From Roselle Park, New Jersey, USA:
My 2 year old son was diagnosed 6 months ago with Type 1. Up until a few weeks before his diagnosis he was a very easy-going child. He obviously was feeling very sick when he was finally diagnosed. But his temperament has radically changed. He is very temperamental, cries a lot, whines a lot and has tantrums. These get much worse when his sugars are high. His control is spotty (which the doctors tell me is expected at this age). He sometimes screams at finger pricks and injections. Is this from the trauma of the diabetes or simply due to age?
He has always been a poor eater and is even worse now. He won't sit still for meals and doesn't care if he goes hungry. I have read Sweet Kids but that addresses older children more than toddlers. Trying to get him to sit or eat simply causes more tantrums. I did not have this problem with my other children. Please advise.
Your child is going through a stage of development which is very difficult when you have diabetes. I'm sure you know it is common at this age for previously well behaved children without diabetes to develop erratic behavior and poor eating habits (There's a reason this age has been called the "terrible two's"). Unfortunately, when your child has diabetes, it is even harder than usual.
I will make a few suggestions that have worked for some of my patients. Unfortunately, like everything else in diabetes, each family must try different approaches to see what works with their own child.
It is of course possible that your child is still reacting to the trauma of hospitalization. You may want to give him a syringe without the needle attached and a lancing device (without the lancet), and get him a new doll or stuffed animal and tell him the stuffed animal just got diabetes. Suggest that he give the doll shots and test the doll's blood and ask him what the doll has to say. You might be surprised at what comes out. He may tell you the doll has diabetes because he misbehaved, or that the doll was punished and sent to the hospital. He may also just tell you the doll hates the shots and tests and you can sympathize with the doll (and your son), but say you know your son loves the doll and doesn't want him to get sick so he will give him shots and test his blood. By the way, Bayer company is coming out with a teddy bear just for kids with diabetes - Rufus, the Bear with Diabetes. The bear has patches where he gets shots and blood test and wears a medic alert.
Many of the parents of young children say their children become irritable when the blood sugar is high. I am sure you are working with your own diabetes team to optimize blood sugars, but at this age, it is virtually impossible never to have high blood sugars if for no other reason than your child will frequently outgrow his dose of insulin and need more. Although you can't always avoid the high blood sugars, with time, you should be able to help your child learn to cope with them. I don't know why young children become irritable with high blood sugars. I can understand behavior changes with low blood sugars because with low blood sugars, the brain isn't getting enough glucose. I somehow doubt, however, that the behavior changes in young children are due to direct effects on the brain. I suspect (but don't know for sure), that the change in behavior is related to the child being upset about being physically uncomfortable when the blood sugar is high (thirsty, full bladder, urinating a lot). As your child becomes more verbal, you can try to teach him that he can be upset if he is uncomfortable, but he can't take it out on other people. He can complain to other people, but misbehaving is not an acceptable way to deal with his frustration. Like any other child, if he misbehaves, you want to try and NOT give him extra attention. (Young children like any attention, even sometimes being yelled at). You can tell him if he can't behave, he should go to his room until he can calm down and then come back out. You can even tell him you are sad, because you were looking forward to playing with him, but can't play with him if he is misbehaving. You can say he must be tired as many children get cranky when they are tired. You can tell him to go to his room and nap. If he really is tired, he may wake up in a better mood. If he isn't tired, he will learn with time that if he is cranky, he will be told to nap (not as a punishment, but as a logical solution to the problem). I have even suggested when the child is old enough, to get him a punching bag and suggest to the child when he is upset that he punch the bag (and not people or other objects in the house).
Children who refuse to eat pose a particular challenge. It is impossible to force a child to eat (in addition to not being a good approach to child rearing in general) If your child doesn't have diabetes, you can just tell the child to go hungry and secretly hope that he will eat healthy food at the next meal because he is so hungry. Obviously, if your child has diabetes, if he doesn't eat, his blood sugar may go low.
A few ways to deal with this problem:
- Speak to your doctor and dietitian about whether you could cut back on the meal plan a little and have smaller meals and snacks in between (You shouldn't do this without discussing with your child's doctor as the insulin may need to be adjusted), It may be better to have your child constantly hungry for a few days and weeks and want to eat at meal time. Also, if each meal and snack is relatively small, and your child doesn't eat the whole meal, he will be less apt to go very low.
- Establish logical rules of consequences of what will happen if he doesn't eat. For instance, he can't go out to play if he doesn't eat. This is not a punishment. Tell your child you are sad he has to eat, but you love him and don't want him to get sick if he doesn't eat and goes out to play (goes low). Even if your child doesn't completely understand you now, he will soon.
- If your child refuses to eat, you don't have to panic unless the blood sugar is actually low. Explain to your child if he doesn't eat, you will have to check his blood sugar every 20-30 minutes. Again, make sure you make it clear this is not a punishment, but logical. If his blood sugar is not low, you need not panic. If it starts to drop, most kids will want to eat. If it starts to drop and he refuses to eat, discuss with your doctor giving glucagon.
- If your child is a very fussy eater, you can discuss with your doctor trying to give Humalog after each meal and adjust the dose according to how much he eats. This would require giving 3 or 4 shots a day.
- You can try giving your child choices for instance yoghurt or meat and potatoes. Soon he will be old enough to make a simple sandwich himself.
- You don't want your child to get used to getting sweets when he won't eat, but sometimes you have to resort to this to prevent a low. You might want to keep on hand both diet and regular soda and jello. He can have the diet soda and jello freely (or refuse it). If he's running low, you might be able to substitute the real thing without him knowing.
- Try putting stickers on a calender every time he eats a meal, tests, or gives a shot without complaining. If you want, tell him he can complain for 60 seconds and you complain too - use a wrist watch with a second hand He'll be the first in the class to be able to tell time with an old fashioned watch Tell him he has to complain the entire 60 seconds before he can give the shot or do the test. If you are lucky, soon you will all be laughing.
- Tell him you are sorry that he has to do all these things, but because you love him, you must make him do what is necessary to avoid being sick. If you have to sit with him for hours because he won't eat, give his shot, or test his blood, you won't have time to do fun things together. Try to set up a special fun thing to do in the evening (read a book, play a game) that you will do if you "have the time" (you will only have the time if he is cooperative). You are giving him the message that you love him and will make him take care of himself. You are also giving him a logical choice. He can have your attention by forcing you to sit and make sure he takes care of himself no matter how long it takes, or he can choose to just do what needs to be done in a timely manner and have time for fun things with his parents.
- Sometimes nothing works and you must be prepared to either give him glucagon if he goes low or make a trip to the local Emergency Room. I've even had parents or babysitters go sit in the local Emergency Room Lobby with their child, food, meter, and glucagon so they can check in quickly if the child goes very low, but can go home without checking in and incurring an expense if the child finally eats and is fine.
Depending on how verbal your child is, you may not be able to try all these suggestions yet. If you feel the situation is really out of control and interfering with family life, you should speak to your doctor about consulting with a child psychiatrist to help you work through this difficult period. In the long run, you may wind up even closer to your child, and your child may learn helpful self-discipline through this difficult, but hopefully temporary experience.
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