Infants, Toddlers, and Preschoolers with Diabetes

Type 1 diabetes is less common in preschoolers than in older children and adolescents. Less than 1% of diabetes is diagnosed in the first year of life. Less than 10% is diagnosed before the age of 5. The diagnosis is often missed in younger children for 2 reasons. The first is because diabetes is less common in younger children. The second is that the symptoms are often confused with other minor illnesses. A baby might be in severe diabetic ketoacidosis before a diagnosis is made. Once the disease has been diagnosed, however, the situation can be corrected quickly and long-term management can begin.

When it comes to managing diabetes in young children, it's helpful to first consider how normal infants and toddlers behave. They generally:

  • determine thoughts by what they see and hear
  • begin to develop a sense of themselves, first by gaining a trust in their environment as infants, and then by testing this environment in the next few years
  • enhance their knowledge of the world around them by constantly exploring, asking questions, and developing language ("Why this? Why that? Why the other thing?")
  • begin to become more curious and independent, choosing some activities and rejecting others

Diabetes care in young children

Diabetes care in children under 5 involves a balance between what might be considered ideal––close to normal blood sugar readings––and what is safe and practical. The target range for these young children is to achieve pre-meal sugars of 6 to 12 mmol/L (110 to 220 mg/dL). This range allows good blood glucose control while reducing the risk of severe hypoglycemia. Too tight control in infants and toddlers is especially risky as they cannot yet recognize the symptoms of low blood sugar. Repeated episodes of severe hypoglycemia in these children may lead to mild intellectual or learning impairment later in life.

Very young children often have changing appetites. They don’t always eat the same amount of food from day to day. It’s important that the diabetes care routine reflects that. If blood sugar levels before meals are allowed to go slightly higher than for older children, the infant or toddler is more likely to remain safe even during periods of food refusal or picky eating. Parents will be less worried and frustrated, and mealtime will be more pleasant. For safety’s sake, young children should eat at regular meal and snack times, having at least 3 meals and 3 snacks a day. But beyond that, imposing a rigid meal plan on an infant or toddler may only increase the stress in the family.

As children grow they become more predictable in their eating. They can also start to recognize and describe their low blood sugar reactions. At that time blood sugar targets also change. More structure in meal planning becomes both possible and necessary.

Signs of a healthy infant or toddler with diabetes

How do parents and others who care for your children know that everything is going well? Look for:

  • normal growth and weight gain
  • developmental milestones, such as rolling over, sitting up, crawling, standing, walking, and talking at about the expected age
  • no signs of high blood sugar levels, no overly wet diapers, no unusual thirst
  • good energy
  • few mild low blood sugar reactions, and no severe reactions
  • no ketones in the urine
  • blood sugar readings that are not often less than 6 mmol/L (110 mg/dL)
  • blood sugar readings that are not over 12 mmol/L (220 mg/dL) for long periods of time
  • a happy and secure attitude in the child

Impact of diabetes on an infant, toddler, or preschooler

Young children with type 1 diabetes go through the same stages of development as their friends without diabetes. However, the routines and tasks needed for good diabetes care may influence and sometimes interfere with this development. All parents of young children with diabetes worry about the effects of diabetes on their growth as individuals, and how they will cope with the condition as they grow older.

Parents are often concerned about:

  • the fact that their young child cannot talk about symptoms of hypoglycemia (for example, is the toddler having a hypoglycemic spell or a temper tantrum?)
  • dealing with their own and their child’s anxiety about the pricks and injections
  • developing a treatment plan that does not interfere with the child’s normal daily activities, including naps
  • giving meals and snacks on time and in the same amounts (toddlers with picky appetites can really cause stress at mealtimes)

Try to balance your child’s need for support against the risk of overprotection and being excluded from activities they would normally do at that age.

Coping strategies

Some helpful hints in coping with diabetes in a young child include:

  • Try to adopt a matter-of-fact approach to insulin injections, finger pricks, and mealtimes. Young children quickly pick up on parents’ anxieties and use them to control their environment. Try to be quick, calm, and reassuring when carrying out routines. Reduce your child’s fears by preparing the insulin or blood testing equipment in another room before involving your child. When it’s over, give her a big hug and kiss.
  • Share responsibility for the routines wherever possible. In single-parent families, have a friend or family member help with the diabetes routines on a regular basis. This prevents the toddler from playing one caregiver off against the other. The parent, the toddler, and the support person can remain confident that the child will be safe in the parent’s absence.
  • Acknowledge your child’s feelings and provide reassurance, but don’t delay needles or finger pricks until he is "ready." Consider using distractions such as toys, songs, or television.
  • Try to allow your child to have some control over the routine if she wishes. For example, she can choose the finger for the next prick.
  • For the really picky eater, set limits on time allowed for meals and snacks. Don’t sit for hours fighting over each piece of food. The child always wins.

Making injection time go smoothly

It’s not unusual for children of all ages to go through periods when they cry, squirm, and try to avoid insulin injections and finger pricks. Sometimes it’s because the needle hurts. More often they are angry about being held still or having their play interrupted. Remember how hard it is just to wipe a toddler’s nose! They may also be reacting to the fear and anxiety they sense in you. Here are some helpful hints for making injection time go more smoothly:

  • Try to take a matter-of-fact approach to the insulin injections and finger pricks.
  • Be quick, calm, and reassuring when you carry out these routines.
  • Reduce your child’s anxious time by getting the dose and/or equipment ready before you involve your child.
  • If possible, go where your child is playing to cause less disruption.
  • Crying, protests, and other delaying tactics are normal. Remember that each time you give insulin or do a finger prick you are helping your child stay healthy.
  • Gently hold or restrain your child if she struggles.
  • Get the needle or finger prick over with quickly. Delaying it only prolongs the agony for everyone.
  • Give your child a big hug and kiss after you give the needle, even if she didn’t cooperate.
  • Praise your child for any sign of cooperation.

Naps and meals: Tommy’s story

Tommy is two and a half, and doing quite well with his diabetes routines. His parents, Heather and Marc, are sharing responsibility for his finger pricks and insulin injections. Heather gives the morning shot and Marc does the second one before the evening meal. Tommy’s 4-year-old brother, Tyler, likes to help his dad with the evening blood sugar check and insulin shot. This leaves Heather free to get dinner on the table. Meal and snack times are consistent. Both boys have their morning snack just as their favourite television program starts at 10 a.m. Afternoon snack works equally well, following Tommy’s nap, at 3 p.m. The only problem for Heather comes when Tommy sleeps past 3 p.m. She hates to wake him, but how long can she safely let him nap? Unlike children without diabetes, he can’t nap right through his snack time. She decides, with the help of her diabetes team, that an extra half hour is the limit.

Lately Tommy has been refusing food, especially at mealtimes. Worried about sugar lows, Heather and Marc have been pleading, coaxing, and even preparing 2 or 3 food choices. In the end Tommy holds out for apple juice. After discussion with the diabetes team, Heather and Marc decide to reduce the insulin dose a little and adjust the blood sugar targets to 8 to 12 mmol/L (145 to 220 mg/dL), from 6 to 12 mmol/L (110 to 220 mg/dL). This allows for Tommy’s refusal of food. They limit mealtime to a maximum of 25 minutes. They also plan to avoid, if possible, replacing the meal with apple juice alone. Food refusal is a temporary stage many toddlers go through. As Tommy’s appetite becomes more predictable, they will have to increase the insulin and reset the blood sugar targets.

Marcia Frank, RN, MHSc, CDE

Denis Daneman, MB, BCh, FRCPC