Your Child Has Diabetes

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Published and distributed by: Pritchett & Hull Associates, Inc. Printed in the U.S.A.

Introduction to your Child Has Diabetes When you first found out that your child has diabetes, how did you feel? Scared? Angry? Sad? Guilty? Many parents have these feelings at first, and they are normal. Finding out your child has diabetes is tough. But did you feel this way because you didn’t think your child could live a normal life with diabetes? Well, that does not have to be the case.

Children with diabetes are just like other children. They can grow up to lead happy and active lives. The only difference is children with diabetes have to keep their blood glucose (sugar) in a certain range to stay healthy. While children who don’t have diabetes don’t have to worry about their blood glucose at all.

You and your child will have to learn how to manage his or her diabetes. But this will take time. So you may have to take the lead in managing it. Learn as much about diabetes as you can.

It can help you and your child cope with any negative feelings you may have. No matter how old your child is, learning about diabetes takes a team effort.

This book was written to teach you the basics about diabetes and managing it. It is not a substitute for what your doctor, nurse, certified diabetes educator (CDE) or any other healthcare professional advises you about your child’s diabetes.

Children need energy Children need lots of energy to grow and be active. This energy comes from food. Once inside the body, food is changed into glucose.

Then it goes into the blood and is carried to the cells of the body.

Insulin is a hormone that opens the cells to allow the glucose inside. Insulin is made in the pancreas (a gland near the stomach). There are certain cells in the pancreas called beta cells.

These cells release insulin into the bloodstream to help glucose get into the body’s cells.

With diabetes, the body either does not make insulin, does not make enough insulin or the cells can’t use insulin the way they should. When there is not enough insulin, the cells don’t open up to use the glucose.

2

Types of diabetes The two most common types of diabetes are:

• type 1 Diabetes • type 2 Diabetes

3

Type 1 Diabetes With type 1 diabetes, the beta cells in the pancreas make little or no insulin. This means there is not enough insulin to help glucose get into the cells. The extra glucose stays in the blood and does not get used. Instead, it is dumped into the urine and the body gets rid of it. This can rob a child of energy and starve the body because the cells can’t get glucose. Because of this, children with type 1 diabetes have to inject insulin to help move glucose into the cells. Most children have type 1 diabetes but some have type 2.

You may wonder what caused your child to get diabetes. There is no known cause.

But it is believed that one or more of these have something to do with it:

• a virus attacks the pancreas • problems with the body’s self defense

system (auto-immune response) that damage the beta cells in the pancreas

• a family history of diabetes

4

Type 2 Diabetes With type 2 diabetes, the body makes insulin but it doesn’t make enough or the cells can’t use it the way they should. type 2 diabetes is much more common than type 1. In the past, most people who got type 2 were people 45 or older. However, children are getting type 2 diabetes more than ever before. This is often caused by:

• being overweight (can be caused by eating lots of fast food and “junk” food)

• lack of activity and regular exercise Some children with type 2 diabetes have to inject insulin or other medicines. But some can control it by:

• eating healthy meals • exercising daily • taking medicine • losing weight

(some children who lose weight don’t need to take medicine)

If your child has type 2 diabetes, now is the time to help him or her start and keep healthy habits.

5

Diabetes from a child’s point of view Children often see things in a different way than adults.

Your child may not understand why he or she has diabetes. Young children who have diabetes might think:

• they “caught” diabetes from someone else • they will die because diabetes begins with “die”

• diabetes is a punishment for something they did

Of course, none of this is true. So to help your child better understand diabetes, explain this to him or her. Older children may understand why they have diabetes, but still have a hard time dealing with it. They may get angry, depressed or you might notice other changes in their behavior. These feelings are normal at first.

With your help, your child can learn more about diabetes and begin to manage it so that many of these feelings go away.

Learning about people with diabetes who have had successful lives can be helpful. You may want to tell your child about celebrities, sports figures or people you know who have diabetes. Some examples are Tom Hanks (actor) and Nick Jonas (singer).

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Managing diabetes For now, diabetes can’t be cured. But it can be managed.

Learning how to manage diabetes can help your child be more healthy. It can also help him or her develop good habits for the future. Managing diabetes means checking blood glucose levels and balancing:

• the amount and type of food eaten • exercise and activity levels • insulin and/or other medicines • stress levels Food and stress raise blood glucose levels, while exercise, insulin and medicine lower it. Keeping a balance between all of these will help keep your child’s diabetes in check. Checking your child’s blood glucose will help you know if his or her management plan is working.

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Tests Your child may feel he or she has to do a lot to manage diabetes.

So be aware of this. You should stay involved in your child’s life and step in at times. But, once your child is able to handle it, he or she should be involved in his or her own care. Being involved can help your child:

• have more confidence and higher self-esteem • feel like he or she reached a goal • start good habits for the future • become more responsible For younger children, helping manage diabetes, little by little, will get them into the habit of good management. Older children want to be independent, and letting them be in control is a good way to see if they can handle it. But try not to rush your child into doing things that he or she is not ready to handle. No matter how independent your child is with diabetes management, you should still be involved.

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Diabetes Care Team* Raising a child can be hard. Trying to manage diabetes can make it harder. When you learned your child has diabetes, you may have felt that you would have to deal with it on your own. That is not the case. Your child’s diabetes healthcare team can help you. The team will work closely to get your child’s diabetes under control.

You and your child are the most important members of the team. You can teach your child to help out in his or her own care.

A Pediatric Endocrinologist/Diabetologist is a doctor specially trained to work with children who have diabetes. .

My child’s endocrinologist/diabetologist is

A Certified Diabetes Educator (CDE) or a Nurse Educator is a person who is specially trained to work with children with diabetes.

Your child’s CDE teaches you and your child all about diabetes and how to manage it. .

My child’s CDE is

A Registered Dietitian (RD) is a person who will help you and your child plan meals and make healthy food choices. .

My child’s RD is

team members continue on next page

* Your child’s diabetes care team may or may not have all of these members.

And you may have some people work with you who are not listed here.

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Diabetes Care Team* An Ophthalmologist is a doctor who specializes in diseases of the eyes. If diabetes is not managed, it can cause problems with the eyes. But with good management, this should not be a problem.

Starting 3-5 years after diagnosis (or at age 9), your child should get his or her eyes checked every year.

My child’s Ophthalmologist is

.

A Podiatrist is a doctor who specializes in care for the feet. If not managed, diabetes can cause problems with the feet. But with good management, this may not be a problem.

My child’s podiatrist is

.

A Social Worker (SW) is a person who specializes in finding and giving information on diabetes related services that you and your child may need to better manage diabetes.

My child’s social worker is Other members of my child’s diabetes care team:

* Your child’s diabetes care team may or may not have all of these members.

And you may have some people work with you who are not listed here.

10

.

Eating healthy meals and snacks Having diabetes does not mean your child can only have bland and boring meals. A healthy meal plan for a child with diabetes is the same as a healthy meal plan for a child who doesn’t have diabetes. This means your child can enjoy a variety of foods.

Your child just needs to eat a healthy diet and add exercise to his or her routine. Losing weight might also help if he/she is overweight. Work with a dietitian to come up with a healthy meal plan that your child will enjoy. Keep in mind that to balance meals and medicine, your child needs to:

• eat at about the same time each day • avoid skipping meals or snacks • eat the right amount of food at each meal

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Meal Planning Try to involve your child in meal planning. The amount of planning depends on your child. An older child might be able to plan all of his or her meals everyday. Younger children may not be ready for this. They could also be picky eaters. So offer them a few different choices at mealtime and let them choose.

Sometimes, things come up that may not fit into your child’s meal plan. A group of friends want to go to a fast food restaurant after school. Or a friend is having a birthday party with lots of cake and ice cream. What should you do?

While it is important that your child sticks with his or her management plan, it is also important to let a “child be a child.”

If things happen from time to time it is OK. Explain that it helps to know about parties and other group activities in advance. Often, food from parties can be worked into the meal plan without too much trouble.

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There is no “diabetes diet” A healthy meal plan for your child is the same as a healthy diet for any child. Overall, it should stress:

• whole unprocessed foods • non-starchy vegetables • a limit on refined grains and added sugars • drinking water instead of soda or sugary drinks How Carb Counting Helps Counting carbs is one way to help plan meals. Carbs break down into glucose quickly. So, monitoring the number of carbohydrates in your child’s diet can help control blood glucose levels. Talk to your child’s doctor or dietitian about carb counting.

• By spreading your child’s carbs out over the course of the day, you can keep his or her blood glucose from getting too high or too low.

• To do this, you need to

know how many carbs to let your child have at each meal or snack. In the side chart, ask your child’s diabetes educator or RD to fill in how many carb grams your child should have each day.

Breakfast Snack Lunch Snack Dinner Snack

Total

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Create Your Plate 1. Divide your child’s plate into 3 sections.

starches

non-starchy vegetables protein

Copyright American Diabetes Association Reprinted with permission from the American Diabetes Association

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2. In the blue section, put non-starchy

vegetables such as spinach, broccoli, green beans, carrots or tomatoes.

3. In the green section, add grains

and starches, such as whole grain bread, brown rice, pasta, tortillas or beans or peas.

4. In the red section, put protein, such as chicken, turkey, lean beef, tuna, salmon, eggs or low-fat cheese.

5. Add a serving of fruit, or dairy or both as your meal plan allows.

6. Add a low-calorie drink like water or unsweetened tea.

reminder note: The more active your child is, the more calories he will need AND the less active your child is, the fewer calories he will need.

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Calories

1,000

1,200

1,400

1,600

1,800

2,000

Grains

3 oz

4 oz

5 oz

5 oz

6 oz

6 oz

Vegetables

1 cup

1 cup

1½ cups

2 cups

2½ cups

2½ cups

Fruits

1 cup

1 cup

1½ cups

1½ cups

2 cups

2 cups

Oils

3 tsp

4 tsp

4 tsp

5 tsp

5 tsp

6 tsp

Milk

2 cups

2 cups

2 cups

3 cups

3 cups

3 cups

Meat & Beans

2 oz

3 oz

4 oz

5 oz

5 oz

5½ oz

How many calories are right How many calories your child needs are based on activity levels by gender. Activity levels are: I = inactive; M= moderately active; A = active Calories 1,000 1,200

1,400

1,600

1,800

2,000

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Boys

Girls

2

I, M, A

3

I

3

M, A

4-5

I

4-5

M

6-8

I

4-5

2-3

I, M, A

4-7

I

4

M, A

5-6

M

8-10

I

A

5-6

A

6-8

M

8-10

M

9-10

I

11-13

I

9-10

M

7-9

A

11-12

I

10-11

M

14-18

I

8-9

A

11

M

10-11

A

13-14

I

12-18

M

To help know your child’s activity level, follow these rules:

• Inactive means your child gets less than 30 minutes

of physical activity each day. This includes riding a bike (less than 10 mph), hiking, yard work or walking briskly (over 3½ miles an hour), etc.

• Moderately active means your child gets between 30 and 60 minutes of physical exercise each day.

• Active means your child gets 60 or more minutes of

physical activity each day. This includes running, riding a bike (more than 10 mph), swimming laps, etc.

Exercise is good for everyone – especially children with diabetes.

Exercise helps the heart pump more blood with less effort, it improves circulation and keeps muscles strong and toned. For children with diabetes, exercise offers added benefits such as:

• lowering blood glucose levels • helping the body use insulin better (if it is used) • losing weight*(if needed) • being physically fit * Most children with type 2 diabetes are overweight.

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Since exercise lowers blood glucose levels most of the time, extra steps have to be taken to avoid hypoglycemia (low blood glucose)*. This means:

• regular blood glucose checks before and after exercise • prepare for longer exercise periods with a snack • glucose checks during longer exercise periods Children don’t always plan out their activities, they just like to go out and play or hang out with their friends. But when a child has diabetes, making a habit of checking blood glucose before activity and always carrying a sugar source snack will help him or her avoid problems.

* see pages 34-36

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Insulin Some children who have diabetes need to take insulin. Like exercise, insulin lowers blood glucose levels. So balancing it between exercise and eating is very important.

You and your child’s doctor will decide upon which type of insulin your child should use. A member of the management team will teach you and/or your child:

• when it starts to work • when it works hardest • how long it lasts • how to inject it

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Talk to your child’s doctor or nurse about the type of insulin your child needs.

Use the chart below to fill in this information.

Type of insulin your child uses:

How many units your child needs: How many times your child should inject per day: How long after injecting before the insulin begins to work: How long it takes for the insulin to work its hardest:

How long the insulin lasts:

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Injecting insulin One of the first things you may have to learn is how to inject insulin. This may seem a bit scary – for both you and your child.

Try to be positive when you inject the insulin. A young child will not really understand why you are sticking him or her with a needle.

You may feel bad or guilty about doing it. But it has to be done for your child’s health.

At some point, you or your child’s diabetes educator will have to teach your child how to inject insulin. Each child is different. Don’t force a child to learn to inject insulin before he or she is ready. An older child may learn how to do it quickly. It might take a bit longer to teach a younger child how.

Your child may need several injections each day. Or, two types of insulin may need to be mixed and injected to make sure your child has enough for a full day. It all depends on your child’s needs.

If your child has an insulin pump, you still need to know how to inject insulin in the event that they have to go “off pump” for a while.

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Insulin Pumps An insulin pump is another way for your child to get insulin.

The pumps:

• are about the size of a small smartphone • must be programmed (You will have to learn how

to do this. Your child may also have to learn this, depending on his or her age.)

• give a steady flow of insulin • have to be worn at all times (except for bathing and swimming)

• may allow more flexible meal times • may allow your child to exercise or do other activities without worrying about glucose levels going too low

Insulin pumps do not check blood glucose. So, regular blood glucose checks are still very important. And, following a healthy meal plan is still needed with a pump.

Talk with your doctor or nurse about the pump. Your diabetes care team can help you decide if it may be right for your child. Pumps can be expensive. So check with your insurance carrier to see if an insulin pump would be covered.

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Other Medicines In addition to insulin and exercise, other medicines may be used to lower blood glucose in children who have type 2 diabetes. These other medicines are not the same as insulin. There are several types of diabetes drugs and they work differently. Some:

• cause the pancreas to make more insulin • slow down the breakdown of carbohydrates • keep the liver from releasing too much glucose • make the muscle cells more sensitive to insulin The other medicines can be given alone or may be used with other drugs or insulin. Some may be pills and some may be injections.

But, they still have to be balanced with meals and exercise. Talk with your child’s doctor about any medicine that is ordered. Add each of them to the chart below.

Medicine

Time your child should take it

Amount your child should take

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Checking blood glucose Exercise, diet and other medicine have to be balanced to keep your child’s blood glucose within a normal range. These levels have to be checked often every day. This means measuring the amount of glucose in your child’s blood.

Your child’s doctor or diabetes educator can help you choose a blood glucose testing kit. This kit may include:

• a lancet (a finger stick device) • testing strips • a meter that reads the test strip to tell the blood glucose level each time

• a booklet to write readings, or advice about apps that can be used to record and share blood glucose levels

• other reading materials about diabetes

blood sample meter

test strip 24

To check your child’s blood glucose level:

1. Read the directions that came with your kit.

2. Wash your hands with soap and water.

3. Wash your child’s hand and make sure the finger you are going to prick is dry.

4. Prepare the lancing device.

5. *Insert the test strip into the meter.

6. Prick his or her finger with the lancet to get a drop of blood (it may hurt less if you prick the side of the finger).

7. *Put the drop of blood onto the testing strip.

8. After a few seconds, the meter shows the blood glucose level.

9. Record the test score in your app or in the booklet.

The prick may scare a young child. Be honest. Say that the prick will hurt. But also explain that the prick will help keep him or her healthy. This may ease your child’s fears. As your child gets older, he or she will need to learn how and when to test blood glucose levels.

* Steps 5 and 7 may be reversed depending on your child’s meter.

Follow the meter instructions.

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Continuous Glucose Monitoring Another way to check your child’s glucose level is by using a continuous glucose monitor system (CGMS). Using this method, no finger sticks are needed for a blood sample. The system uses a device called a glucose sensor to take reading automatically every few minutes.

The sensor uses a fluid under the skin (interstitial fluid) to check readings. You will attach the sensor and then leave it in place for several days. A smart phone, watch or other hand held device shows the glucose results on a screen.

CGM does not replace other blood sugar monitoring. You will still need to check your child’s blood sugar using a regular glucose meter.

26

Healthy Blood Glucose Range Despite good management, your child may have blood glucose levels that are high or low from time to time.

Emotions and hormones can sometimes cause high or low blood glucose levels. This is often the case with teenagers who are going through puberty. But sometimes high or low blood glucose levels occur because children, especially teenagers, become frustrated with managing their diabetes. This frustration could cause them to:

• eat off schedule • not eat at all • not exercise • not take their insulin or other medicines 27

Knowing your child’s normal blood glucose range can help both of you know if you are managing diabetes well. Fill in the box below so you or your child can refer to it when needed.

You can’t be with your child every minute of every day. So, remind your child why managing diabetes is so important. And encourage your child to follow the plan. You may need the team to work more closely with you and your child during unstable times.

Healthy blood glucose range ’s target blood glucose range is: Before meals:

to

2 hours after the start of meals: to

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Blood glucose problems Problems with blood glucose will come up from time to time.

Sometimes they are caused by not following the management plan.

But even with good management, high or low blood glucose levels may happen. You and your child (if old enough) need to know the symptoms of these and how to treat them to avoid complications.

The two main problems that can happen with blood glucose are:

• Hyperglycemia (hi-per-glie-see-mee-uh) high blood glucose

• Hypoglycemia (hi-poe-glie-see-mee-uh) low blood glucose

29

Hyperglycemia (or high blood glucose) The symptoms of high blood glucose often include:

• being very thirsty • going to the bathroom a lot • being tired a lot Teach your child these symptoms and what causes them so he or she can avoid high blood glucose. Also teach anyone who will look after your child (teacher, coach, babysitter, etc.) about the symptoms and what to do about them.

30

High blood glucose may be the result of:

• over eating • being sick • not taking enough insulin • taking other medicines that affect blood glucose levels

• not exercising enough • stress

High blood glucose may be a result of two or more of these.

31

Ketones When there is a lack of insulin, there is a buildup of glucose in the blood. If the cells can’t get enough energy, they may start to break down fat for energy. When fats are broken down, the body produces acids called ketones. Ketones are passed out of the body through the urine. But quite often the body can’t get rid of them all.

When ketones are in the body for too long, it can lead to ketoacidosis (key-toe-acid-o-sis). This can be very serious.

A urine test is the main way to test for ketones. Your child’s doctor can tell you how to do this.

When large amounts of ketones are present in the body, they can be poisonous and can lead to:

• lethargy (tired all the time) • being very weak • coma (this normally only happens to children who have type 1 and have really high blood glucose levels)

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Ketones are measured in 3 levels: small, moderate and large. Ask when you should call the doctor or nurse about ketones. Many only want to be called if the ketones are moderate or large.

Poor diabetes management can lead to ketones.

So you have to make sure your child is following his or her management plan. If your child is following the plan and ketones are present, changes may have to be made to the plan. Talk with your child’s team about making changes in the plan when needed. If your child is not following the plan, see why this is happening. You may need to step in.

33

Hypoglycemia (or low blood glucose) The symptoms of low blood glucose often include:

• feeling irritable, nervous or shaky • being hungry • feeling dizzy • sweating too much • feeling weak • being confused or not thinking clearly • having trouble seeing • seizures

34

Low blood glucose is often caused by:

• eating off schedule • not eating enough • exercising a lot and not eating enough food

• taking too much insulin • not eating a snack during exercise

35

Treating hypoglycemia Low blood glucose needs to be treated right away. If untreated, it can lead to seizures or passing out.

To treat low blood glucose, give your child the recommended amount of a fast-acting carbohydrate, such as:

• skim milk (1 cup = 15 grams carbs)

• regular (non-diet) soda (1/2 cup = 15 grams carbs)

• hard candy, jellybeans or gummy bears

(see labels for amounts) No chocolate!

Re-check your child’s blood glucose levels after 15 minutes. If it is still low:

• give him or her more carbohydrates • if your child is not going to eat for a while,

give him or her a long acting carbohydrate like crackers

Your child’s doctor or diabetes educator can tell you about other ways to help your child avoid low blood glucose problems.

36

The amount of carb your child needs to treat low blood glucose varies depending on their age.

Ask your diabetes team what the right amount is for your child.

When diabetes is not managed Now you know that managing diabetes involves a balance of diet, exercise and medicine, as well as daily blood glucose monitoring. If this balance is kept, it can help your child delay or avoid long-term problems caused by diabetes.

If diabetes is not managed, it can lead to:

• heart problems • stroke • visual problems

• circulation problems • kidney problems medicine

meals

Balance is the key

exercise

37

Taking diabetes to school Being a child can be hard. Learning new things at school, making friends and trying to fit in are all parts of growing up.

But having diabetes may make these things harder.

Teach everyone who will look after your child (teacher, coach, principal, bus driver, babysitter) about your child’s diabetes.

It may be helpful to schedule a meeting at the beginning of the school year to talk about your child’s diabetes and to let them ask any questions they may have. It may also be helpful to write a letter* that explains:

• what diabetes is • what to do about hyperglycemia, hypoglycemia and ketoacidosis

• when your child should eat meals and have snacks

• who to call in case of an emergency

*See sample letter on page 40

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Explain to teachers that your child may need to eat snacks through the day and check his or her blood glucose. This is especially true before any activity (recess or gym class) or whenever your child feels his or her blood glucose is low.

Also tell them that your child may need to take medicine during class time (either injections or pills). Teachers also need to know that your child may need to use the restroom more often than other children. If a teacher knows about this ahead of time, it might be easier for your child to stick to his or her diabetes care plan. And, it may prevent jealousy among the other students who may think your child is getting special treatment.

Keep in mind that under section 504 of the Rehabilitation Act of 1973, your child has a right to education. Your child also has the right to a discrimination free environment. If you have any questions about this Act, talk to your child’s team about it.

39

Sample letter Dear

,

, has type My child, My child’s diabetes management plan includes:

diabetes.

1. Taking medicine (either injecting or taking oral medicines). The type of medicine my child takes is: .

2. Eating meals and snacks at the same time each day.

3. Exercising everyday.

4. Checking blood glucose.

Please allow time for my child to do this.

Low blood sugar can occur. The symptoms include feeling nervous, irritable, dizzy, confused, weak, sweaty and hungry. To treat low blood sugar: Give my child grams of a fast acting sugar source (like milk or non-diet soda). Check his or her blood glucose after 15 minutes.

If it is still low, give my child another grams of fast acting sugar. Please call me.

High blood sugar can also occur. High blood sugar symptoms include going to the bathroom a lot, being thirsty and feeling tired.

To treat high blood sugar, give my child water. Please call me.

High blood sugar can lead to ketones and ketoacidosis.

The symptoms of ketoacidosis include heavy breathing, fruity smelling breath and passing out. If my child shows signs of ketoacidosis, call me or my child’s doctor right away.

My name My work number My home number My cell number My child’s doctor’s name Doctor’s office number

40

Or, download a Diabetes Medical Management Plan (DMMP) from the American Diabetes Association website (www.diabetes.org).

Other helpful tips • Keep in mind that managing diabetes is a team effort.

You, your child and your whole family should work together.

• Even though managing diabetes is a lot of work, let your child be a child.

• A child with diabetes needs lots of attention.

If you have other children, talk to them and involve them in the care plan so they don’t feel left out. Make time for them too.

• Always make sure your child carries extra snacks, especially when traveling.

• Look into sending your child to a camp for children

with diabetes. At these camps, your child will learn how others deal with diabetes. Your child will also learn that they are not alone.

• If your child has high or low blood glucose because of

something he or she did, try not to be too hard on him or her.

But remind your child how important it is to balance food, exercise and medicine.

• Having your child wear MedicAlert ® ID can also be helpful.

This will let people know about your child’s diabetes in case of an emergency. Help your child choose the type of ID that works best for him or her.

• Join a social media support group so that you can connect with other parents going through the same things you are (search ‘parents of children with diabetes’ on Facebook).

Reviewers: Erin Cooper, RD Talbert Medical Group Michael Fox (Parent of a child with diabetes) Thanks to previous reviewers:

Janet Haas, RN, CDE Lisa Waller, RN, CDE Wynola N. Wayne, RN

3440 Oakcliff Road, NE, Suite 126 Atlanta, GA 30340-3006 1-800-241-4925 www.p-h.com

We

believe that you have the right to know as much as you can about your health. Our goal is to give you enough facts to get the main points clearly in mind. We do this with medical accuracy, warmth and humor. The result for you: less tension, more healing and a good idea of what to ask your doctor, nurse or others.