Growing Up with Diabetes
Early Childhood: A Developmental Perspective
This page is one branch on the tree “Growing Up with Diabetes: a Developmental Perspective”. If you haven’t already, you can read the introduction here.
The following section describes the normal developmental patterns, goals for diabetes care, challenges to diabetes care, and suggested coping strategies for very young children (under 6 years old).
(See also Suggested Coping Strategies for Middle Childhood, and Suggested Coping Strategies for Adolescence.)
Stage: Early Childhood
Includes: Infants, Toddlers and Preschoolers
Ages: under 6 years old
Normal Developmental Patterns for Early Childhood
- Are extremely limited ability to communicate about or to deal with stressors.
- Have full dependence on caregivers to meet basic physical and emotional needs.
- The focus is on physical, motor and neurological growth.
- feel most secure and stable when routines are consistent; they expect and need predictability in daily activities.
- are beginning to learn how to control their own behaviour. It’s important for parents to set fair limits and boundaries (and stick to them).
- have difficulty controlling their own feelings and behaviour; temper tantrums are common.
- Social Referencing (looking to others for how to feel or react to something) is based on external factors, including:
- overt actions. (A parent jumping away from a spider tells a child to be afraid of the spider.)
- observable display of emotions. (Tears, or a panicked “Are you OK?” when a child falls conveys to him that they should feel frightened or sad.)
- strive for increasing independence: they want to do more things on their own.
- show increasing creative thinking, including imagination and pretending skills; they can think about things that are not actually present, activities that are not actually happening at that moment.
- possess evolving, but still basic emotional self-regulation skills; coping with stress involves basic physical and verbal responses, such as: running away or covering their ears/eyes to block out distressing input; using stock phrases to talk themselves through stressors. (A young child may repeat to himself phrases he has heard his parents use to comfort him, such as “It’s okay”, or “Mommy’s here”.)
- Play is central to learning.
- Self-concept is based on observable characteristics. (A little girl feels good about herself because she’s wearing a pretty dress.)
Goal for Diabetes Care for Early Childhood:
Balance between “ideal” blood glucose and a safe/practical target
Challenges to Diabetes Care for Early Childhood:
- Child is unable to detect or tell others when he is experiencing a low blood glucose.
- Difficult to discern if temper tantrums are due to low blood glucose or “just being 2 years old” (3…4…).
- Children (and parents) are often anxious about finger sticks and injections. Many small children will struggle and cry during these necessary tasks.
- It’s challenging to develop a flexible treatment plan that does not interfere with the child’s normal activity.
- Child may be picky when it comes to eating. An inconsistent appetite is common in young children (they may eats lots for lunch one day, very little the next). This makes it hard to plan insulin dosing for a given meal.
For Dealing with Lows:
- Know your child’s visible characteristic symptoms of a low (see Low Blood Glucose for more information) and tell other caregivers (relatives, babysitters, teachers, day care staff) what to look for.
- Do a blood glucose check to make sure that acting out behaviour is not due to a low. If a check is not possible and a low is suspected, remember: “If in doubt, treat”.
- When your preschooler is low, label that experience for him by telling him “You have low blood sugar”. Over time, this will help him learn to identify symptoms of lows when he feels them.
- If your child is more active than usual, give extra food to prevent low blood glucose.
(See also the Exercise articles on this website, starting with How Exercise Affects BG.)
- If your child is not with you, make sure his caregiver has a supply of rapid-acting carbohydrate to treat lows.
(Get some tips on what else to bring along: Low Kits.)
For Dealing with Anxiety Around Diabetes Care
- Adopt a “matter-of-fact” approach to diabetes-related routines. State that it is time for your injection or finger poke and get it over with quickly (even if that means having to hold your child down). Reassure him with a hug and kiss when you are done giving the injection.
- After the actual injection or finger poke, acknowledge your child’s feelings and provide reassurance. Be careful of providing too much reassurance right before the injection – this delay could lead to increasing anxiety.
- Use play as a way for your child to express his feelings. Even play that does not directly involve diabetes-related activities may help your child process feelings of anger, fear, or powerlessness.
- Let your toddler play with a pretend insulin pen or syringe (a toy syringe from a pretend doctor kit, another object (such as a crayon) representing a syringe, or a real syringe WITH THE NEEDLE REMOVED) – maybe he could pretend to give an injection to Mommy, Daddy, or his favourite teddy bear.
- Prepare the injection and blood glucose monitor out of sight.
- Give toddlers a short and simple reason why he needs the injection or finger prick (“So you don’t get sick”, or “To make your sweetness just right”). Be aware that explanations like “so you can eat” may lead a young child to reason incorrectly that if he refuses to eat, he can avoid the injection.
- Try to stay relaxed yourself – your child will pick up on your cues regarding how nervous he should be about injections or finger pricks. Because social referencing in very young children is based on external factors (as outlined above), it’s relatively effective for parents to “fake it ‘til you make it”. You can be terrified and anxious, as long as you don’t look terrified and anxious.
- Keep your preschooler busy/distracted by other things while you are giving the injection (looking at a book, labelling objects on a food box or around the room, wiggling his toes, watching TV, anything he likes to do). But avoid tricking him (it’s a fine line!) – this will only come back to bite you in the form of distrust.
Tips from the Trenches
We have found that distraction goes a long way! We used to get our pre-school-aged son to “show us how high you can count” when we were giving injections. But only sometimes, so he didn’t learn to associate that task with injections.
- Teach your child basic calming techniques: deep-breathing, counting, progressive muscle relaxation. Even young children can work on learning the basics of relaxation skills.
- Reward your child for holding still during injections. You could praise him, use token systems such as sticker charts, or provide primary reinforcement (a small toy or treat that your child enjoys). If you choose to do so, just make sure that the reward you use is actually motivating for your child. Be aware that rewarding your child for suppressing/denying emotions such as fear may send the wrong message: you want him to know that it’s okay to feel whatever he feels, but it’s not okay to struggle/hit someone/run away when he feels that way.
For Eating Issues
- Set routines of three meals and three snacks per day.
- Set limits on time allowed for meals and snacks (30 minutes for meals, 15 minutes for snacks).
- Accept that your child’s eating habits may vary from day to day; avoid power struggles over food.
- Be prepared to “top him up” with additional carbs if your child eats less than you expected when you dosed the insulin. Try to use the least-desirable sugar source when doing so, so that it is less rewarding for your child to refuse to eat. If timing allows, you could delay the delivery of the “top up” carbs until 10-15 minutes after he leaves the table, so that receiving juice, for example, is not directly related with a refusal to eat the main meal. This strategy assumes that you still have time within the insulin action time (fast-acting insulin peaks at about 1 hour) and that you don’t forget to give the missing carbs (which would likely result in low blood glucose). If you can’t count on this, then admit the limitations and give the “top up” at the table.
Tips from the Trenches
In our family, when my son was young we used milk to make up for any missed carbs; although he liked milk, he loved cookies, juice and chocolate even more, and we didn’t want him to benefit too much from “trading up”.
- Talk to your diabetes team about a more flexible insulin program if your child’s appetite varies a great deal.
- Share the responsibility with others (spouse, friends; grandparents, aunts, uncles of the child…).
- Allow your child to have some control over the routine by giving age-appropriate choices (ex. A toddler may choose between two fingers for a finger stick, or two injection sites for the insulin. Or maybe he could pick which blood glucose monitor you use, or where he sits when you do the check.)Be aware that offering too many options may lead to confusion or greater anxiety. While allowing for reasonable choices at a given age level, it is also important that parents guide those choices, taking “bigger issues” into account. For example, your child may want to choose his injection site, but if he is consistently choosing the same site, you will need to present a choice between two other sites, in order to prevent lipohypertrophy (a fatty lump).
- Involve your child in diabetes-related task as age-appropriate. For example, consider letting him help with things like setting up the blood glucose monitor, pressing the button, mixing the cloudy insulin, and dipping the ketone strip.
(See Diabetes Self-Care: What Does My Child Need to Know? for an outline of possible tasks for your child to be involved in.)
The Alberta Children’s Hospital has some great resources for kids in this age group: “Tips for Toddlers with Diabetes” and “Pointers for Preschoolers with Diabetes”
As with any challenges, if your family is facing serious obstacles to good mental health and social functioning, please contact a professional who can help you sort it all out. Many pediatric diabetes teams include a psychologist and/or social worker, so contacting your child’s diabetes health care team is a good place to start. Also, you could arrange a consultation with a mental health professional that you seek out on your own – you could check the registry for licensed psychologists or social workers in your province, or reach out to a diabetes expert who is also trained in your family’s area of need (teenagers, behaviour change, eating disorders, anxiety, etcetera).
This article was compiled from the following sources:
- Presentation by Dr. Carol Huang (Assistant Professor, U of C Dept of Pediatrics) at JDRF Outreach Event, March 19, 2011
- Parenting workshop by Michael Watts (Medical Social Worker) at the Alberta Children’s Hospital, March 26, 2011
- Presentation by Joe Solowiejczyk (Diabetes Nurse Educator and Family Therapist) at the Alberta Children’s Hospital, February 10, 2011
- Alberta Children’s Hospital Handouts “Tips for Toddlers with Diabetes” and “Pointers for Preschoolers with Diabetes”
- Presentation by Dr. Tracy Vaillancourt (Associate Professor, Educational Psychology) for the Alberta Centre for Child, Family & Community Well-Being, November 3, 2008
The above information was reviewed for content accuracy by clinical staff of the Alberta Children’s Hospital Diabetes Clinic.