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Children may have type 1 or type 2 diabetes. Type 1 diabetes (also known as juvenile-onset diabetes) is typically a disease of childhood and can appear in children at any age. Its highest incidence, however, is in children 10 to 14 years old. In recent years, the onset of type 1 diabetes in ages under 5 years has also increased. Recently, type 2 diabetes that is typically a disease of the adults has also been occurring in children in alarming proportions. The goals of diabetes treatment in children with type 1 and type 2 diabetes are almost the same as in the adults. The goals are to:

• Achieve and maintain blood sugar at a safe and near to normal level

• Reduce the risk of diabetes emergencies such as low blood sugar, very high blood sugar, and increased acids in the blood

• Reduce the risk of long-term complications of diabetes

• Control diabetes related disorders, including high blood pressure, abnormal levels of cholesterol and other blood fats

• Maintain normal physical growth and mental development of children

In general, the principles of diabetes care that are relevant to adults are also applicable to children with diabetes. There are, however, certain aspects of diabetes care that are either unique or have a greater relevance for children. One such aspect is your role as a parent or family member. Because your young child cannot manage his or her diabetes independently, you must take the full responsibility of managing the diabetes care of your child.

TYPE 1 DIABETES IN CHILDREN
The course of type 1 diabetes in children, as in adults, can be divided into three main stages: diagnosis, honeymoon (a brief period in the early stages of type 1 diabetes  when blood sugar is well controlled), and full-fledged diabetes.

Managing Type 1 Diabetes in Diagnosis Stage
This is the stage when diabetes is diagnosed in your child. The news that your child has diabetes is a psychological shock for you, but you and your child have to live with this disease, and manage it to have a fruitful life. During this stage, you must keep a close contact with the health care professionals who will assist you in managing diabetes care of your child. These professionals will help you to:

• Recognize the symptoms of low blood sugar, very high blood sugar, and increased acids in the blood

• Treat low blood sugar with food or by injecting glucagon

• Test blood sugar and ketones in the urine

• Know the basics of insulin therapy

• Plan healthy meals for your child

• Learn special diabetes care when your child is sick

Because the body produces little or no insulin in type 1 diabetes, your child having type 1 diabetes must get insulin injections. In the early stage of type 1 diabetes, the destruction of beta cells is partial and the body is still secreting some insulin. The insulin requirement of infants and children is small in this stage. During this stage, two daily injections of insulin consisting of intermediate-acting NPH or lente and regular insulin (see Table below) may be sufficient to control blood sugar.

During the course of treatment, various adjustments can be made in the insulin plan to achieve better control of blood sugar. For example, the dose of intermediate-acting insulin in the morning can be increased in the above plan to improve blood sugar control before dinner. Also, rapid-acting insulin lispro or aspart may be added to improve blood sugar before lunch. Other adjustments, including increase or decrease in the insulin doses, are also possible.

Managing Type 1 Diabetes in Honeymoon Phase
Although blood sugar control will improve during the honeymoon phase, insulin therapy should not be discontinued. The insulin dose, however, may be decreased at this stage. Insulin in small doses helps preserve beta cells, delay their destruction, and prolong the honeymoon phase by achieving better control of blood sugar.

Insulin should be carefully administered during this phase because even in this stage the pancreas will still be producing some insulin, and administration of insulin might pose a risk of low blood sugar. To prevent this risk, insulin doses may be reduced and adjusted. If, for example, your child is receiving any intermediate-acting or long-acting insulin injection before dinner, reduce its dose to prevent low blood sugar during the night. You can make other adjustments also for safe insulin therapy.

Managing Full-Fledged Type 1 Diabetes
After the brief honeymoon period (several weeks to several months) during which blood sugar has remained under control, diabetes reappears. Diabetes in this stage may be quite severe and will not be controlled by the reduced doses of insulin administered during the honeymoon phase. To control blood sugar in the diabetes stage, doses of insulin injections will have to be increased.

Insulin requirements of children with diabetes increase with age. This is mainly due to insulin resistance arising from increased secretion of growth hormone as the child grows, or the extended destruction of beta cells over time. This is the stage when insulin therapy has to be intensified to control blood sugar. With time, beta cells in type 1 diabetes are totally destroyed and your child becomes dependent on insulin injections for survival. In this stage, the child may require three or more insulin injections every day or continuous infusion of insulin (insulin pump) to control blood sugar.

INSULIN NEED IN CHILDREN
Insulin treatment has to be highly individualized according to the insulin needs and typical conditions of your child:

• Infants with diabetes require very small amounts of insulin. The regular insulin of U-100 strength is diluted into U-50, U-25, or U-10 strengths. To dilute insulin, use the diluting solution provided by the manufacturing company.

• As your child grows, his or her insulin needs will increase as noted before. How much insulin your child will need is to be determined by the doctor. The daily insulin need of a young child, for example, may be 0.5 unit per 1 kg of body weight as noted in the Table shown above. This requirement will increase as the child grows and becomes a school age child. At this age, he or she may need 1.0 unit of insulin per 1 kg of body weight per day. Because growing age and puberty are associated with insulin resistance, the growing adolescents need greater amount of insulin. At this stage, they may need 1.0 to 1.5 units of insulin per 1 kg of body weight per day to fight back insulin resistance and to control blood sugar. Since the insulin need of a child changes with the passage of time as he or she grows, it is necessary that the insulin requirement of your child is periodically reassessed by the doctor.

• As the children grow older and reach adolescence, their lifestyles tend to be hectic and their meal times become irregular. In such settings, fixed doses of insulin at consistently the same time every day will not be appropriate for these children. The better option will be to build insulin plans around the meals. This means your child with diabetes should take insulin when he or she takes meals and not at fixed times of the day. To build such a plan, there can be various options of insulin combinations. One option can be to devise an insulin plan in which your adolescent receives a long-acting insulin such as ultralente or insulin glargine in the morning, and the short-acting regular or rapid-acting insulin lispro before each meal.  Such treatment plans will provide increased flexibility of lifestyle to the adolescent, while achieving good control of blood sugar at the same time.

TIGHT CONTROL OF BLOOD SUGAR
In children, the importance of blood sugar control increases with age. Although tight control of blood sugar is less important in infants, it is critical as the children grow older. Some key considerations are:

• Strict control of blood sugar is not desirable in infants because it heightens their risk for low blood sugar. Frequent episodes of low blood sugar are harmful to the infants because at this age they are undergoing rapid physical and mental development, and low blood sugar can damage their growth. Blood sugar with a range of 100 to 200 mg/dL (whole blood value) is safe in infants and does not pose a risk for low blood sugar.

• As children with diabetes grow older, their risk for diabetes complications tends to increase. To reduce this risk, blood sugar in children 6 to 10 years old should be kept within the range of 70 to 150 mg/dL. Higher levels of blood sugar will be harmful for these children. As the child grows, your concern should be to achieve a tight control of his or her blood sugar to prevent long-term complications. However, the increased risk of low blood sugar associated with tight blood sugar control should be recognized in children and handled properly in consultation with the doctor.

• Adolescence (age13 to17 years) is the most critical period when type 1 diabetes usually occurs. You should plan to achieve a tight control of your adolescent’s blood sugar to prevent long-term complications of diabetes. Because sufficient brain development has already occurred by the time a child becomes an adolescent, low blood sugar episodes will not usually damage the brain in this stage. The landmark DCCT study recommends an intensive treatment of diabetes in adolescents to keep their blood sugar within near to normal range.

TYPE 2 DIABETES IN CHILDREN
Although type 2 diabetes is typically a disease of the adults, it has recently been occurring increasingly in children and adolescents and is growing to be a public health problem. Several factors are responsible for this increased incidence:

• Obesity. Eighty-five percent of children who have been diagnosed with diabetes are overweight or obese. Obesity produces insulin resistance in the body, resulting in raised blood sugar levels.

• Increasing use of sugar-sweetened soda drinks by children is implicated in unhealthy weight gain. Excess weight raises the risk of occurrence of type 2 diabetes in these children

• Physical inactivity. In addition to the above factors, there are various uncontrollable factors such as genetic tendency, which also increase the risk for the onset of type 2 diabetes in children.

PREVENTING TYPE 2 DIABETES IN CHILDREN
Excess weight has been the most critical factor in the recent increased incidence of type 2 diabetes in children. To help prevent obesity in infants and children, and lower their risk of getting type 2 diabetes:

• Limit fast food snacking and intake of other high-calorie commercial snacks in children. These foods are usually high in saturated fat and trans fat and are likely to produce insulin resistance, increasing the risk for incidence of type 2 diabetes. Encourage the children to eat healthy foods prepared at home.

• Limit their use of sugar-containing soft drinks.

• Encourage the children to be physically active.

• Discourage them to spend too much time in watching TV.

• Encourage them to eat fruits and vegetables.

• Discourage overfeeding.

• Encourage exclusive breast-feeding for infants. It has been shown that infants who receive exclusive breast-feeding during the first 6 months tend to have healthy weight.

• Avoid the use of added sugars when feeding the infants and young children on feeding-formulas.

SCREENING FOR TYPE 2 DIABETES
The American Diabetes Association (ADA) recommends screening for type 2 diabetes in overweight children who have any of the following risk factors:

• Type 2 diabetes in the first degree relatives

• High blood pressure, high blood cholesterol, and other blood fat disorders

• Belonging to a certain ethnic group such as American Indians, African Americans, Hispanic Americans or Asian / South Pacific Islanders The preferable method of screening is to get blood sugar measured in a fasting state by a laboratory. Screening for type 2 diabetes in the above children should usually start at the age of 10 years. When the test is normal in these children, their diabetes monitoring should continue and the test should be repeated every 2 years.

Unless a child on diagnosis of type 2 diabetes presents such critical medical conditions as increased acids in the blood or extremely high sugar (conditions that require insulin therapy right away), children with type 2 diabetes are treated in almost the same way as the adults with this disease are treated:

• First, try lifestyle measures such as weight reduction, increased physical activity, and healthy eating.

• Limit children’s TV watching and video viewing because these habits, being idle, contribute to weight gain as they:
  • Displace physical activity
  • Slow down body’s metabolism and the rate at which it burns calories at rest
  • Encourage snacking while watching TV, or eating fattening foods promoted by TV advertisements.

• When lifestyle modification alone fails to control blood sugar, the doctor will add diabetes pills in the treatment plan.

• To treat children with type 2 diabetes, the metformin type of diabetes pills may be used first for two main reasons: metformin, unlike sulfonylurea, does not raise the risk of low blood sugar, and second, it is helpful in reducing weight in obese and overweight children.

• When metformin added to lifestyle modification fails to control blood sugar, diabetes pills of the sulfony lurea class may be added.

• Diabetes pills of the meglitinide class are quick in controlling the after-meal rise of blood sugar. This drug may be especially useful in adolescents whose meal times are irregular. Taking these pills just before meals will help control after-meal rise of blood sugar.

• Because diabetes pills of the troglitazone class have been linked to liver failure, use of these pills is not recommended in children.

• If combination therapy, comprising of different classes of diabetes pills, fails to control your child’s blood sugar, insulin therapy may be added. Insulin treatment may be started by administering insulin injection once or twice daily.

• When diabetes becomes chronic and blood sugar control is lost, diabetes pills are discontinued and full-fledged insulin therapy is started.

DIABETES CARE PLAN FOR YOUR CHILD
A doctor will draw a diabetes care plan for your child with diabetes. This plan will be a set of instructions that will show how to follow a healthy meal plan, exercise regularly, selfmonitor blood sugar, test ketones in the urine, and take prescribed insulin injections and or diabetes pills to control blood sugar. Give your input to the doctor while preparing this plan.

Many school-age children with diabetes, who are 12 years old or even younger, can self-monitor their blood sugar, mix insulins, give themselves insulin injections, count carbohydrates, and make various other decisions related to diabetes self-management. However, adults will have to take full responsibility of diabetes care for the children who cannot self-manage their diabetes, and for the infants and toddlers who are too young to take their care. Diabetes management in children requires special care:

Insulin Therapy
Because infants and toddlers cannot mix insulins nor can they give themselves insulin injections, you will perform these tasks for them as a parent or guardian. If the child uses a prefilled insulin pen, or the  insulin is drawn by a parent or guardian, the child may give himself or herself the insulin injection. But it is desirable that a knowledgeable adult is present when the child takes insulin injections.

Low Blood Sugar
Like adults, children with diabetes treated with insulin are at increased risk of experiencing low blood sugar. Administration of multiple insulin injections every day, irregular meal times, and increased physical activity unmatched with food intake, raise the risk for low blood sugar. The child should be taught to recognize the symptoms of low blood sugar. He or she should always carry a quick-acting carbohydrate food (such as glucose tablets) to take immediately as and when the symptoms of low blood sugar appear. Friends and relevant people at school should also know how to recognize the symptoms of low blood sugar, how to treat falling blood sugar with food, and how to give glucagon injection to the child in an emergency situation of low blood sugar.

Meal Planning
Meal planning in children with diabetes is a challenging task. Well planned meals not only control blood sugar, but at the same time they are nourishing to promote growth and development of the child. A good meal plan is one that accommodates the personal food choices of the child and the cultural preferences of the child’s family. A dietitian can help in planning such meals.

You, as a parent or family member of a child with type 1diabetes, should well understand how to use carbohydrate counting in planning the meals of your child. Make sure the child eats an adequate amount of carbohydrate to prevent low blood sugar when treated with insulin.

Self-Monitoring of Blood Glucose (SMBG) and A1C Testing
Self-monitoring of blood glucose or blood sugar is extremely helpful in management of diabetes. Although school-age children (6 to 12 years old) can learn to self-monitor their blood sugar, infants and toddlers cannot do this task independently. You will have to perform blood sugar testing for your infant or toddler. Blood sugar testing at least four times a day, once before each meal and once at bedtime, is usually recommended for all people with type 1 diabetes, including the children having this disease.

Because of the fear and pain associated with fingersticking (piercing the finger with a lancet to extract a blood drop), blood sugar testing is an unpleasant task, at least in children. However, some newer devices have made blood sugar testing less painful or almost pain free. These devices include lancet devices that allow you to take blood samples from less painful sites such as an arm or leg; a laser lancet that extracts a drop of blood without pricking the skin; and the newly introduced glucose testing device called Glucowatch Biographer that continuously measures blood sugar, every 20 minutes, through the skin without pricking. When these noninvasive devices become affordable and common in SMBG, frequent testing of blood sugar in children will not remain a big problem.

Hemoglobin A1C testing is a reliable test that shows how well blood sugar has been controlled during the last 3 to 4 months. Children with type 1 and type 2 diabetes, like adults, should be tested for their hemoglobin A1C every 3 months to monitor the long-term control of their blood sugar. These results should be used for making right treatment decisions.

Monitoring Lipid Disorders
Obesity and increased body weight, which contribute to premature onset of type 2 diabetes in children and adults alike, are also associated with cholesterol and other blood fat disorders (lipid disorders). High blood cholesterol has been shown to promote blockages in the blood vessels even before 20 years of age. Lipid disorders in young age increase the risk of developing heart disease in adulthood. The ADA recommends a fasting lipid profile for all children older than 12 years, with type 1 or type 2 diabetes, at the time of diagnosis of diabetes. However, children with diabetes, older than 2 years, who have a family history of blood cholesterol disorder, heart attack, or stroke before the age of 55 years, should also be screened for their fasting lipids. In both these cases, if LDL cholesterol falls within the acceptable range (less than 100 mg/dL or 2.6 mmol/L), the test may be repeated after 5 years, otherwise it should be performed annually. Abnormal lipid levels in children are recommended to be treated in almost the same way as in adults. LDL cholesterol exceeding 130 mg/dL in children with increased risk for heart disease should be treated with a lipid lowering therapy preferably the statin drugs. The aim of the therapy should be to bring LDL cholesterol below 100 mg/dL.

Monitoring Other Disorders and Complications
In addition to lipid disorders, diabetes is associated with various other disorders and complications, including high blood pressure, heart disease, diabetic eye disease, and kidney disease. Children with diabetes, like  the diabetic adults, should be monitored regularly for these complications.

Sick Day Management
As with adult population having diabetes, children with diabetes should be closely monitored when they are sick such as when they have fever, vomiting, or some other infection. These conditions tend to impair diabetes control and may lead to diabetes emergencies, including increased acids in the blood (DKA) and very high blood sugar (HHS). It is recommended that during the sick days, blood sugar of your child should be tested every 2 to 4 hours; if blood sugar is more than 250 mg/dL, give the child an additional dose of insulin injection. To prevent dehydration due to excessive urine and vomiting, a diet beverage or some other drink preferably with an artificial sweetener may also be given to the child. Use a dipstick such as ketostix to check the urine of your child for ketones. Ketones in the urine should gradually decrease with insulin treatment and with the resulting improvement of blood sugar. If ketones continue to remain high, contact the doctor or hospital immediately.

Ongoing Diabetes Care
Your child with diabetes should remain under the ongoing care of a diabetes care team. This team will usually include a doctor, specializing in children’s diseases (pediatrician) with experience in dealing with diabetes, a nutritionist, a diabetes educator, a nurse, an eye doctor, a foot doctor, and a psychologist. The pediatrician will devise a treatment plan. The key elements of this plan will be: drug plan consisting of insulin injections or diabetes pills or both; a suitable exercise plan for the child; monitoring of blood sugar at home; and maintaining or adjusting the treatment in light of SMBG and hemoglobin A1C test results. The diabetes educator and nurse will guide you in learning the basic skills to manage diabetes of your child, the nutritionist will help devise a meal plan right for the child, and the other speciality doctors will take care of the related complications of diabetes.

School and Diabetes Care
Under the law in the United States, schools that receive federal funding are required to accommodate the school children for their diabetes-related needs. To carry out the responsibilities under these legal provisions and to accommodate your child with diabetes:

• School administration should designate officials who will be responsible for the diabetes care of children.

• The designated school officials should have the basic knowledge of diabetes care and be able to handle diabetes-related emergencies that may occur in the school children. These officials should be familiar with:
  • Self-monitoring of blood sugar
  • Insulin administration, including giving insulin injection
  • Testing ketones in the urine
  • Recognizing the symptoms of diabetes-related emergencies, including low blood sugar, very high blood sugar, and increased acids in the blood; and handling diabetes emergencies, including treatment of low blood sugar through administration of glucagon injection

• The school should accommodate your child for his or her diabetes related needs.The ADA urges that schools should give maximum facilities to children with diabetes to manage their diabetes care such as:

• Permission to use food even in the classroom to treat low blood sugar; permission to miss the school or a school test with a doctor’s note and facility for a make up test; and permission to use the rest rooms.

• Facility to check blood sugar and take insulin injection in privacy;storage facility for insulin syringes and insulin bottles; and

• walk-in facility to see school medical personnel.

Talk to the school administration about the diabetes related needs of your child. It is a good idea that the school prepares a personal diabetes care plan for your child. Your input as a parent/guardian and the input of your child’s health care professionals will assist the school officials to make a meaningful diabetes care plan for your child.

INSULIN PUMP AND THE CHILDREN
The use of insulin pump has recently increased in children with type 1 diabetes. One main reason for this increased use is the willingness of parents/caregivers to use technology and monitor blood sugar more frequently. Insulin pump might give your child more control over his or her blood sugar and a more flexible lifestyle. But at the same time, effective use of an insulin pump will require more frequent blood testing and close attention for its safe use. These tasks may be too challenging for the young child. In addition, the pump may be socially unacceptable for some children who may think that wearing the pump makes their disability more prominent. The decision to use an insulin pump in a child should be based on the need for intensive insulin therapy and the willingness of the child to use the insulin pump. Most children, however, can achieve and maintain a good control of their blood sugar by taking multiple injections of insulin every day. With the new short needle syringes, taking isulin injections has become less uncomfortable.

How well you control the blood sugar of your child has a great impact on the child’s physical and mental development. Blood sugar control of your child determines the extent he or she will be protected in the future from organ damage due to diabetes. A good control of blood sugar will improve this outcome, a bad control, on the other hand, will have serious consequences.