From Brantford, Ontario, Canada:
I am a Diabetes Educator. We generally encourage toddlers to have higher sugars because of the risk of hypoglycemia. How strictly do you control the diet in this age group? Do you use a specific meal plan or just encourage regular meals and snacks? What teaching aids do you use? Are you using lispro insulin [Humalog®] in this age group? At the clinic where I work we have had few children diagnosed at this age, but recently had a 4 year old.
At our program, we suggest that parents let toddlers eat normal meals, limiting only concentrated sweets and fruits accorting to a diabetes version of the Food Guide Pyramid. Check out Sweet Kids: How to Balance Diabetes Control & Good Nutrition with Family Peace by Betty Page Brackenridge, MS, RD, CDE and Richard R. Rubin, PhD, CDE.
We sometimes use Ultralente with Humalog after meals, based on what the child has eaten. We generally aim to keep the blood sugar levels in toddlers under 200, rather than aiming for tight control, because of the same concern that you mentioned: that there's a bigger risk of hypoglycemia in tight-control programs.
Additional Comments from Dr. Lebinger:Although it is very difficult to get a toddler to follow an exchange list based or carbohydrate based meal plan, I still have all my young patients' families meet with the dietitian and devise a meal plan to aim for, emphasizing day to day consistency in timing and amount of carbohydrates and recommending changes in food to match activity. The more consistent the child can be in the timing and amount of carbohydrate intake from day to day, the easier it is to control the blood sugars. Also, if the child refuses to eat the "prescribed amount of food" at a given meal or snack, the parents will know how much extra or less "than usual" the child ate and can try to compensate by changing the amount of insulin or exercise (or at least be prepared for a high or low blood sugar.) It is very important to try and base this meal plan as close as possible on the child's usual eating habits and try as much as possible to "creatively" match the insulin to the food intake.
It is easier to prevent excessive food intake than to insist the child eat enough. You can't force a child to eat. I do suggest ways to help the parents get the children to eat when they don't want to. For instance, I suggest they keep both regular soda and jello and diet soda and jello in the house. They can give the diet soda and jello to the child whenever the child is hungry as they contain no carbohydrate. If the child absolutely refuses to eat, they can substitute the regular soda or jello in an emergency to prevent a low blood sugar, and hopefully avoid having the child refuse to eat "healthy food" in order to get sweets. On the other hand, I try not to worry too much about vegetable intake. Many little kids just won't eat them and you can control the blood sugar without them. (Hopefully when they get older they will acquire a taste and also appreciate that many vegetable can be eaten "freely" as they have little or no sugar.) If they also don't eat fruit or cereal supplemented with vitamins, I suggest they give their children a children's daily vitamin.
I have not been able to use much Humalog yet in toddlers because there is no diluent available yet to enable giving very small amounts of Humalog to small children. When the diluent becomes available, I think it will be very helpful.
Original posting 30 Aug 97
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