DISCUSS HOW ONE CHILDHOOD CONDITION AFFECTS THE NORMAL GROWTH AND DEVELOPMENT OF A CHILD AND FAMILY AND THE POSSIBLE INTERVENTIONS TO ALLEVIATE THESE ISSUES
HESC 2006 CHILD HEALTH ROLES AND RESPONSIBILITIES
THEME 4 SICK CHILDREN IN A NORMAL ENVIRONMENT
DISCUSS HOW ONE CHILDHOOD CONDITION AFFECTS THE NORMAL GROWTH AND DEVELOPMENT OF A CHILD AND FAMILY AND THE POSSIBLE INTERVENTIONS TO ALLEVIATE THESE ISSUES
This report will aim to look at diabetes, its causes, symptoms and treatment in children. Commonly thought of as a 'mild' condition, the seriousness of diabetes is often not recognised (www.diabetes.org.uk); therefore this report shall attempt to illustrate the potential risks involved, whilst raising awareness of the condition.
The digestion of starchy foods, sugar and other sweet foods all produce glucose, as well as the liver which produces glucose naturally (www.diabetes.org.uk). 'Diabetes mellitus is a condition in which the amount of glucose (sugar) in the blood is too high because the body cannot use it properly' (www.diabetes.org.uk:1). This occurs when the insulin produced by the pancreas is not sufficient to allow the glucose to enter the cells to be used as fuel (www.diabetes.org.uk). Without insulin this process cannot take place proving fatal.
A common health condition, diabetes is thought to affect about 1.4 million people alone in the UK; this is on average three in every 100 people, however at least another one million people do not actually know they have the condition 'Diabetes is at the forefront of chronic disease in childhood, where responsibility is handed over to the patient and their family' (Shield and Baum. 1996:574).
There are 2 types of diabetes Type 1 also known as insulin dependent diabetes mellitus (IDDM) and Type 2 also known as non-insulin dependent diabetes mellitus (NIDDM). (www.diabetes.org.uk). Type 1 has also been called 'JOD- Juvenile Onset Diabetes' (Craig 1982:23). Whichever type, 'diabetes is for life; although cannot be cured, it can be successfully controlled' (British Diabetes Association 1980:DH103:1).
Type 1 diabetes occurs 'if the body is unable to produce any insulin' (www.diabetes.org.uk) naturally in order to use the body's glucose efficiently. This form is more common in the under 40 age group (www.diabetes.org.uk) therefore more children are likely to experience the disorder. It is treated by insulin injections and a healthy diet, with regular exercise also recommended (www.diabetes.org.uk).
Type 2 diabetes is when the body can still produce insulin, but not enough, or when that produced does not work properly (known as insulin resistance) (www.diabetes.org.uk). Often appearing in the over 40's it is treated by diet and exercise or by a combination of exercise, tablets, diet or exercise and insulin injections (www.diabetes.org.uk).
Since Type 2 is less common in children the focus of this study therefore will be upon the incidence of Type 1, discussing the causes, symptoms, complications, growth implications, and who is involved in the care of a diabetic child.
Diabetes is the most common endocrine disorder of childhood and is a life long chronic condition (Court and Lamb 1997:106). Normally, cells in the pancreas secrete hormones necessary for energy production, regulating blood glucose. Insulin, produced in beta cells, 'lowers blood sugar by allowing glucose to move from blood to the cells' (Phillips 2000:7). When the beta cells have been destroyed for one reason or another diabetes results (www.diabetes.org.uk). 'The most likely cause is abnormal reaction of the body to the cells' (www.diabetes.org.uk), which 'may be triggered by a viral or other infection' (www.diabetes.org.uk). Infection may also bring to light an underlying diabetes and exacerbate the symptoms e.g. tonsillitis' (Bloom 1975:100).
'The onset of diabetes in childhood is rapid' (Craig 1982:1), sometimes over a period of only a few weeks. 'Diabetes in childhood is an insulin-dependent disease with very few exceptions with characteristic symptoms, which makes it an easily recognizable condition' (Shield and Baum. 1996:609). These include 'increased thirst, extreme tiredness, weight loss, genital itching or regular episodes of thrush, blurred vision' and excessive urination especially at night (www.diabetes.org.uk).
With diabetes comes many different complications, most of which are not life threatening, however 'the two most common acute conditions are hypoglycaemia and ketoacidosis'(Court and Lamb 1997:201).
Hypoglycaemia is when the blood sugar levels are too low, causing hunger, nervousness and shakiness, dizziness, confusion, and anxiety, which if left untreated will lead to unconsciousness (www.diabetes.niddk.nih.gov) and require hospital treatment. .
Diabetic Ketoacidosis (DKA) carries a high morbidity and mortality Treatment demands urgent admission to hospital (Williams and Pickup 1999). Signs of this are vomiting, stomach pains and rapid breathing (www.diabetes.niddk.nih.gov). 'DKA is likely in younger children because of emotional stress, infections and missed injections; however in adolescence because of under dosage of insulin, binges/excessive alcohol assumption' (Shield and Baum 1996:208).
Although diabetes in theory could occur at any time, type 1 'is extremely rare under the age of 9 months' (Shield and Baum 1996:614), being most common in the 6-12 year old stage (Craig 1982:23), with 'increasing incidence up to puberty and a decline thereafter' (Shield and Baum 1996:614). This said it does occur equally in boys and girls, but is 20 times more likely if already present in family history (Bloom 1975).
It has also been found 'that the incidence of diabetes in childhood is increasing and the onset is occurring at a younger age' (Court and Bloom 1997:106), so a better understanding of the condition should be held by professionals and families alike, in order to notice any signs to keep it under control.
Although diabetes can be effectively treated there is still yet to be a cure (www.diabetes.org.uk). The main aim of treatment for diabetes is to sustain levels of blood glucose and blood pressure as near to normal as possible (www.diabetes.org.uk) so that the body can ...
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It has also been found 'that the incidence of diabetes in childhood is increasing and the onset is occurring at a younger age' (Court and Bloom 1997:106), so a better understanding of the condition should be held by professionals and families alike, in order to notice any signs to keep it under control.
Although diabetes can be effectively treated there is still yet to be a cure (www.diabetes.org.uk). The main aim of treatment for diabetes is to sustain levels of blood glucose and blood pressure as near to normal as possible (www.diabetes.org.uk) so that the body can use it properly as fuel in the cells. Aims of treatment in children are in two main directions. Firstly, the child must be relieved of symptoms, and be able to lead a full and happy life at home and school. The second aim of treatment is to safeguard the future and to reduce the risks of ill health in later life (Bloom 1975:101). This can be divided into: short term goals to control and prevent hyperglycaemia and hypoglycaemia; medium term to promote normal growth and physical maturation; long term to prevent any other related diseases (Court and Lamb 1997:130) such as micro vascular disease, eye disorders, kidney and feet problems (Phillips 2000).
In order to control the treatment needed 'diet is the cornerstone of all treatment for diabetes; its importance cannot be stressed enough' (Bodansky 1994:18); however for children this may prove difficult as 'diet should fit in with peers' (Craig 1982:141). It is essential to 'eat regularly because injected insulin continues to operate and goes on lowering blood sugar until food is taken to restore the balance, and if not the blood sugar level may fall to low, causing hypoglycaemia (British Diabetes Association 1980:DH102:7).
There have been a number of studies into the effect of exercise to diabetes; with evidence for improved glycaemic control following an 8 week programme of exercise, as exercise increases the ability of muscles to take up and oxidise free fatty acids during exercise and also increases the activity of lipoprotein lipase in muscle (Court and Lamb 1997:282).
Insulin for type 1 is mandatory as previously stated and as a treatment deserves careful thought and consideration in such a report because without, death would most certainly occur.
Because the beta cells cannot produce insulin, it has to be provided in another form to allow the body to function properly. Insulin was discovered by Banting and Best in 1922 'subsequently saving millions of lives' (Bloom 1975:57). Until the 1980s, insulin was extracted from the pancreas of animals (pork and beef ) but insulin of human structure produced by genetic engineering is now used for most insulin preparations (Tatersall R: ). Insulin is given in the form of injections, usually two to four times a day because if it were to be given by mouth it would be destroyed by the digestive juices in the stomach (www.diabetes.org.uk and British Diabetes Association 1980:DH104:1). The aims of its treatment are to: control blood glucose and disordered metabolism; avoid hyperglycaemia and hypoglycaemia; achieve satisfactory growth in children, and achieve and maintain normal body weight' (Bodansky 1994:27). With these aims achieved, previous results of type1 diabetes have been alleviated providing a better future for all those with the condition, especially because before insulin, diabetes resulted in death (Espinal, J. 1989).
Administering the insulin to oneself should be encouraged at around age 7-8 (Court and Lamb 1997:32) in order to provide in depth knowledge and understanding of ones own condition and what it entails.
'A sign of well-being in the diabetic is that he is growing properly' (Craig 1982:12).
Before the introduction of insulin an controlled treatment it was often common for diabetic children to have ' Mauriacs Syndrome; stunted, liver enlarged, slightly rounded face, maybe buffalo hump at back of neck', this diabetic dwarfism was common, but with advances in long-lasting insulin it is less so (Craig 1982:19).
Although nowadays diabetes does not have a great effect on the 'normal' growth of children it does still affect them, with likeliness for shortened height and obesity.
The reason for height to be effected in diabetics is complex; however an attempt will be made to discuss this with the most essential facts mentioned. Every person has a calendar age (CA) and a bone age (BA), growing until BA17. 'It has been found that diabetic children at the onset of diabetes, CA 6-10 years, are slightly taller than average and that their bone age is slightly advanced (Craig 1982:14). However non diabetic children enter puberty, at CA of 11-13 years, when growth spurt occurs which is earlier than diabetic children. Therefore 'normal' children will be taller at this age.
The diabetic child tends to 'lose' height because the growth hormone /IGF1 (insulin-like growth factor 1) axis is dependent on insulin, with insulin promoting production of IGF1...so in diabetes there is a situation of low IGF1 (and poor growth) and high growth hormone which because of its antagonistic effects to insulin increases insulin resistance and worsens control, the effect being most marked in puberty, including the normal physiological insulin resistance seen at this time (Court and Lamb 1997:241).
The pubertal growth spurt may be blunted and or delayed especially in girls and this may lead to a reduction in final height. However growth failure in adolescents with type 1 diabetes is rare nowadays, possibly because of improved management and monitoring of diabetes. (Ref...)
In summary 'Diabetic children grow well though diabetes in a child still does seem on average to reduce their ultimate adult height slightly in that they are usually about one to two inches shorter than their parent of the same sex, again on average' (Craig 1982:13).
When addressing weight the body mass index (BMI) needs to be discussed. 'the BMI of healthy females increases rapidly during the period from 9-11 years reaching a plateau after 13 years then decreasing again at age of 14-15 years to follow the values of healthy males. (O'Dea and Abraham, 1995) In contrast the BMI of diabetic females continues to increase during the teenage years (O'Dea and Abraham 1995:643); similarly, the BMI of diabetic males increased significantly from the age of 15-16 years compared with healthy males' (Shield and Baum 1996:643-645).
In diabetics 'excessive weight gain is common, particularly in adolescent girls with diabetes' (Court and Lamb 1997:130), sometimes resulting in 'obesity' (Craig 1982:62).
Although height and weight are most important in physical growth, in girls who develop diabetes before puberty, the onset of menstruation is sometimes delayed for a year or two; however this is not always the case and not serious enough to cause major concern (Bloom 1975).
In diabetics 'weight loss equals poor control associated with insufficient insulin and or insufficient food and excessive weight gain equals too much insulin and or food. The combination of poor control and excessive weight gain must equate to excessive or inappropriate dietary intake and excessive insulin' (Court and Lamb 1997:241), therefore it is essential to control diet and have an active exercise regime in order to prevent any further complications resulting from weight gain, which are also common in non-diabetics.
Up to now the main focus of this report has been upon the child, but as any childhood condition shows, the family is as important, deserving time and support themselves. This is shown as 'Diabetes in a child is more than a disease, it is a way of life. It involves the whole family and all those outside the family who are caring for the child' (Craig 1982:5). Diabetes is for life, and those in contact with the child need to be aware of any potential problems, however 'There is no getting away from the fact that the control of a diabetic child may be very difficult and that the best of parents will at times feel self-doubt' (Craig 1982:5).
The family are essential in day to day life; therefore an understanding of the child's condition ensures the correct care for that child. The family is very important, and all should be involved in such things as giving insulin and knowing about hypoglycaemia, with such help as no sugar at the table-other siblings should still get them but not in front of diabetic child (Craig 1982) so that no prejudice or dislike occurs on either part.
'The simple fact of having diabetes may make a child feel inferior, different from his friends; and if he also feels he has to be constantly watched his feelings of inadequacy increase...Diabetes in childhood is a family illness; the child needs support and so do the parents' (Craig 1982:5). This is provided through and by a range of professionals who should help within the family which is necessary as 'The diabetic child is happier when diabetes is regarded as a family illness' (Craig 1982:124).
Professionals include doctors, nurses, and teachers etc. all of these must be able to recognise any symptoms or complication of diabetes. It is also necessary for interaction with the family to understand more about that child and his/her needs.
Children with diabetes must not in any sense be regarded as ill or as invalids, and must be encouraged to take part in all school activities including games and physical exercise (Bloom 1975:104) to promote their well-being as well as being included in class activities to ensure no exclusion from peers.
In relation to administering insulin a GP or diabetes nurse should be on hand to show and explain to those with diabetes how to take injections, whilst providing support and help (www.diabetes.org.uk), as the amount of insulin required will vary from day to day according to diet how to do a blood or urine test to measure glucose levels will also be shown (www.diabetes.org.uk). These are all important factors so that too much or too little is not given. Also important are regular (3-4 months), accurate measurements of height and weight must be part of the diabetes management strategy and can often be used to explain and discuss a problem in management with the child or parent (Court and Lamb 1997:247), to assist with the need for growth patterns to remain steady as possible.
The professional has a number of roles. Usually, diabetes should be managed by a diabetes specialist nurse, dietician, paediatrics and clinical psychologist or psychiatrist (Court and Lamb 1997). They need to be involved in: 1. Giving advice and support to parents over management. 2. Education of parents, family and child about diabetes. 3. Monitoring of condition and feedback. 4. Direct management of crises. 5. Counselling, psychological support and intervention. 6. Support for family in wider community - nursery school, social services (Court and Lamb 1997:49). With this in use families and children will receive the best possible care they are entitled to. They provide a well rounded support team for both the child and family with diabetes.
It is also 'important for teachers to watch diabetic children for low-blood sugar (hypoglycaemia)' (British Diabetes Association 1980:DH127:2) as this is where a lot of time will be spent by children, they need to be watched for their safety.
In investigating diabetes, it is certainly clear that although a common condition, generally not a lot is actually known about it, especially in relation to the severity and complications that can arise. It is important for all those working with children, for example nursery workers and teachers, to hold an understanding of diabetes, what it entails and how to alleviate any problems which arise so that the child be treated correctly without being 'left out' from his/her peers' activities and to enjoy an as 'normal life' as possible.
REFERENCES
Bloom, Dr. Arnold., (1975) Diabetes Explained, Lancaster, UK: Medical and Technical Publishing Co Limited
Bodansky, Jonathan. (1994) Diabetes, London UK: Wolfe Publishing
British Diabetic Association., (1980) The Diabetics Handbook, London UK: Jaguar Press Limited
Court, Simon. And Lamb, Bill., (1997) Childhood and Adolescent Diabetes, Chichester, UK: John Wiley & Sons Ltd
Craig, Oman, (1982) Childhood Diabetes The Facts, Oxford: Oxford University Press
Espinal, J., (1989) Understanding Insulin Action, Principles and Molecular Mechanisms, Chichester UK: Ellis Harwood Limited
Phillips, Robert H, (2000) Coping with Diabetes, New York: Avery
Shield, J.P.H., Baum, J.D., (1996) Clinical Paediatrics, Childhood Diabetes, International Practice and Research, Volume 4/Number 4, London UK: Bailliere Tindall
www.diabetes.org.uk accessed 11/03/04.
www.diabetes.niddk.nih.gov accessed 09/05/04
ABC of diabetes - 4th edition Peter J Watkins 1999
Page 3: Aims of treatment are firstly to save life and alleviate symptoms and secondly to achieve the best possible control of diabetes with blood glucose concentrations maintained as near normal as possible to minimise long term complications. Control is achieved by lowering blood glucose using diet alone, diet and oral hypoglycaemic agents or diet and insulin
Page 9: Maintaining tight control requires optimisation of insulin regimen and diet, careful blood glucose monitoring and substantial professional support.
Page 11: For type 1 diabetics, if they eat too much, diabetic control deteriorates; if they eat to little they become hypoglycaemic. Important principles are that the carbohydrate intake is steady from day to day and that it should be taken at fairly regular times each day. If this discipline is not followed diabetic control becomes difficult. Severe carbohydrate restriction is not necessarily required; indeed if the diet is fairly generous patients are less likely to resort to a high fat intake which may be harmful in the long run.
For social convenience it is customary to advise that most carbohydrate should be taken at the main meals - breakfast, lunch and dinner - even though these are not the times when, according to blood glucose profiles, most carbohydrate is needed; for example, less carbohydrate at breakfast and more at mid morni9ng and lunch often improves the profile. Snacks should be taken between meals - elevenses, during the afternoon and bedtime - to prevent hypoglycaemia. At least the morning and night snacks are essential and should never be missed.
Page 19: Fatty lumps at injection sites are common, and occasionally so large as to be unsightly. Their cause is unknown but they sometimes develop if injections are repeatedly given over a very limited area of skin. For this reason it is best to vary the site from day to day. They are rarely troublesome, but once present they tend to persist. .....Fat atrophy is rarely seen since the introduction of purified insulins.....Red itchy marks at injection sites after starting insulin are now rare and if they do occur, usually disappear spontaneously....Abscesses at injection sites are also remarkably rare
Page 27: Most patients experience the early warning symptoms of hypoglycaemia and can take sugar before more serious symptoms develop....With increasing duration of diabetes in those who are tightly controlled, there is a tendency for early warning symptoms not to occur and patients develop the more serious problems..Friends and relations are more often aware of a hypo than the patients themselves, observing them to be slow witted with a vacant expression and perspiring face and hands. Many diabetics, especially children, need reassurance that they will not die in their sleep. Nevertheless, a very small number of otherwise unexplained deaths at night have been reported in young insulin dependent diabetic patients and may have been caused by hypoglycaemia.
Baby and Child Health Carolyn Meggitt (2001) Oxford UK: Heineman Educational Publishers
Page 267-268: The effects of chronic illness - reactions of brothers and sisters
Just as there are variations in the way parents react to a child's illness, the way in which the sick child's brothers and sisters react will differ greatly. Their reaction will depend upon their age and stage of development - and particularly their level of understanding. Common reactions include:
Jealousy. Children may feel jealous of all attention the sick child is getting. Parents and other relatives appear to be focusing all their attention on the ill child with disruption of previous routines. Some children regress and develop attention-seeking behaviour in an effort to claim more of their parent's time.
Guilt and fear. Siblings may feel guilty that they are well and able to play and do things their sick brother or sister can't. They may be frightened at the strength and power of their parents' feelings of sadness and may evem be afraid that they too could develop the same illness.
Grief. Children may go through a similar grieving process as do adults. They may feel overpowering feelings of sadness and loss; these feelings my result in: loss of appetite and lack of energy; mood swings - one minute seeming full of energy and optimism, and the next seeming withdrawn and uncommunicative; sleeping problems
Neglect: siblings can feel unloved and neglected by parents and others, whose loving attention may seem exclusively reserved for the sick child. They feel somehow very different from their friends, for whom life seems to go on as normal.
Supporting the family of a child with chronic or life threatening illness
It is important that support given to the child and family is family-centred. This means the child's parents have a major role in making decisions about the sort of car the child receives, where the care takes place and how they can establish networks of support.
Professional carers, such as doctors, nurses, social workers and early years workers should recognise the needs of the child and the whole family and aim to meet those needs in an honest, caring and supportive manner:
parents should be involved in every aspect of their child's illness and be encouraged to make decisions about the care their child will receive, for example how much they will be involved in practical care. Parents should never feel pressurised to undertake nursing tasks, such as changing dressings unless they feel comfortable about it;
information about the child's illness and care and treatment involved must be given in a way that is easy to understand, and professionals should operate on n "open door" policy which encourages parents to ask about any aspect of care they are unsure about;
care plans should be drawn up with the parents involvement and should take account of the physical, emotional and social needs of the whole family;
parents who are caring for a sick child at home may feel isolated, and may parents will experience emotional stress and tension in their marital relationships. Support groups can help enormously, by putting both parents in touch with others who are going through the same difficulties.
Diploma of Childcare and education Tassoni and Beith (2004) Oxford UK: Heineman Educational Publishers
Extracts as put together by Jo Bonnet!
Role of early years practioner meeting the needs of a diabetic child
Diet: The child should discuss their diet with a dietician. Sugar intake needs to be controlled. Child need a well balanced diet with regular meals to reduce the needs of hypoglycaemic attacks. Diabetic foods not particularly encouraged as they tend to be expensive, and high in fats and calories.
Physical activity: This is important for the child's general health. It is important to remember that physical activity lowers the blood glucose so the child should carry sugar to avoid hypos.
Treatment: Through diet and insulin. The child's parents may administer the insulin injections until the child is old enough to learn how to do it; this age varies.
Insulin is injected into the abdomen or thighs, but other sites may be used.
Children need an individual regime planned for them.
Insulin is usually given by insulin pen.
Parents' role: To learn about the condition/giving injections/controlling diet and measuring blood glucose levels.
Know what to do in a hypo.
Teach the child to give injections him'herself and how to measure blood glucose.
Make sure the child carries glucose
Regular visits to doctor
Inform school and friends about child and signs of hypoglycaemic attacks and how to treat.
Effect on child: Illness may require hospitalisation resulting in child missing school; this could lead them to fall behind and find it difficult to bond in friendship groups.
