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The Challenge of Childhood Diabetes: Helping Children Manage Their Disease

Online Health Chat with Dr. Douglas Rogers

June 20, 2012

Introduction

Cleveland_Clinic_Host: Everyday in the United States nearly 80 people are diagnosed with type 1 diabetes, also known as juvenile diabetes. One in every 400 children and adolescents is living with type 1 diabetes. Juvenile diabetes is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy.

Juvenile diabetes develops when the body attacks beta cells in the pancreas. The beta cells become unable to produce insulin, which the body requires to convert glucose in food to energy. In order to stay alive and healthy, children with type 1 diabetes must constantly monitor their food intake and receive insulin injections. When a child is diagnosed with juvenile diabetes, it is important for the entire family to be involved in the understanding and management of the disease. Juvenile diabetes can be controlled with proper care, which includes regular visits with your child’s endocrinologist, developing an individualized treatment plan, and monitoring glucose levels.

Douglas Rogers, MD, joined Cleveland Clinic in 1991 as Head of the Section of Pediatric and Adolescent Endocrinology. Dr. Rogers completed his undergraduate studies at the University of Michigan, Ann Arbor, MI. He graduated from The Chicago Medical School, Chicago, IL, in 1978 and trained in pediatrics at SSM Cardinal Glennon Children's Medical Center, St. Louis University School of Medicine, St. Louis, MO. Dr. Rogers also completed a fellowship in pediatric endocrinology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO. He is board certified in both pediatrics and pediatric endocrinology.

Dr. Rogers was the Medical Director of Greater Cleveland's children's diabetes camp, Camp Ho Mita Koda from 1997 to 2010. He served on the executive committee of the Diabetes Association of Greater Cleveland from 2006 to 2010. He is a member of the following organizations: American Diabetes Association, The Endocrine Society, Pediatric Endocrine Society, and American Association of Clinical Endocrinologists.

Dr. Rogers has co-authored more than 40 medical journal publications and eight textbook chapters. His publications cover various topics, including diabetes mellitus in children, diabetes complications, growth disorders, thyroid disorders, puberty disorders, celiac disease, and nutrition issues.

Cleveland Clinic Children’s Hospital offers a comprehensive approach to help manage juvenile diabetes. Group clinic visits offer unique programs to help improve the child’s management of his or her diabetes. The group visits consist of educational sessions with members of the Pediatric Endocrinology team, reviews of glucometer readings, adjustments of insulin doses, and individual exams and lab reviews. Cleveland Clinic Children’s Hospital’s commitment to family-centered care and use of state-of-the-art technology helps your child best manage his or her juvenile diabetes while maintaining an active and healthy lifestyle.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Douglas Rogers. We are thrilled to have him here today for this chat on childhood diabetes. Let’s begin with some of your questions.


Infancy and Type 1 Diabetes

shobone: I am pregnant for the first time and living with type 1 diabetes, does that mean that my child is more at risk to also be born with type 1 diabetes? Is it possible that he could be diagnosed at birth and if so, should I alter my feeding plan? If so, what would be recommended?

Dr__Rogers: Children of type 1 Diabetes mothers have a 4% chance of developing T1DM (type 1 diabetes mellitus) in their lifetime. Breast feeding is the most important thing you can do to decrease that risk. Delay the introduction of cereals until after 4 months of age.

toe_the_line: Can a child of any age have diabetes?

Dr__Rogers: Yes, some children are born with diabetes. The youngest child I have diagnosed was 8 days old.

toe_the_line: What would make a doctor suspect diabetes in an infant?

Dr__Rogers: Weight loss, increased urination, and yeast infections.

wait_and_see: Do all infants diagnosed with diabetes have to go on insulin? Are there any alternatives?

Dr__Rogers: Some infants less than 6 months of age can be better treated with an oral medication called sulfonylureas. These patients are rare.


Making It Through Puberty

jbs99: My daughter is 12 years old, and living with type 1 diabetes. She struggles a lot with managing her condition and is embarrassed to talk about it when she’s eating or working out with friends. Are there support groups available for someone her age, for kids struggling with the same problems?

Dr__Rogers: Check for diabetes camps in your area. We have group clinics for adolescent girls here at the Cleveland Clinic, and have found those to be helpful, too. Contact the Juvenile Diabetes Research Foundation in your area to see if they have any support groups.


Parental Guidance and Support

gretag: My son was recently diagnosed with juvenile diabetes, and at this point I am not highly educated on the topic. As a start, I was wondering if you could fill me in on whether there are certain foods that a person with type 1 diabetes should avoid eating?

Dr__Rogers: Not any more. Most patients try to estimate the amount of carbohydrates they plan to eat, and then cover that with rapid acting insulin. Of course patients have to eat wisely, not overdo any one food group, and spread their meals throughout the day.

momo: My daughter is going off to college in the fall and until now I’ve done a bit of enabling by really managing her diabetes for her (in the foods I make, the activities I keep her involved in, etc.). How can I get her more involved in her own management, so that I don’t need to worry about her when she goes off to school?

Dr__Rogers: Check to see if your diabetes clinic has a "transition clinic." Start having your daughter reorder their supplies, and pick them up.

jacko: My son will soon be off our health insurance. What resources are available to help him pay for his necessary supplies and medications?

Dr__Rogers: Your son should be able to stay on your insurance until age 26 now. Contact your local American Diabetes Association for direction on help with supplies in your area if needed.


Diabetes and Athletics

bobbyk: I am a football coach with several players joining my team this season who wear insulin pumps. Is there anything I need to know about keeping them safe on and off the field during practice and games? What could be the repercussions of them working too hard in the summer heat? Are there any signs or symptoms I need to look for that they might be in distress due to their condition?

Dr__Rogers: First, allow them to drink as much water as they want. Also, allow them to check their blood sugar levels whenever they feel the need. Insulin pumps can be disconnected for up to 2 hours if needed. The kids should have both water and beverages that contain sugar in case they need it. They should have snack foods (granola bars) available, too.

CampNurse: I work at a summer camp as a nurse (not a juvenile diabetes camp) and we often have kids with diabetes—both on insulin and with insulin pumps. These kids are extremely knowledgeable. Do you have any recommendations for those kids that are going on trips outside of the camp property? They go on long bike rides (with distances of 500 to 1200 miles) over a number of days, kayaking, hiking, etc. Is there anything extra we should include for the people leading these trips? Obviously, the camper has been cleared by a physician to go.

Dr__Rogers: Take more supplies than you anticipate using. Have glucagon kits to treat severe low blood sugars. Know that insulin doses will need to be reduced, often drastically, as the children become very active. Make sure all the diabetic kids have identification on them that states they have diabetes.


Complications and Prognosis of Type 1 Diabetes

helko: My four-year-old daughter was just diagnosed with type 1 diabetes and I was wondering what the long-term effects of the disease could be given that she’s developed it at such a young age? Also, is the disease managed differently as those diagnosed at a young age grow from child to adolescent to teen to adult?

Dr__Rogers: Your role as a parent will change over time. Now you are the care provider, soon you will be a provider and teacher. Most children will start to check their own glucose levels at age 6 or 7 years. They start to give their own insulin at age 8 or 9. As the children get into puberty, you become more of a coach and advisor, not monitoring them all the time, but available for consultation when they have an issue with their diabetes. Good luck.

hallee: My 8-year-old niece has recently been diagnosed. How will this disease progress throughout her lifetime?

Dr__Rogers: A child diagnose with type 1 diabetes will always have type 1 diabetes. She should live a long and healthy life, but it requires a lot of work to manage diabetes.

starre: Can a child ever grow out of this (Type 1 diabetes), or do they have diabetes for life?

Dr__Rogers: Type 1 diabetes is for life.

up_town: In children, what complications are associated with diabetes?

Dr__Rogers: Complications like eye disease, kidney disease, and nerve disease do not start until after the onset of puberty, and after the child has had diabetes for at least 3 years. We rarely see retinopathy in kids anymore. Staying in good control, an HbA1c (hemoglobin A1c test) less than 7.5% is the best way to reduce the risk of complications. Elevated blood pressure also contributes to diabetic complications, so treat hypertension aggressively.

jolo: Can diabetes cause seizures in children?

Dr__Rogers: Yes, usually due to low glucose levels.


Type 1 Diabetes Symptoms

penny: What are the symptoms to look for that would indicate whether my child has diabetes?

Dr__Rogers: The onset of symptoms in children is usually rapid and dramatic. A marked increase in thirst and frequency of urination are the most common. A previously dry child may start wetting the bed again. Yeast infections in girls who are potty trained may be another sign.


Diabetes Types

cammy: Is all childhood diabetes type 1?

Dr__Rogers: No. Older obese children may develop type 2 diabetes. About 5% of our new diabetic children have type 2 diabetes. In some clinics in the Southwest, almost 50% of the new children with diabetes have type 2. Native Americans and Hispanics are more at risk of developing type 2 diabetes than other ethnic groups. There are also some rare genetic forms of diabetes that run in families and are different than type 1 diabetes.

find_it: I understand that heredity plays a factor in type 2 diabetes. Does the same hold true for type 1 diabetes?

Dr__Rogers: Heredity is much stronger for type 2 diabetes than type 1 diabetes. Generally, if you have a first degree relative with type 1 diabetes, your risk of developing type 1 diabetes is about 5%. It's a little higher if your father has type 1 diabetes, and a little lower if your mother has type 1 diabetes.

runnon: What is the difference between type 1 and type 2 diabetes? Which is worse, if you could classify it that way?

Dr__Rogers: Type 1 diabetes is due to autoimmune destruction of the insulin secreting cells in the pancreas. This has to be treated with insulin and is permanent. Type 2 diabetes is due to the body becoming resistant to insulin. People with type 2 diabetes can initially be treated with oral medications to make their body more sensitive to insulin. A person with type 2 diabetes may be able to come off all medications if they lose weight, become active, and eat a healthy diet.


Diabetes Care in Schools

lisamchil: My son is almost 14 and heading to high school. He's been homeschooled. What's the most common problem families have with schools' care for kids with type 1? How can I make sure he's well cared for?

Dr__Rogers: Many schools now have their own diabetes care plans, or your diabetes clinic may have a school care plan for you. Find out if the school has other children with diabetes, and how they are cared for. Then modify this to suit your son’s needs.

Mental Health and Substance Abuse in Diabetes

987idk: Are mood swings and depression caused by the diabetes or a by-product of having it?

Dr__Rogers: Children with any chronic disease are more prone to depression. Counseling may help, but sometimes antidepressant medications are required. The important thing is not to ignore this.

have_fun: Is there a specific problem with a 16-year-old diabetes patient smoking marijuana? I think my son is. Do I need to be even more worried than normal?

Dr__Rogers: It will cause the "munchies" and increase his carbohydrate intake. It will also make him less interested in taking care of his diabetes. Yes, you should be worried; he may be headed for other more dangerous risky behaviors.

crayo: What effect does alcohol have on juvenile diabetes?

Dr__Rogers: This is a major problem. I have had very few kids with diabetes die, and alcohol was involved in all of them. Alcohol causes the blood sugar to first go up, and then come crashing down. When underage kids drink, they take in a lot of alcohol in a short period of time. This makes the effect much worse. I tell my patients that if they choose to drink, that they do it slowly, no more than one drink per hour, always eat when they drink, and never, ever drive after drinking.


Insulin Pumps

shoop: What are the advantages and disadvantages to insulin pumps? At what age do you suggest them to your patients?

Dr__Rogers: The youngest child I have started on a pump was 15 months old. Pumps allow variable basal rates to better match what a patient needs. They do not make your life easier though. They require a lot of attention. Overall, I think our patients on pumps generally do better though.

pard3: What are the risks involved in a teen that relies on an insulin pump and eats any and everything they want?

Dr_Rogers: We started telling kids they could eat what they wanted as long as they covered the carbohydrates with insulin. This was a mistake, as our patients started becoming obese like the rest of America’s children. Children need to eat healthy, limit intake of sugar, and increase intake of fiber, whether they have diabetes or not.

larkin: I am on a pump and play sports throughout the summer in my neighborhood. I am 15. Do you recommend keeping the pump attached the entire time I am playing? If I detach it, depending on what I am doing, could it be dangerous? I don’t keep it off for too long. When would you suggest detaching it?

Dr__Rogers: You can detach the pump for up to 2 hours but no longer. You have to test your blood sugar when you re-attach, and bolus as usual for a higher sugar if needed.


Weight and Diabetes

Let_it_be: How crucial is weight as it concerns juvenile diabetes, for both type 1 and type 2?

Dr__Rogers: Obesity is almost always present in children with type 2 diabetes. Children who develop type 1 diabetes are usually not overweight, although they can be obese. A child's weight does not play a role in the risk of development of type 1 diabetes.


Lifestyle Choices

howdie: I am 16 years old, and was diagnosed with diabetes at age 12. I am thinking about a military career. Is this a possibility for a type 1 diabetic or not? I heard it was not.

Dr__Rogers: The military does not currently take patients with type 1 diabetes.

baby_no_more: What are your thoughts on tattoos for an 18-year-old diabetic?

Dr__Rogers: You have to choose your battles. I wouldn't want my kid to get a tattoo at age 18, but I wouldn't fall on my sword over it.


Insulin

hardy3: How is insulin dosage determined?

Dr__Rogers: When starting a newly diagnosed child with type 1 diabetes, we base the dose on weight. After that it is based on the blood glucose patterns we download from the patient's meters.


Possible Side Effects of Diabetes Care

pluncket: My 8-year-old daughter started getting headaches soon after she was diagnosed. Are headaches associated with childhood diabetes, a reaction to the medications, or are they totally unrelated?

Dr__Rogers: They could certainly be related to all the stress of the recent diagnosis. But headaches are not directly related to diabetes.

50392: What causes ‘knots’ in the area where my son gives himself his insulin shots? Do they ever go away?

Dr__Rogers: This is called lipohypertrophy. Insulin stimulates the growth of fat under the skin in some patients. This can be avoided by rotating injections. If it has developed, you must avoid the area completely till it melts away. This usually takes months.

cosst: What do you do to help stop bleeding? My son’s fingers seem to bleed too long after doing his blood tests.

Dr__Rogers: Try using the forearm, or setting the pricker to not prick so deep.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic Children's Hospital specialist Dr. Douglas Rogers is now over. Thank you for taking the time to answer our questions today about Childhood Diabetes.

Dr__Rogers: Thanks for the great questions! I have enjoyed chatting with you today. For more information about Childhood Diabetes, you can always contact us at 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437.


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