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Volume 68 May 1975

Section of General Practice President N C Mond FRCGP

Meeting 16 October 1974

Valedictory Address Diabetes in Children by Stuart Cane FRCGP (Grove Health Centre, Goldhawk Road, London W12) For the past ten years 1 have been the visiting medical officer at Palingswick House Hostel for Diabetic Children. At any one time we have in the hostel from 25 to 45 diabetic children of both sexes, from all parts of the country. The children are resident in term time but go home for school holidays. One or two are in the care of their local authority because they have no home. Whilst at Palingswick House they go to ordinary schools in the vicinity, depending on their age and educational abilities. This paper is based mainly on my experience with these diabetic children. In a child who has diabetes, all too frequently the first presentation is coma. In other children brought to the doctor a little earlier, the story is of lassitude, thirst, polyuria and weight loss. Any one of these symptoms in a child is sufficient to warrant dipping a Clinistix into a sample of urine; in 50 seconds one has the answer. Few diabetic children have difficulty in providing a specimen on the spot and such is the emergency that it would not be safe to allow the child to leave the consulting room without first testing the urine. Nocturnal enuresis is said to be a diagnostic feature. Certainly it is my experience that many diabetic children are bed-wetters, but I have not myself seen the records of a case in which investigation of the urine in an otherwise asymptomatic bed-wetter revealed, for the first time, the presence of glycosuria. In a child with confirmed glycosuria, the only alternative diagnosis which needs to be considered is a low renal threshold to glucose. Such a child is, of course, asymptomatic but if there

is any doubt, a random blood sugar will clinch the issue. In my opinion, any child in whom glycosuria has been detected for the first time should be admitted as an emergency to a pediatric unit if he has any symptoms at all, such as thirst, polyuria, lassitude or weight loss. The presence of acetone in the urine Ketostix will give the answer in 15 seconds-will confirm the gravity of the immediate situation but even if there is no acetone present, it would be unwise to delay a fuller assessment. The role of inheritance in the etiology of diabetes is by no means clear, but certainly the incidence of diabetes in children is greater in those families with a history of the disease. Once the child is in hospital he will need to be stabilized and if there is any delay in getting him there there is no harm in injecting 40/60 units of insulin. I will not be discussing the care of the diabetic child while in hospital, but the management of the case once he is discharged. There is a wide range of insulins available, each with its advantages and proponents as well as its disadvantages. The quantity of insulin supplement must be such as to balance the quantity of food eaten and the activity undertaken by the patient. Children, however, burn up enormous quantities of energy in play, and their play cannot be predicted in time. Furthermore, a child has particular nutritional demands required for growth. The control of a diabetic is most easily based on estimations of the amount of glucose in the urine, and for this Clinitest is very satisfactory. In practice it is found that providing the carbohydrate consumption is controlled, there is no need to worry about the amount of protein and fats eaten. Charts are available from the British Diabetic Association, which give the carbohydrate equivalent of almost every food available in this country, including sweets. -

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Sweets are, of course, a problem. Practically every child likes to eat sweets and being deprived of them is one of the major burdens borne by diabetic children. As in everything else, compromise is essential. There are available diabetic sweets and chocolates in which the sucrose is replaced by sorbitol. In limited amounts, one or two pieces of diabetic chocolate or three or four of these sweets may be eaten as a treat without worrying about their effect on the diet. Ordinary sucrose sweets can be eaten provided their carbohydrate content replaces an equal portion of another food at the appropriate meal. Who should be in charge of the child's diet? There can only be one satisfactory answer: the child himself. It is therefore essential that every diabetic child understands fully why he or she is on the diet, and what factors have to be assessed in regulating it. He will thus learn to appreciate that he is being trusted. The parents - both parents - must also fully understand the situation so that they can cooperate. In the final analysis it must be the child himself who will choose what be eats at many meals. A plan is prepared showing how many carbohydrate portions he may have at each meal and within that range he is free to exchange: 2 tablespoons of baked beans in exchange for half a slice of bread: 2 plain biscuits instead of 1 sweet one. If the child says he is still hungry with his allocated portions, providing he is not overweight he is allowed more carbohydrate, and his urine checked to see what adjustments, if any, are needed to his insulin. It is important to stress that the balance of portions between the different meals cannot be varied ad lib because this, obviously, necessitates an adjustment in the timing and dosage of the

have twice that number of plain biscuits instead. For their mid-day meal they will probably include 6 oz (170 g) of potatoes, which is 3 portions (that is 3 potatoes, each about the size of an egg) and another 2 portions of carbohydrate in the pudding. The older children over the age of 11 stay for school lunch and are as much in control of what they eat there as every other child at the school cafeteria. They have their second insulin injection when they get back from school at 4.30 p.m. Most children need some isophane insulin in addition to their soluble insulin at this time, to avoid a heavy glycosuria in the first urine tested in the morning. At their high tea bread, jam, cakes, pies, sweets and potatoes - in any permutation or combination - total 4 to 6 portions. Supper at 7.0 p.m. is a light meal, with another 3 to 4 portions, plus a cup ofmilk. The urine is tested thrice daily. It is on these tests, which the children do themselves under supervision, that subsequent insulin adjustments are made. Once a term the Inner London Education Authority arranges a blood glucose analysis for each child. The results are quite horrific! We have learned to accept that a random blood glucose of a diabetic child is likely to be quite high without there being any apparent harmful effect. Urine glucose testing, besides being infinitely more convenient, is more useful in regulating the diet and insulin of a diabetic child. Once the initial diagnosis has been made, for which a blood glucose estimation is essential, subsequent estimates are only of value in recognizing hypoglycaemia or in the control of ketoacidotic coma. The earlier a diabetic child learns to give his own injections, the better it will be for all concerned, not least the child himself. Even 5 to 6 year old children are capable of learning how to do it, though from time to time they will revert to 'Sister, you do it for me this time'. This temporary regression must be accepted for what it is - a reassurance to the child that help will still be forthcoming if anything goes wrong. Education of the diabetic child is probably the most important feature in the management of a case. Not only must the child learn to give his own injections and understand his own dietary requirements, including 'extras', he must also understand what is likely to go wrong and what action to take if it does. The parents must also both be involved in this process of learning about the disease. It is never too early to start. This task of educating the family is not easy: a lot will depend upon the maturity of the parents, and the degree of maturity is related neither to age nor income. Failure to cooperate in the diet can easily upset the diabetic balance.

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insulin injections. In addition to their normal diet, the children are taught that it is essential to take extra carbohydrate before they exercise. These extras are in the form of a Dextrasol tablet or a slice of bread and butter. Let me give you some idea of an average day. The morning injection is usually plain soluble insulin given about 15 minutes before breakfast. Some children are found to have a heavy glycosuria practically every day when they come home from school, and for them isophane insulin is also given in the morning, together with the soluble, mixed in the syringe. For breakfast they will have about 4/6 carbohydrate portions, such as will be available from a bowl of cereal, a cup of milk, and 1 to 3 slices of bread. Mid-morning at school the younger children have their onethird pint of milk, plus two biscuits. The older children who are not eligible for milk take the equivalent, an extra sweet biscuit, or they may

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In many respects hypoglycLemia is far more managed diabetic child the warning signs of important to the diabetic than hyperglyc;emia, impending coma should be easily recognized if because it occurs more frequently and because the child tests his urine thrice daily. Besides its onset can be relatively rapid. It occurs when finding that his urine contains more than 2% the blood glucose level drops below about glucose, the test for acetones will be positive. 50 mg/100 ml, though this varies with the rapidity This requires an immediate adjustment of his at which the rate drops. The child will get a insulin and/or diet, which means that unless he or warning that an attack is coming on, and each his parents are fully conversant with the managechild must be allowed to have 1 or 2 attacks so ment of the disease, advice must be sought from that he can learn his own symptomatology. his family doctor or the diabetic clinic without Parents should be allowed to observe the event delay. The only factor likely to disturb the balance in so that they can learn how to help. It must be remembered that a urine test at the time cannot an otherwise stable diabetic child, is an interbe relied upon, as it may reflect the much higher current infection. Infection increases the insulin blood glucose of an hour or two previously. A requirement. Management is complicated by the second urine sample will be reliable if one can fact that the child may have no appetite and may even be vomiting. This may tempt the parents to get one. The treatment is the administration of carbo- reduce or even stop the insulin but they must be hydrate in any form, glucose being the easiest warned against this. The insulin dose must be way to do this. If the child recognizes an attack increased: 2-4 extra units of soluble insulin is coming on, he can take 1 or 2 Dextrasol tablets. should be given if the child is pyrexial, and the Every diabetic should carry an emergency supply urine tested more frequently. Initially every all the time. If he is too far gone to do this, his sample should be tested for glucose and ketones, parents should encourage him to drink a and subsequently specimens should be tested at sweetened liquid: sugar will do if glucose is not least four times a day until the child is again stabilized. immediately to hand. If the child cannot or does not want to eat If the child is unconscious and unable to cooperate by drinking his glucose, an intra- solid food, he must be persuaded to drink sweet muscular injection of glucagon will usually liquids, replacing the missing carbohydrate mobilize enough glucose from the body's stores portions at each meal with glucose (1 heaped to elevate the blood level sufficiently to rouse the teaspoon equals 1 portion). Even if the child is child in about 10 minutes, so that he can then vomiting, insulin is essential and whatever insulin the child is normally having, the extra is be fed his glucose orally. You will note that I have omitted reference to best given as soluble insulin. Almost all of the children at Palingswick House the casualty officer's standby for these occasions intravenous glucose. Besides being more difficult are there because they are disturbed. There is no to inject, and carrying the risk of thrombosing reason whatsoever why a diabetic child who the vein, it offers no advantages. I have only understands his illness, and comes from an known one of our children need intravenous understanding and stable family, should not live glucose in the ten years I have been at Palingswick at home and go to a normal school. But it is not easy being a diabetic child. Diabetes is different House. An epileptic attack can be very frightening and to other chronic handicaps, in that the child has to practice self-restraint. He has to watch his can occur in some children when they are hypoglycamic. Diabetic children are only a little more food intake all the time and things like sweets, likely to have an epileptic attack than non- which other children are allowed to eat, have to diabetic children, and every diabetic child who be fitted into the diet. As if this was not enough, suffers from fits should have his diet and insulin they have to have an injection once or twice a checked carefully to see if the attacks are being day. They fear the future: what is to become of brought on by hypoglycemia. If the attacks are nocturnal they may be difficult to recognize and them when they grow up? When they are old it may be necessary to do repeated blood sugar enough they ask themselves: 'Will I be able to estimations throughout several nights to see if have children and will they be diabetic like me?' the glucose drops too low. Adjustment of the They want to know why they were singled out insulin and diet may then solve the problem. for such a punishment - though they rarely There is, of course, the possibility of a child being express this thought overtly. They have guilt both diabetic and epileptic, but in these children feelings towards their parents which are difficult the characteristic EEG changes should be present. to control, and many parents of diabetic children Diabetic coma with keto-acidosis is, of course, feel equally guilty about their children: 'What did I do that harmed my child?' more serious when it does occur but in a well-

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Proc. roy. Soc. Med. Volume 68 May 1975

Table 1 The number of children in England, Scotland, Wales and Northern Ireland notified to the British Diabetic Association in 1973 as suffering from diabetes by age of diagnosis. (Figures supplied by the Pediatric Research Group of the BDA) Age at diagnosis I 2 3 4 5 6 7 8 9 10 11 12 13 14

No. of No. of males f.emales 9 11 19 20 25 22 33 20 36 43 27 28 37 38 39 33 49 53 55 35 58 58 67 58 58 59 23 33

Total 20

39 47 53

18 From the figures supplied by the BDA I have made a calculation which gives a prevalence rate of diabetic children aged 0 to 4 years in the UK of 0.13 per 1000 (Table 1). This figure is consistent with the reported incidence of only one case of diabetes in the 21 600 children under the age of 5 in the RCGP 1970 national morbidity survey. Similarly, the prevalence rate among the age group 5 to 14 is 0.85 per 1000.

79 55 75 72 102 90 116 125 117 56

What does this mean in practice? If my arithmetic is correct, it means that the average general practitioner - the fellow I have already mentioned with 2500 patients. whose ages correspond to the national average - will have about one chance in 100 of having a diabetic child under the age of 5 on his list, and about one chance in 11 of having a child aged 5 to 14. Assuming 40 years In an attempt to overcome the feeling of guilt in general practice before retirement, one general and frustration, the diabetic child may start to practitioner in 14 will have an under 5 diabetic challenge society. Stealing is common; shop- on his list at some time in his career and about lifting sweets ('If I don't pay for it it doesn't 5 general practitioners out of 6 will have a 5 to count as a portion' a child once told me) leads to 14 year old. However, as many patients change bigger and better loot. Frequently the result is doctors because they move home at some time excessive hospitalization because faulty eating during their life, the chances will be somewhat habits lead to hypoglycemia, which the unstable greater and most general practitioners will see child is unable to recognize and the immature 1 or 2 diabetic children before they hang up their parents unable to treat. This leads to the loss of stethoscopes. a great deal of schooling and this brings most of What advice have I to offer the general practithe children to Palingswick House. Once there, in the company of other diabetic children and in tioner who has a diabetic child in his practice? the care of a stable knowledgeable staff, their Firstly, get to know the child and his parents. school attendance record is at least as good as Find out about his diet and what insulin he is having. I do not think it does any harm to let ordinary children. them tell you what they are doing and how they When I first went to Palingswick House we manage the various complications: they probably had anything up to 10 bed-wetters at one time know more about the disease than most doctors! but since I began several years ago treating them all with tricyclics, we have forgotten what stale urine smells like at the hostel. Of the other complications of diabetes, the only which we have so far met are nephritis and retinopathy.

ones

What is the likelihood of that mythical fellow, general practitioner with an NHS list of 2500 patients having a diabetic child on his list? Strange as it may seem, there are no complete statistics for the prevalence of diabetes in children. The British Diabetic Association has recently begun to keep a register. I have also been provided with data by the Records and Statistical Unit of the Royal College of General Practitioners in Birmingham. an average

Let the child tell you about his portions and see that he knows about 'extras'. If the parents are not already in touch with the British Diabetic Association, give them the address. Find out if the child goes to a diabetic holiday camp where he can meet other diabetic children. If there are enough diabetic children in the area, it might be an idea to suggest to the Area Nursing Officer that one of her Health Visitors takes on the responsibility for all the diabetic children.

If the child is missing a lot of school, discuss with the school health authority the possibility of his going to Palingswick House or one of the other diabetic hostels. It may only be necessary for the child to stay a year, or even less, to learn how to look after his own illness.

Diabetes in children.

15 277 Volume 68 May 1975 Section of General Practice President N C Mond FRCGP Meeting 16 October 1974 Valedictory Address Diabetes in Children b...
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