Children 2 to 4 years

There are a number of behaviours and stages that any child goes through regardless of whether or not they have diabetes. It is important as a parent to understand these behaviours as well as how they may impact on your child’s diabetes.

Your child wants to be in control, wants to “do”, to be in charge and they start to achieve tasks. They learn by repetition, gradually becoming more competent.

Their imagination grows and daydreams, the use of magic and pretend-play are common in their day-to-day life.

They may have an imaginary ‘friend’ who is very real to them and with whom they have long conversations! Language skills start developing and vocabulary grows.

Your child is curious about the world and may constantly ask “Why? Why?”

They start to develop a range of gestures to express themselves. Your child will be very intuitive and will seem to be able to ‘read’ you like a book.

This is the age when they start testing the waters, so they may throw (and recover from) tantrums frequently and easily.

At this age children tend to think in ‘black and white’, right or wrong, good or bad. As their parent or carer, you are the main attachment in their lives. They are still quite self-centred, happily playing with a toy alone, then gradually learning to share toys.

If a brother or sister join the family they will have to gradually learn to share the love of their parents.

It is difficult for your child to understand what has happened and that an injection helps them to stay healthy. They may see the injections as a punishment. You may be able to simply explain to your child that diabetes just happened – “Johnny got asthma, it’s nobody’s fault, you didn’t catch it”.

Your toddler is developing a will of their own so they may resist finger pricks and injections. Again you may explain – “Injections are medicine, so you don’t have to go back to hospital”.

Painful procedures are frightening to toddlers and pre-schoolers so these should be performed quickly and treated as routine. Prolonging the agony only makes things worse for you and your child.

Your child may gradually be taught about hypo symptoms. From about four years old, you can draw their attention to the way they are feeling during a hypo, so that they begin to recognise their symptoms and ask for help.

You may gradually encourage your child to learn about food choices… but they will not have developed a concept of time at this age so they will not be able to connect times with insulin and food.

Make sure you give lots of hugs and kisses after any diabetes related procedure.

From 18 months onwards, play becomes an important coping mechanism and games such as allowing your child to give pretend injections to a doll or soft toy (break the needle off to avoid accidents), gives your toddler a chance to take part in their diabetes routine. It can help lay some groundwork for their involvement in diabetes-related tasks.

As your child approaches four or five years and asks “Why?” try to make your answer concise and encourage small tasks, one at a time, to fit in with your answers. For example, they may choose which finger to be pricked or a site for their injection. (If you do this remember not to give in to the same spot being used all the time).

At times when you’re tired and overwhelmed with it all, remember that your child will eventually become independent. However, they need your help along the way.

You need time out whenever possible. If you have relatives or friends close by, they may be persuaded to attend education sessions to become comfortable with diabetes and to look after your child, if only for a short time.

You will probably be very reluctant to let your child out of your sight, but preschool is an opportunity for your child to spread their wings and learn independence (and give you a chance to spread yours).

To take this huge step you must feel comfortable that your child will be safe as well as happy.

Provide your preschool with options for education on diabetes.  This might include a school visit from your local diabetes educator or Diabetes NSW.  If this is not an option you can encourage your preschool to watch the school visit podcast available through Diabetes NSW.

It is essential that you provide one or two hypo kits for staff to store in prominent places. Remember to restock hypo kits regularly.

A photograph of your child placed in the staff room and details of hypo symptoms is advisable. An emergency action poster for hypos next to the photo as a reminder is also a good idea.

Your child should wear some type of diabetes identification chain or bracelet. This habit is a good one to start at a young age as it may encourage them to maintain that habit as they get older.

Pre-school staff may be willing to assist with diabetes related tasks e.g. finger pricks, injections, and insulin pump boluses; however, it is not mandatory for them to do so. Discuss this with the director of the preschool.

If you don’t have access to an educator, some points you may like to raise with your child’s teacher include:

• If the teacher is unsure if it’s a hypo, they are better off treating it as a hypo.
• The teacher or carer should not be afraid to re-treat the hypo if your child is not feeling better. A child should not be sent alone to get treatment.
• The teacher should stay with your child until fully recovered.

The school pack, available from Diabetes NSW, is a useful resource to give to your child’s pre-school. This resource is currently being reviewed and updated - Keep a look out on the Diabetes NSW website for updates.

What does any child do with food at this age?

After the age of two, low-fat dairy foods can slowly be introduced into your child’s diet. Before this age, it is difficult for children to consume adequate amounts of energy for their requirements and regular full-cream dairy products are needed.

Some high saturated fat foods that should be limited include:

• Processed meats (such as devon and salami)
• Sausages
• Fried foods (such as battered fish and chips)
• High fat snack foods like crisps, corn chips
• Cream and chocolate-coated biscuits
• Pastries
• Chicken skin and visible fat on meat

In addition, more fibre rich foods can also be encouraged, such as wholemeal breads and crackers and high fibre cereals.

Being a toddler means learning to be an independent person in their own right. It also means learning the boundaries of this independence. Eating food... how much, what, when and where is a way in which a child at this stage explores the boundaries of behaviours and rules.

A toddler (like many adults) will choose foods because they like them, not because the foods are healthy. Toddlers also learn very quickly that refusing one food will mean they will get their favourite, so try not to fall into the trap of providing less nutritious alternatives.

Much of the stress of food refusal can be eased if you keep calm. Keep food preparation simple, so if it does end up on the floor or on the wall, you don’t feel you have wasted time.

The love/hate relationship with food that often occurs with toddlers is quite normal. Likes and dislikes of food can change on a daily basis. There is no logic in their actions, so don’t be tempted to bribe. Meeting demands for a favourite cup or plate is reasonable, but preparing special, separate meals is not.

If the same food is eaten for three days in a row there is no reason to be concerned as you’ll notice that over the next week or two, the range will broaden.

HAS A FUSSY APPETITE 

At this age it is very common for appetite to vary from day to day and meal to meal. Snacks are important; refer to the list on the previous page for great snack ideas.

Drinking too much milk or juice can contribute to poor appetite. Anaemia and tooth decay can result if fluids are chosen in place of food, particularly from a bottle. To prevent this, it’s very important to wean toddlers from a bottle to a cup. This helps decrease the amount of fluid taken and leaves more room for solids. As a guide, toddlers only need 500mL milk each day.  Try not to provide juice as a drink (except in the case of hypo treatment).  Encourage water as the best choice of drink. It’s also a good idea to avoid giving drinks just before a meal or snack as this can reduce appetite.

TIPS

If you’re worried that your child doesn’t seem to be eating anything, try writing down all the food and drinks taken over the day – you might be surprised. Young children can nibble away at food over the day and take in quite a reasonable amount. It’s important that snacks are nutritious.

Sometimes the variety may be limited to two or three choices such as cheese sandwiches and bananas, but if the foods are nutritious there’s no need to worry. Try introducing new foods a little at a time and often during the day. The problem may resolve itself over time. Toddlers are learning about their likes and dislikes and are testing them out.

Begin to share family foods

At this stage, seating your child at the table is an important social event. Your child can enjoy many (if not all) of the meals that the rest of the family eats, such as stews, casseroles, mild curries, bolognaise sauce and pasta. Food may have to be cut into smaller pieces, but cooking two meals is not necessary, offering praise for eating well encourages positive eating habits in your toddler.

Sometimes midday and evening meals may need to be served earlier than the rest of the family. Smaller children can’t wait as long as older children or adults. Their attention span is shorter, they may lose interest in eating and they also may become very grumpy if a meal is delayed too long.

Snacking between meals is important for young children. This can reduce the risk of hypos occurring. Keeping carbohydrate-based finger foods well stocked is a good idea such as crackers, rusks, fruit fingers, and fruit.

If meal times become a battle and hypos occur as a result of poor carbohydrate intake, adjusting the insulin plan may help. A dietitian and diabetes educator can be very helpful with any queries regarding food and insulin issues.

ERRATIC EATING

Food fads, fussy eating, variable likes and dislikes and tantrums are common in toddlers – with or without diabetes. For the parent of a child with diabetes, these food behaviours are often an additional source of stress. In particular fears about hypos are common.

Although many parents worry that their child is not eating enough, the rate of growth usually slows around this age, so a reduction in food intake is common. A grazing style eating pattern with regular carbohydrate choices is encouraged.

Children of this age are very aware of parental stress, so where possible try to remain calm about your child’s mealtime behaviours.

It’s important to keep food choices simple and offer the choice between one or two foods.

Keep encouraging healthy food choices and resist the temptation to offer treats if your child refuses to eat.

You may find that changing from a bottle to a cup also helps encourage appetite at meal times.

Avoid bribes, force-feeding or following your child around the house trying to coax them to eat. Sometimes a simple plate of finger food without fuss is enough to encourage your child to eat.

Offering meals and snacks ahead of time or giving insulin after meals may also help reduce stress and avoid some of the problems that may arise with food.

 There’s more to meals than food

For obvious reasons, carbohydrate foods often become the focus for parents and children with diabetes. Remember, for overall good nutrition and appropriate growth and development, other foods are equally as important. So don’t forget about increasing their variety of vegetables, lean meats and other protein foods.

It may be tempting to resort to any carbohydrate food such as sweets or juice to prevent hypos but this is not a nutritious habit to get into. Try to encourage a variety of food choices instead.

 The importance of a flexible insulin regimen

If you are having difficulties with amounts and timing of your child’s food intake, discuss possible variations to the insulin plan with your child’s diabetes doctor or educator. If your child is refusing to eat and their blood glucose levels are not low, it may be okay to wait a short time before offering the meal again.

It may also be possible to make adjustments to the timing or dose of insulin to prevent hypos, or, consider an insulin pump. Talk to your diabetes team about possible changes to your child’s management plan.

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