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Diabetes in Our Littles

This isn't the first time I've written about diabetes, nor I am sure, will it be my last. Diabetes has become a true epidemic, alongside obesity. Here's a shocking statistic for you though: for every two adults diagnosed with Type 2 Diabetes, a child is being diagnosed. What's even more surprising, or maybe more frustrating to me, is that many of the chronic diseases I am now diagnosing in children are going missed by their previous practitioners because we assume these are adult issues, so unless little ones complain, we trust they will mature uneventfully. As well, the necessary labs aren't being drawn because well, insurance won't pay for them. When asked though, parents happily assume the costs of a few additional labs for $20 to $30 to get a better picture of their child's health, but again, we don't mark up our labs thousands of dollars which is standard, so maybe physicians simply don't have this privilege in their practice. It's a broken system and I am glad to have the autonomy of private practice.


Know though, that children with diabetes often present without any symptoms whatsoever, or the symptoms they do have are not associated with blood sugar regulation. It can be a challenge as well, once diagnosed, to determine if the child is suffering with Type 1 Diabetes which is an autoimmune disease from Type 2 Diabetes which is more about insulin resistance and impaired insulin secretion. A quarter of those with Type 1 Diabetes are obese, which use to cause us to assume this was Type 2 Diabetes, but even more interesting to my nursing-friends, another quarter of children who present with ketoacidosis have Type 2 Diabetes. As I said, accurate diagnosis can be a challenge.



Accurate diagnosis is dependent on clinical expertise as there aren't clear recommendations for diagnostic testing in children. The American Diabetes Association recommends screening for Type 2 Diabetes in all children who are obese, ten years-or-older, and have two additional risk factors. Diagnostic criteria is a fasting blood glucose of 126 mg/dL or higher, a two-hour plasma glucose level of at least 200mg per dL during an oral glucose tolerance test, an A1C level of 6.5 percent or greater, or a random plasma glucose level of at least 200mg/dL plus symptoms of polyuria, polydipsia, r unintentional weight loss.


Management of Type 2 Diabetes is Multi-Faceted


Education is key here. Assuming the A1C level is less than 9 percent, the first steps should be lifestyle modifications. Nurse practitioners are the experts in healthcare education and counseling. Advocating and building relationships with our clients is where we shine as practitioners. This is especially true in the management of Type 2 Diabetes with children, as optimal care often includes a team of subspecialists.


Nutritional counseling is paramount. Our practice use to refer to the diabetes center but they were often taught to switch from Coke to Diet Coke and this just didn't resonate with our clients. As I often share, I am a huge advocate of the MRT & LEAP therapy so this is typically where we go first. However, one needs to also become self-aware, a bit more embodied, in effort to identify their tendency towards emotional eating or stress exposure. Maybe they feel busy and even overwhelmed, but this is all in logic and not in physical movement? Exercise should be very individualized as well. This is as unique to a person as the foods they eat, so a wellness-minded clinician is important here. Sleep is also vital, and sleep on a schedule with the moon.


Lifestyle changes are most successful when the child's entire family is involved so making a doable plan, one that can truly be implemented is important to success. Medications sometimes are necessary, but more often, we can successfully implement nutraceuticals where appropriate. Labs should be reevaluated every three months with conventional medicine holding a goal of the A1C being 7 percent or less, but higher, then further interventions are recommended. This might be increasing visit frequency, initiating blood sugar monitoring at home, implementing pharmaceuticals, or further evaluation and modification of diet and exercise.


Of course diabetes invites a plethora of other issues, such as elevated lipids, elevated blood pressure, #thyroid chaos, declining eye health, and sleep apnea, so ongoing assessment of overall health is also important. Another discussion about #vaccinations should also be had at this point. Throughout though a mutually trusting important relationship is important.


References

Xu, H., & Verre, M. C. (2018). Type 2 diabetes mellitus in children. American Family Physician, 98(9), 590-594.

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