Sweet Success
Monday August 15, 2005
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At Saint Peter's University Hospital, New Brunswick, N.J., the pediatric endocrinology team is familiar with the care of children with Type I diabetes. Donna Dziedzic, RN, MSN, CDE, diabetes educator, pediatric endocrinology, and Jodi Moore, RN, BSN, CDE, coordinator, pediatric endocrinology, help these children along the road to good health.
Though the long-term complications are serious, Moore notes, children have trouble visualizing life 20 years into the future."We don't focus as much on the long-term problems when we talk to the children about diabetes," she says. "Certainly we teach the parents as well as the children about all the possible complications that come from long-term, uncontrolled hyperglycemia, but children are more focused on the here and now."
"We talk about how uncontrolled blood sugar causes delays in growth," she continues. "We remind them that they don't feel good when their blood sugars are too high and they can't play with their friends as easily."
The "411" on diagnosis
and management
Type I diabetes, usually viewed as an autoimmune disease, is typified by the body's inability to manufacture any insulin because the body has destroyed the beta cells of the pancreas. The presence of the antibodies indicates Type I diabetes. The individual must replace the lost insulin by subcutaneous injections.
One of the most helpful, recent advances for management of diabetes is the newer, long-acting insulin, glargine. An "analog" insulin, it is a breakthrough medication made in the laboratory that has an effective duration of 24 hours. This new tool helps the individual adjust his or her blood sugar when used in conjunction with shorter-acting insulins, like Novolag? and Humalog?. Using these with meals and adjusting with increased activity mimics the actual activity of the pancreas and offers more dependable control of blood sugar.
The insulin pump is another new tool that is helpful in managing diabetes for older children. Teenagers are a prime group for this kind of tool, but parents find pumps helpful to improve control of younger children as well. New safety features lock younger children out and prevent unplanned bolusing. The pump is a little larger than a deck of cards, and the flexible catheter is inserted subcutaneously in the abdominal area. The insertion site is changed every 48 to 72 hours. The benefit to the child is the ease with which insulin dosing can be manipulated and adjusted to increased activity or changes in diet.
There are books available for all ages of children, from storybooks that illustrate the general way the body works, to workbooks for preteens, to more detailed books geared to teens. "The 'Babysitter Club' series is popular with preadolescents, and one of the characters, Stacey, has diabetes," says Moore. "I always recommend the books when the child is the right age for them."
Sometimes children learn best when they have a three-dimensional model to work with, and Moore and Dziedzic use two teddy bears that "have" diabetes, Rufus and Ruby Bear. The bears have areas for finger sticks and areas where an injection would be appropriately given.
"We try all sorts of techniques," says Moore. "We designed a board game that we use sometimes with older children. They answer questions and move their game pieces a given number of spaces depending upon their answers. There are video games available through a variety of sources."
Getting the right start
One common belief is that youngsters should become responsible for their diabetes management as early as possible. The approach taken by Moore and Dziedzic is slightly different. Family involvement and waiting until the child is ready for the responsibility is the key to success.
"We want them to have as normal lives as possible," says Moore. "We tell families that the child needs to be involved from the beginning, but in an age-appropriate way. It's really important to listen to the child and assess whether or not he or she is ready. We do find that if there is participation by the entire family, the child tends to do better."
Dziedzic points out that initially the child is usually hospitalized and that is where teaching is started at the inpatient stage. "There is an intensive teaching program that's initiated when the child is first diagnosed.We give the child the skills to get a good start, and then the ongoing education is done in the outpatient department."
Education is a team effort, says Moore. "Most endocrinologists have teams of diabetes educators and nutritionists in place who can educate children and their parents when the diagnosis is confirmed. They use resources like the Juvenile Diabetes Resource Foundation's 'CARES [Connecting Area Resources Education and Support] Network Program,' which connects families of newly diagnosed children with those of similarly aged patients, to share their experiences and support."
Lives change, needs change
Tailoring the skills and involvement to the child's age can make a big difference in the rate of successful management. A 4-year-old may be able to select a finger for testing, or a site for injection, but is not mature enough to be responsible for the injection.
It is something of a paradox that children who have the responsibility of managing their disease too early have control problems later on, notes Dziedzic. "These are the children who skip injections or lie about their medications," she says. "They aren't trying to get away with something; they are just overwhelmed with the enormity of the problem."
Moore points out that the children can be a big part of the process but should be supervised every step of the way. Children can participate in menu planning and shopping, but glucose testing and injections should be closely supervised. School nurses should encourage children to self-test, but the nurse should closely supervise the injection, the testing, and any sharps disposal.
As children grow and their bodies change, the protocols for management of their disease change as well. Sports activities and social events will alter the need for insulin and will affect the blood sugar. Moore and Dziedzic recommend testing at least four times a day. The goal range is between 80 and 120, but the target for children under age 7 is 80 to 150.
Caring for children, not diabetics
Moore and Dziedzic are always aware that they care for children first, and "diabetics" as a part of that group. Acting from fear and rebellion, children sometimes work against themselves.
"We had one young girl who was diagnosed as a preteen," says Moore. "She was so good-natured, we had no idea there was any kind of a problem. She did really well at first, and she was the kind of kid who smiled even when she wasn't happy. Her HbA1C was very high, so we brought the family in to find out why. It turned out that she had her pump with her at all times, but she was only taping the catheter to her skin; she wasn't inserting it into the skin. She did better as time went on, and she recently called to say she's starting nursing school to become a diabetes educator."
There are no "bad" kids, say Moore and Dziedzic - there are only children who make less-than-healthy choices. Setting a child up to be perfect will always lead to
failure. Offering these children the tools to succeed and supporting their growth and
development will give them a basis to
manage their disease throughout long, healthy lives.
Marylisa Kinsley, RN, BSN, is a frequent contributor to Nursing Spectrum.
Reference
1. American Diabetes Association website,
http://www.diabetes.org/diabetes-statistics/children.jsp. Accessed July 10, 2005. Visit the ADA's "Resources for Parents" area: http://www.diabetes.org/for-parents-and kids/ resources.jsp for a list of books for children of all ages.
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