Keywords

FormalPara Key Points

  • Children with diabetes have essentially the same nutritional requirements as other children

  • Nutritional recommendations should include healthy eating practices for the whole family, taking into account its culture, habits and customs

  • Frequent dietetic review should take place to take account of changes in dietary requirements and habits with age

  • Nutritional management should be tailored to the child’s insulin regimen and should include specific advice to cover exercise and intercurrent illness

Introduction

Diabetes mellitus is the most common metabolic disease of childhood and is characterised by a defect in the secretion or action of insulin. Deficiency of insulin at tissue level results in abnormalities in the metabolism of carbohydrate, protein and lipid. Diabetes is diagnosed on the basis of blood glucose criteria and the presence or absence of typical symptoms such as polyuria, polydipsia, and weight loss [1] (Table 16.1). In the absence of symptoms more than one blood glucose result is required in order to make a diagnosis.

Table 16.1 Criteria for the diagnosis of diabetes mellitus
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Classification of Diabetes

Diabetes mellitus is not a single entity and can be classified according to aetiology [2] (Table 16.2). This classification has important implications with respect to subsequent management of the condition.

Table 16.2 Classification of diabetes mellitus in childhood
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Type 1 is the most common form of diabetes in childhood. Onset is typically acute with characteristic diabetic symptoms and if untreated may progress to ketoacidosis, coma and death; treatment is with insulin. The incidence of Type 1 is increasing; the EURODIAB study showed a 3.2% annual increase for 1989–1998 and a 3.9% increase for 1989–2003, with the highest increase in incidence in children under five years of age [3]. However, at present only about 4% of children with Type 1 diabetes are under 2 years of age. Neonatal diabetes is very rare with an incidence of about 1 in 400,000. Many cases are transient and associated with parental disomy and imprinting defects of chromosome 6 [4].

Type 2 diabetes occurs where there is insufficient insulin secretion to meet increased requirements secondary to insulin resistance. It is often seen in association with other aspects of insulin resistance such as obesity, dyslipidaemia, hypertension, acanthosis nigricans and non-alcoholic fatty liver disease. Whilst it is being recognised with increasing frequency in childhood and adolescence [5], it is rare before the second decade of life. The major nutritional consideration is correction or limitation of obesity. It is important to differentiate type 2 which often does not require insulin treatment and MODY, a group of monogenetic forms of diabetes from Type 1. MODY2, caused by defects in glucokinase is the form most likely to affect younger children. It causes a mildly raised blood glucose concentration, typically 5.5–8.5 mmol/L. In this condition the glucose is regulated at a higher “set point” which tends not to be associated with complications hence these children do not require treatment.

Aims of Nutritional Management

The aims of nutritional management of diabetes are presented in Table 16.3.

Table 16.3 Aims of nutritional management of diabetes
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Initial dietary advice should be provided to young children and their careers as soon as is practicable after diagnosis, by a dietician with specific training in paediatric diabetes. At this consultation simple advice should be given within the context of the family’s specific eating habits and customs. The child’s usual food intake, specific likes and dislikes and meal times should be discussed, together with relevant weekly activities, for example attendance at nursery or swimming lessons. A further appointment should be arranged for more detailed discussion, with follow-up as necessary in order to deal with changes in the child’s growth and eating and exercise patterns and any specific dietary issues that may arise.

Guidelines on Energy Balance and Individual Food Components

There is relatively little research looking specifically at nutritional requirements in children with diabetes and current guidance is largely consensus based [6, 7] using principles drawn from knowledge of general dietary requirements [8] and nutritional management of adults with diabetes [9, 10]. This means that any dietary recommendations are suitable for the whole family who should ideally all be involved in making improvements to their diet based on healthy eating principles. Energy intake recommendations are given in Table 16.4. Five portions of fruit or vegetables a day are also recommended [11].

Table 16.4 Energy intake recommendations in diabetes mellitus in infants and children
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Carbohydrate

Carbohydrate should form 50–55% of daily energy intake. The glycaemic index is a ranking of foods based on their acute glycaemic index compared to glucose. Carbohydrates with a low glycaemic index, such as wholegrain breads, pasta and low fat dairy products, cause a more gradual, less pronounced rise in blood glucose than those with a high glycaemic index and are preferred dietary sources. In children denial of sucrose containing foods can be difficult and they can be used in the diet in moderation, although sucrose-sweetened drinks have been noted to cause hyperglycaemia and have been associated with weight gain so are best avoided.

For children above the age of one year a daily dietary fibre content of 2.4–3.4 g/mJ is recommended. A more practical approach is that the fibre requirement (g/day), for children over 2 years is age in years +5.

Fat

Fat should be limited to 30–35% of energy intake in older children, although infants and children up to 2 years may derive 40% of their energy intake from fat. Saturated fat, found in fatty meats, full fat dairy products and high fat snack food should be reduced with a relative increase in polyunsaturated and monounsaturated fat. Note that the use of reduced fat milk is not recommended for children under 2 years of age as it is lower both in energy and fat soluble vitamin content than whole milk. Sources of polyunsaturated fat include sunflower oil and oily fish. Ten to twenty percent of energy should be derived from monounsaturated fat, for example in olive and sesame oil, nuts and peanut butter.

Protein

Protein requirements fall during childhood, being highest in infancy. During childhood years protein should comprise 10–15% of total energy intake. Suitable sources include legumes, fish, lean meat and low fat dairy products.

Trace Elements

Recommendations for vitamin and mineral consumption in infants and children with diabetes do not differ from those of other children [8].

Salt

Salt intake is associated with hypertension and limitation of intake to less than 6 g/day is advised in all adults, particularly those with diabetes. Recommended maximum salt intakes for children are lower being <1 g/day until 1 year, <2g/day from 1 to 2 years and <3g/day from 4 to 6 years of age [12]. Dietary advice should be given regarding choice of low salt products and not adding salt to meals.

“Diabetic” Foods

The use of proprietary “diabetic” foods is discouraged. It should be possible to eat normally and healthy without recourse to such items which tend to be high in fat and sweet tasting, thus encouraging unhealthy eating habits.

Artificial Sweeteners

These are sometimes classified as nutritive and non-nutritive. Nutritive sweeteners, such as fructose and the sugar alcohols sorbitol and xylitol, are only partially absorbed and excessive use will cause diarrhoea. Non-nutritive sweeteners include aspartame, saccharin and acesulfame K. Their consumption in products such as diet drinks and low fat dairy products does not affect glycaemic control and is ­acceptable in moderation.

Nutrition Advice for Different Insulin Regimens and Specific Circumstances

In Western nations about 90% of childhood diabetes is Type 1. Acquired forms of diabetes are less likely to occur in infants and young children than in older children and adolescents. Immediately after diagnosis with Type 1, children may experience a “honeymoon period” during which insulin requirements are low and it is relatively easy to maintain good glycaemic control. After this, as insulin requirements increase, more intensive regimens may be required to achieve the same degree of glycaemic control. The twice daily injections using a combination of short/rapid and intermediate acting insulin before breakfast and the evening meal can be used in young children. Three meals and three snacks are recommended to ensure optimal glycaemic control and daily carbohydrate consumption should be reasonably consistent. Treatment of hypoglycaemia should be with short acting carbohydrate followed by a longer acting form. Older children may achieve better control using three injections—a mixture of short/rapid and intermediate before breakfast, short/rapid before the evening meal and intermediate acting in the evening. More intensive diabetes management may be achieved using multiple daily injections with a basal dose of long-acting insulin and rapid acting insulin before meals although tends to be used more in teenagers whose daily routine is more variable than that of younger children. It allows greater flexibility in meal timing and quantities although requires an ability to adjust insulin dose according to the carbohydrate content of the meal. Snacks between meals are not a necessity and only short acting carbohydrate is required to treat hypoglycaemia. An alternative to this is continuous subcutaneous infusion (insulin pump therapy) in which a continuous subcutaneous infusion of basal insulin is given with bolus doses to match carbohydrate eaten. Insulin pumps have been used successfully, even in very small children and babies.

Exercise

Children with diabetes should be encouraged to participate in regular exercise to promote cardiovascular health and aid achievement or maintenance of an optimal body weight. Many older children with diabetes engage in physical training and competitive sports. For younger children exercise is often part of their normal daily activity and can be managed accordingly. Addition, anticipated regular exercise such as weekly football practice may be able to be accommodated by a change in meal plan and reduction in insulin dose on that day. Unplanned exercise should be managed by use of short-acting carbohydrate, careful monitoring of blood glucose and subsequent reduction of long-acting insulin if necessary to prevent delayed hypoglycaemia.

Illness

Young children are prone to frequent intercurrent illnesses. These can make diabetes hard to manage, particularly if accompanied by nausea or vomiting. Specific advice to parents includes continued administration of insulin, monitoring of blood glucose and testing for the presence of ketones. Dietary management involves provision of regular carbohydrate, if necessary as small frequent snacks rather than larger meals.

Age-Specific Advice

Infants

Exclusive breastfeeding is recommended, with weaning in line with general recommendations for infants [13]. Infants whose mothers have chosen not to breast feed should be given an appropriate formula milk. Regular feeding, for example every 3–4 h will help maintain euglycaemia. The diagnosis of diabetes in very young children poses particular management problems and great concerns for parents and carers. Infants do not exhibit classical catecholamine responses to hypoglycaemia not are they able to easily communicate any sensations associated with hypoglycaemia that they do experience. Hypoglycaemia is therefore particularly feared in this age group. In addition, as the brain of young children is still developing the adverse risk of hypoglycaemia is potentially greater than in older children. Some consider less strict glycaemic control is appropriate in this age group and in pre-school children [14]. However, there is some evidence that hyperglycaemia may impair cognitive performance [15], reinforcing the need for good glycaemic control.

Toddlers

In toddlers dietary management may be problematic as tantrums, “pickiness” and food refusal are common. As relaxed an approach to mealtimes as is possible should be adopted so that negative food-related behaviours are not reinforced. Carbohydrate should be substituted for any food refused but not in the form of snack food.

Young Children

Young children can begin to participate in aspects of their own diabetes care such as helping with aspects of blood glucose testing and can begin to understand their dietary needs. At this age they begin to spend time away from their own home at nursery, school and with friends. All those involved in the care of a child with diabetes will need to be educated about the condition and its treatment and dietary management.

The major role of nutritional management in diabetes in infants and young children is in the treatment of those who have type 1 diabetes and are insulin dependent. The fundamental principles of nutrition do not differ from those of other children, although there is less flexibility with respect to timing of meals and dietary carbohydrate content. In younger children food intake tends to be erratic at times due to behavioural issues and intercurrent illness and hypoglycaemia is harder to recognise making management more difficult.