy said.
“Magical thinking is active, and the toddler may actually believe they caused the diabetes themselves, leading to feelings of guilt,” Dennehy said. “[They may say] ‘I feel fine, I’m not sick, why are you doing all these things to me?’ They have difficulty understanding the need for treatments.”
Provide support
Diabetes educators and other health care providers need to focus on the entire family — and sometimes the child’s daycare provider, nanny or teachers — to navigate these challenges, Dennehy said. Parents may be depressed and anxious, siblings may be jealous, and childcare providers may find the diabetes care plan confusing or overwhelming.
“This is where positive coping comes in,” Dennehy said. “The benefits of seeking professional support revolve around planning how to cope with emotions in a healthy way.”
The ultimate goals, Dennehy said, are optimal glycemic control for each developmental level, optimal growth and development, and a socially, emotionally and psychologically healthy child who just happens to have diabetes.
Continuous glucose monitoring can also ease the burden on parents and caregivers, potentially reducing stress and fears of hypoglycemia. Dennehy spoke of one family who, upon using a continuous glucose monitor for their young daughter, benefited from increased dose consistency, the ability to immediately assess the impact of certain foods, allowing their daughter to sleep through the night and going from checking blood sugar 10 to 14 times a day to less frequent checks — all while lowering their daughter’s HbA1c from over 9% to 7.8%.
Parents should keep any finger sticks and injections quick, follow up with reassurance, and keep the emphasis on positive interactions, Dennehy said. Parents should also make an effort to keep a safe place in the home, one room where no procedures are done, while stressing that treatments are meant to keep them healthy, not as a punishment.
“Children need to feel some control over their world,” Dennehy said. “Consider giving them some choices when appropriate ... a choice between two snacks, which finger to use for testing.”
The recommended toddler diet
For a toddler with type 1 diabetes, what they eat or don’t eat can be a source of constant stress for parents, who may be tempted to provide unhealthy foods when anxious about blood sugar levels.
“We try not to let the toddler rule the roost,” Dennehy said. “They quickly realize that if they don’t eat after insulin, everyone goes crazy, and they start giving them cookies and juice and things to supplement the carbs that have been missed.”
To properly meet the nutritional needs of toddlers, parents should offer three meals and two to three snacks per day, said Colleen Farley-Cornell, MS, RD, CDN, CDE, of the department of nutrition at Long Island University. Toddlers, Farley-Cornell said, have small bellies and often cannot consume a large amounts of food at one time.
A typical 2- to 4-year-old requires between 1,000 and 1,400 calories per day and an average of 130 g of carbohydrates, Farley-Cornell said. Approximately 45% to 65% of those nutritional needs come from carbohydrates for energy.
A child with type 1 diabetes, Farley-Cornell stressed, has the same nutritional requirements as a child without diabetes.
“So when a parent decides that the child’s blood sugars are high and restricts the carbs, it may not meet the needs of the child,” Farley-Cornell said. “We often remind [the parents] that the child is insulin deficient, not carbohydrate deficient.”
Protein makes up 5% to 20% of caloric needs, Farley-Cornell said, while fats make up about 30% to 40% of caloric needs. By encouraging a wide variety and presenting new foods alongside familiar ones, while also keeping milk intake to between 16 oz and 24 oz, parents can help their children better meet their nutritional needs, Farley-Cornell said.
Serving sizes, Farley-Cornell said, are small, with toddlers requiring an average of one tablespoon of solid food per year of age. The serving size is about half that of a school-aged child. For example, the equivalent of one serving of dairy for a toddler is half a cup of milk or half an ounce of cheese, while a quarter slice or half slice of bread is the equivalent of one serving of grains. A few tablespoons of ground beef, fish, poultry or beans meets the toddler’s protein requirements, according to Farley-Cornell.
“Often parents are concerned that they are not getting enough protein in, but as you can see, it’s very little that they need,” Farley-Cornell said.
Once servings are determined, parents can form a toddler meal plan that consists of three meals and one to three snacks per day, with consistent amounts of carbohydrates. Meals and snacks given at the same time each day help determine insulin dose.
“Consistency is the key to a successful meal plan,” Farley-Cornell said. “But any meal plan must be flexible and realistic, taking into account the child’s likes and dislikes and lifestyle.”
The toddler period is often a time of exploration and independence, and this includes eating. If a toddler chooses not to eat a particular food, Farley-Cornell said, don’t give up. Continuing to serve familiar foods with new foods, rotating acceptable foods, and providing a regular schedule (including regularly scheduled nap times) will help avoid erratic blood sugars.
“My best advice is to always plan ahead, and be prepared with food, snacks and drinks,” Farley-Cornell said. “Encouraging parents to follow the same schedule will help minimize blood glucose excursions. The meal plan should be flexible and give parents some room to make adjustments.” – by Regina Schaffer
- Reference:
- Dennehy S. T22. Presented at: The American Association of Diabetes Educators Annual Meeting; Aug. 5-8, 2015; New Orleans.
Disclosure: Dennehy and Farley-Cornell report no relevant financial disclosures.