For Parents: Diabetes Care (3 to 5 years)

Diabetes care in young children is not always easy. It might seem like there is a lot for you to remember. But you don't have to do it alone! You'll work with your child's doctor, nurse, diabetes educator, dietitian, and others to make a diabetes management plan.

You should have a diabetes management plan that instructs you on the overall treatment plan for your child's diabetes. It should include:

• What medicines your child takes, how to take them, and when to use each
• How to check blood sugar levels
• What the symptoms of low blood sugar (hypoglycemia) are and how to treat it
• What the symptoms of high blood sugar (hyperglycemia) are and how to treat it
• How to count carbohydrates (carbs) in meals and snacks
• What to do about physical activity and sports
• What to do if your child is sick with a cold or the flu
• What to do in an emergency

Also make sure you talk about day care and school with your child's doctor. Educate other caregivers, including those at your child's day care or school, so that they know about your child's health condition.

You will check your child's blood sugar using a lancet device on the sides of the fingertips. At first, young children may be scared of finger sticks for blood sugar checks. You can help your child feel more in control. Let them pick the finger or site to be used for the check. If needed, offer nonfood rewards, such as stickers or time playing favorite games. This can help your child feel better about checking blood sugar. A lancing device kept at minimum settings may reduce the pain and fear associated with blood sugar testing. At this age, children often need checks in the middle of the night. You can do blood sugar checks while your child is sleeping. Check your child's blood sugar as often as advised by your doctor. You may also need to check their blood sugar levels when you suspect hypo- or hyperglycemia.

You may sometimes need to check your child's urine for ketones. Ketones are chemicals that are made when fat, instead of glucose, is burned for energy (ketosis). To check for ketones in very young children, place a cotton ball inside your child's diaper to absorb urine. Then press the cotton ball to the ketone test strip. If your child is no longer in diapers, follow the instructions that come with the strips and from their doctor, nurse, or diabetes educator. If ketones are present, always call your child's doctor right away. Some people also use home glucose and ketone monitors to check the blood for ketosis. Ask your child's doctor, nurse, or diabetes educator for more information.

It's very important for young children's blood sugar not to get too low. Very low blood sugar (hypoglycemia) can affect a child's developing brain. So manage your child's blood sugar as much as possible without letting it get too low. Very young children can't tell you when they have low blood sugar. Over time, you will learn what is normal for your child. This will help you recognize symptoms of low blood sugar. Pay close attention to how your child is acting. Your child may have low blood sugar if they are:

• Fussy or irritable
• Sweaty
• Lethargic (sleepy or drowsy) or pale
• Staring into space or glassy-eyed
• Shaky
• Confused or having trouble concentrating
• Complaining of vision problems, headaches, or nightmares
• Uncoordinated
• Dizzy

If you think your child has low blood sugar, check it right away. If the result is less than 70 mg/dL, or another number your child's doctor has advised, take action. Treat your child right away with a fast-acting sugar as you were told by the doctor. Check your child's blood sugar again in 15 minutes to be sure it's no longer low. If it's still low, give your child more of the fast-acting sugar. If your child is confused, unresponsive, unconscious, or having convulsions (seizures), they may have severely low blood sugar. Treat your child right away with injectable glucagon. This is a substance that will raise your child's blood sugar very quickly. Always have an emergency kit with a shot of glucagon with you. (Your child's healthcare team will teach you how to give a glucagon shot). Ask your child's doctor about nasal glucagon. It is approved for children 4 years and older.

Contact your child's doctor right away, call 911, or go to the hospital emergency department if your child has any of the following symptoms. Your child:

• Is hard to wake or unresponsive
• Passes out (faints)
• Has a blood sugar level below the “danger number” given to you by the doctor
• Needs glucagon
• Has a seizure

The amount of insulin your child needs and how often it's needed may vary. This includes both slow-acting and fast-acting insulin. Basal or background insulin is always needed whether your child is eating or not. Meal-based insulin is adjusted based on how much your child eats. Your child's doctor, nurse, or diabetes educator will teach you when and how to give your child shots. In young children, the best places to give shots are the fatty areas of the:

• Buttocks
• Belly (stay 2 inches away from the belly button)
• Sides of thighs
• Back of upper arms

Ask your child's doctor to teach you how to correctly rotate the injection site and how to stay away from areas of lipohypertrophy. This is a bump under the skin caused by injecting insulin in the same spot multiple times. Also, ask about correct insulin injection technique and how to prevent injecting insulin into the muscle. Accidentally injecting into the muscle or into an area of lipohypertrophy can affect how insulin is absorbed.

As your child gets older, more choices for blood sugar control will be available. For example, insulin pumps are now approved for use in children ages 2 and older.

At first, you may have some concerns about giving shots. If you are nervous, you may want to practice on yourself first. Ask your child's doctor about giving yourself an injection of sterile saline to learn how a shot feels. (If you are afraid of needles, using an injection device may help ease your fear.). How quickly your child adjusts may depend on how comfortable you are giving shots. Treat shots as a normal routine. Never threaten or scare your child that shots are a form of punishment. Modern-day insulin pens are accurate, easy to use and practically pain-free even for children with diabetes.

It's not unusual for children to cry and be upset when they get shots. But most children adjust very quickly to diabetes care. Shots and blood sugar checks may not be easy for your child to deal with at first. Here are some tips to help make getting shots easier for your child:

• Always give your child love and attention before and after shots. Encourage cooperation with the shots and other treatments.
• Use toys or other types of play so your child can focus on something fun.
• Help your child adjust by demonstrating shots on stuffed animals. Your child may even be able to practice giving shots to stuffed animals using a needle-less syringe.
• Talk to your child's healthcare team about other ways to help your child deal with insulin shots.

Even young children can start learning about foods that affect blood sugar the most. Keep these things in mind:

• Your child's doctor, nurse, or diabetes educator will teach you about carbohydrates. Carbohydrates are one of the macronutrients (the other being protein and fats) in foods that give your child the energy they need to grow. But they also raise blood sugar higher and faster than other kinds of foods. But, not all carbs are the same. Complex carbs, such as those in vegetables and whole grains, do not raise blood sugar levels as much as processed or simple carbs, such as those in candies, cakes, and juices. You will learn about “carb counting.” This is a technique to help you figure out how many carbohydrates your child eats each day. Carb counting helps you decide how much insulin your child needs.
• Your child's doctor, nurse, or diabetes educator will also teach you about fat and protein. Meals with more fat and protein may cause blood sugar to drop too soon after eating, or make it rise later than usual. You will learn how to adjust your child's insulin dosing to help keep a more stable blood sugar depending on meal content.
• Remember that kids will be kids! While you may need to limit eating at times to control glucose levels, no foods should be "off limits." Children will sneak treats, especially those they love. And some children are very picky eaters. So work the foods your child likes to eat into their meal plan. Adjust insulin dosages as needed. You will learn to adjust your child's insulin based on what your child eats. Talk to your dietitian if you are having trouble maintaining a meal plan for your child.

Like food and insulin, physical activity plays a big role in managing your child's blood sugar. Being active helps reduce the amount of glucose in your child's blood. But too much activity can cause your child's blood sugar to get too low. That's why it's important to check your child's blood sugar often when they are active. Talk to your child's doctor to learn how to balance your child's activity with food and insulin.

If your child attends preschool or kindergarten, you will need to meet with teachers or other staff. You will need to work out a diabetes care plan for your child. This is sometimes called a 504 plan. You may even wish to find a preschool or day care provider with diabetes care experience. Keep in mind that the school needs to be able to reach you in case of an emergency.

Have your child wear a medical ID showing they have diabetes and whom to contact in case of an emergency.

Caring for a young child with diabetes is a full-time job. You may sometimes feel worn out or overwhelmed. This can lead to burnout. Feeling burned out means that you might have a harder time managing your child's blood sugar. These tips can help you:

• All the adults in the household should be involved with diabetes management. Anyone else who takes care of your child, such as a babysitter, must also be prepared to manage your child's diabetes. A diabetes class can help. So can joining a diabetes support group or talking with a social worker.
• It may take some time for your family to adjust to diabetes care. At first, it might seem like your child with diabetes needs more attention than siblings without diabetes. Try to give siblings equal attention. Your other children will also benefit from the healthy diet and activities that your child with diabetes follows.

Despite your best efforts, your child's blood sugar numbers will sometimes be too high or too low. But try to remember: The numbers are tools to help you make decisions about your child's management plan. As your child grows, their body changes quickly. This means that perfect blood sugar control is impossible. Adjustments to your child's management plan are not a sign of failure. They are a normal part of your growing child's diabetes care. Still, within these limits, most families manage to have very good blood sugar control.

For more information about diabetes, visit these websites:

• American Diabetes Association
• Children with Diabetes
• Juvenile Diabetes Research Foundation
• American Association of Clinical Endocrinologists
• National Institute of Diabetes and Digestive and Kidney Diseases
• Endocrine Society