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Understand and Prevent Diabetes

(33) Diabetes

 Diabetes Effects on Body Animation 3D

Diabetes

糖尿病

السكري

Diabète

Диабет

Diabetes

Diabetes33

Contraception and vasectomy

I have diabetes and want to start on the Pill. Are there any extra risks that women with diabetes run in using it?

Use of the oral contraceptive pill is the same in both women with diabetes and women without diabetes. It is now well known that the pill carries with it small risks of rare conditions such as venous thrombosis (where a vein becomes blocked by a blood clot) and pulmonary embolus (where an artery in the lung becomes blocked by a blood clot), as well as occasionally high blood pressure, although these risks are obviously less than those of pregnancy itself. This is why all women should be examined and questioned before starting the pill because there are a few conditions where it is best avoided and other methods of contraception used. The same arguments apply equally to women with and without diabetes. Healthy women with diabetes who have been checked the same way as those without diabetes may certainly use the pill and there are no additional risks.

When women with diabetes start using the pill there is sometimes a slight deterioration of control. This is rarely a problem and is usually easily dealt with by a small increase in treatment, which in those taking insulin may mean a small increase in the dose. It is a simple matter to monitor the blood or urine level and make appropriate adjustments.

There is nothing to suggest that the pill causes diabetes. It is all right for the relatives of people with diabetes to use the pill but of course they, like others, should attend for regular checks by their general practitioner or family planning clinic.

My doctor prescribed the pill for me but on the packet it states that they are unsuitable for people with diabetes. As my doctor knows that I have diabetes is it safe enough for me?

Yes. There used to be some confusion about whether the pill was suitable for women with diabetes but there is now general agreement that they may use the pill for contraceptive purposes without any increased risks compared with those who do not have diabetes.

I want to try the progesterone-only contraceptive pill. Is it suitable for women with diabetes?

Yes, although recently these have become less popular for all women.

I have just started the menopause and wondered if I have to wait two years after my last period before doing away with contraception?

Although periods may become irregular and infrequent at the start of the menopause, it is still possible to be fertile, and this advice is a precaution against unwanted pregnancy. It applies equally to women with diabetes as to those who do not.

I have diabetes and I am marrying a man with diabetes in 8 weeks’ time. Please could you advise me on how to stop becoming pregnant?

We are not quite clear whether you wish to be sterilized and not have children at all or whether you are just seeking contraceptive advice. If you and your fiancé have decided that you do not wantto have the anxiety of your children inheriting diabetes and have made a clear decision not to have children, you have the option of your fiancé having a vasectomy or being sterilized yourself.

These are very fundamental decisions and will require careful thought because they are probably best considered as irreversible procedures. If you are quite certain about not having children, one of you having sterilization would be the best plan.

We would advise you both to discuss this with your doctor and seek referral either to a surgeon for vasectomy for your fiancé or to a gynaecologist for sterilization. Whichever you decide, you must both attend since no surgeon will undertake this procedure unless he is convinced that you have thought about it carefully and have come to a clear, informed decision.

If our interpretation of your question has not been right and you are merely looking for contraceptive advice, then the best source of this is either your doctor or the local family planning clinic.

All the usual forms of contraceptives are suitable for women with diabetes, so it is just a question of discovering which best suits you and your partner.

Can you please give me any information regarding vasectomy and any side effects it may have for men with diabetes?

Vasectomy is a relatively minor surgical procedure, which involves cutting and tying off the vas deferens – the tube that carries sperm from the testes to the penis. Vasectomy may be carried out under either local or general anaesthesia usually as a day case. It would be simpler to have it under local anaesthesia as this will not disturb the balance of your diabetes. Side effects of the operation are primarily discomfort although infections and complications do rarely occur.

There are a few medical reasons for avoiding this operation but they apply equally to men without diabetes as they do to men with diabetes and your doctor will be able to discuss these with you.

I have been warned that IUDs are more unreliable in women with diabetes. Is this really true?

IUDs (intrauterine contraceptive devices) are generally regarded as slightly less reliable contraceptives than the pill, and there has been one report suggesting they may be even less reliable when used by women with diabetes. Not all experts agree about this, as there are no other reports confirming this observation. There has also been a report suggesting that women with diabetes may be slightly more susceptible to pelvic infections when using an IUD.

On balance, our recommendation is that IUDs should be considered as effective and useful in women with diabetes as in those who do not have diabetes.

Thrush

I keep getting recurrence of vaginal thrush and my doctor says that, as I have diabetes, there is nothing that I can do about this – is this correct?

Thrush is due to an infection with yeast that thrives in the presence of a lot of glucose. If your diabetes is badly controlled and you are passing a lot of glucose in your urine, you will be very susceptible to vaginal thrush and, however much ointment and cream you use, it is likely to recur. The best line of treatment is to control your diabetes so well that there is no glucose in your urine, and then the thrush will disappear, probably without the

need for any antifungal treatments, although these will speed the healing process. As long as you keep your urine free from glucose you should stay free from any recurrence of the thrush.

I suffer with thrush. My diabetes has been well controlled for 10 years now. I do regular blood tests and most of them are less than 10 mmol/litre and, whenever I check a urine test, it is always negative. I have been taking theoral contraceptive pill for 3 years and I understand that both diabetes and the pill can lead to thrush. Can you advise me what to do?

Since your diabetes is well controlled and your urine consistently free from glucose, diabetes can probably be excluded as a cause of the thrush. One has to presume that in your case you are either being reinfected by your partner or that it is a relatively rare side effect of the pill, and you would be best advised to seek alternative forms of contraception.

Hormone replacement therapy (HRT)

Can you tell me if hormone replacement therapy for the menopause is suitable for people with diabetes?

Hormone replacement therapy (HRT) for the menopause consists of small doses of oestrogen and progesterone given to replace the hormones normally produced by the ovaries. Oestrogen levels in the blood at this time begin to decline and, if they decline rapidly, they can cause unpleasant symptoms, such as hot flushes. Replacement therapy is thus designed to allow a more gradual decline in circulating hormones. Hormone replacement therapy is not usually advised in people with certain conditions such as stroke, thrombosis, high blood pressure, liver disease or gallstones. HRT may have a slight worsening effect on diabetes similar to the contraceptive pill. Some doctors are reluctant to give HRT to any woman and may use diabetes as an excuse for not prescribing it.

However, small doses of female hormones can cause dramatic relief of menopausal symptoms and there is no reason why you should not benefit from them provided that you have no history of stroke, thrombosis, etc.

There is good evidence that HRT reduces both osteoporosis and possibly vascular disease in postmenopausal women. The benefits probably outweigh the risks.

I want to try and avoid osteoporosis by taking HRT. As I have diabetes, is this sensible?

Yes. See the question above for our answers on taking HRT generally.

Are the patch forms of HRT as suitable for women with diabetes as the tablets?

Yes.

During the past 5 years I have had trouble with my periods being very heavy and on several occasions I have become very anaemic. I have tried HRT, which interferes with control of my diabetes, and it has been suggested that I have a hysterectomy. I have heard that depression is common after this operation and that HRT is often given to alleviate this feeling but, if this treatment makes my control more difficult, how will I cope?

Many people do have the impression that depression is common following hysterectomy. There is no reason for this. Anyone might get depressed after an operation in the same way that they would after any illness. A few women may feel that, if they have their womb removed, they have lost some of their femininity and therefore will become depressed. However, the womb is merely a muscle and has no effect at all on feminine characteristics apart from its relationship with menstruation. Unless the ovaries are taken out at the same time, there is no reason why you should require HRT. If the ovaries are removed, then HRT should not then upset your diabetes as you will be taking it to replace the hormones that you were producing yourself before the operation. The best person to discuss this with is your doctor.

 

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(34) Diabetes

The Myth about Blood Sugars and Diabetes - Video

Diabetes UK - Care, Connect, Campaign

Gestational diabetes

Centers for Disease Control and Prevention - USA GOVERNMENT - Diabetes and Pregnancy: Erin’s Story

Diabetes34

Termination of pregnancy

I have become pregnant and really don’t want a baby at the moment. Are diabetes grounds for termination of pregnancy?

No, not unless your doctor considers that the pregnancy would be detrimental to your health, which may occasionally be the case. All the reasons for termination of pregnancy apply equally to people without diabetes as to people with diabetes.

I am going into hospital for an abortion. I am worried that the doctors might not do it as I have diabetes. Should I have told someone?

There is no added hazard for women with diabetes, who undergo termination of pregnancy, and care of the diabetes during this operation does not raise any special difficulties but it is still a good idea to tell your gynaecologist.

Infertility

I have recently got married and my wife and I are keen to start a family. Are people with diabetes more likely to be infertile than those who do not have diabetes?

There is nothing to suggest that men with diabetes are any less fertile than men who do not have diabetes and this is generally true also for women. In the case of women, however, extremely poor diabetes control with consistently high blood glucose readings is associated with reduced fertility. This is probably just as well as there is good evidence to show that the outcome of pregnancy is much worse in women who conceive when their control is poor. I have been trying for a baby for years and we have now decided to go for fertility counselling and possible treatment.

Can people with diabetes expect the same treatment for infertility as people without?

Yes. As mentioned in the previous question, diabetes is rarely the cause of infertility. If control is anything other than excellent, then improving control should be the first goal. If that is not successful than expert opinion on management from a specialist is the next step.

Pregnancy

Pregnancy was the first aspect of life with diabetes where it was shown without any doubt that poor blood glucose control was associated with many complications for both mother and child and that these complications were avoidable by strict control.

The outcome for women with diabetes who are pregnant and for the babies that they carry is directly related to how successful these mothers are in controlling their blood glucose concentration. If control is perfect from the moment of conception to delivery, then the risks of pregnancy to mother and baby are little greater than in women without diabetes.

We now know that poor control when the egg is fertilized (conception) can affect the way in which the egg divides and changesinto the fetus (in which all organs and limbs are present but very small) in such a way as to cause congenital abnormalities (such as harelip, absence of the bone at the base of the spine, and holes in the heart). The risk of this happening can be reduced to a minimum, and possibly even eliminated, by ensuring perfect control (normal HbA1c) before you become pregnant.

For women who become pregnant when their control is poor, there will be an increased risk of congenital abnormalities in their babies – some of which may be detectable by ultrasound very early in pregnancy, when termination is possible, if a major defect is found. When no defect is detected, the outcome of the pregnancy will still be dictated by the mother’s degree of control during her 40 weeks of pregnancy and during labour and delivery.

Modern antenatal care is usually shared between the diabetes specialist and the obstetrician, often at a joint clinic. So long as control remains perfect (normal HbA1c) and pregnancy progresses normally, there is no need for hospital admission. With the excellent control that is now possible, the baby will develop normally and we believe that the pregnancy can be allowed to go to its natural term (40 weeks). If spontaneous labour begins, the procedure is no different from that for a woman without diabetes, other than the continued need to keep the mother’s blood glucose normal to prevent hypoglycaemia in the infant shortly after birth.

Women with diabetes are not immune to obstetric and ante-natal complications and these will be treated in the same way as they would be in women without diabetes. If a woman cannot achieve satisfactory control of her diabetes at home, then her admission to hospital becomes essential, but there are very few mothers who cannot achieve and maintain normal blood glucose values as an outpatient, at least while they are pregnant. It is a remarkable example of the importance of motivation in the struggle for good diabetes control. The single-mindedness of a pregnant woman makes her able to cope with almost anything to protect her growing baby from harm. Sadly this motivation is often lost once the pregnancy is over and control slips back to where it was before.

A very comprehensive pregnancy magazine is available from Diabetes UK.

Prepregnancy

The man I am going to marry has diabetes. Will there be any risk of any children we have in having diabetes?

If you do not have diabetes yourself and there is no diabetes in your family, then the risk of your children developing diabetes in childhood or adolescence, if their father has diabetes, is probably about 1 in 20. Provided that you are both in good health it is certainly all right to have a family. If you and your fiancé both had Type 1 diabetes, then there would be an even greater risk of your children developing diabetes.

There is a rare form of Type 2 diabetes in which there is a strong hereditary tendency. This is called maturity onset diabetes of the young, commonly known as MODY. Were you or your fiancé to have this, the risk of your children getting diabetes of this unusual kind would then be rather high. It is often a relatively mild form of diabetes and runs true to type throughout the generations.

The study of inheritance of diabetes is a complicated subject and you would be well advised to discuss this further with your specialist or a professional genetic counsellor.

I am worried that, if I become pregnant whilst my husband’s diabetes is uncontrolled, the child will suffer – am I right?

No. There is no known way in which poor control of your husband’s diabetes can affect the development of your child.

I am 25 years old and have Type 1 diabetes. My husband and I plan to start a family but first I would like to complete a 3 year degree course at university. By the time this course finishes I will be 29. Can you tell me if I shall then be too old to have a baby?

You pose a difficult question as to the ideal age at which someone with diabetes should have a baby. The age of 29 is not too old tostart a family but there are certain advantages in starting younger, particularly if you have diabetes and if you plan more than one pregnancy. Starting a family may be hard work whether you have diabetes or not. If you add increasing age to the difficulties, we are sure that you will understand why it is normally recommended starting earlier rather than later. It is difficult to give exact personal advice to individual people and the right person to talk to is your clinic doctor who knows both you and your diabetes.

I have diabetes treated by tablets, which I chose to take rather than insulin, and I want to become pregnant again. As I have had a previous miscarriage, I am worried about the chance of this recurring. Both my husband and I smoke a lot. How can I make sure that this pregnancy is successful?

Your control of your diabetes will certainly affect the outcome of your pregnancy – better control leads to more successful pregnancies. As you are planning your pregnancy, you can make sure that you establish good control before conception. Your control is probably best maintained by either diet alone or, if this fails, by diet with insulin. We do not advise women to take tablets throughout pregnancy, although they do not harm the baby if they are taken inadvertently in the early part of pregnancy. The tablets can cross into the baby’s circulation and stimulate insulin secretion from the pancreas causing hypoglycaemia in the baby shortly after birth.

It should also be said here that most women of childbearing age are already being treated with insulin, so they are not normally faced with your decisions. You obviously know already that smoking affects the baby and that heavy smoking is associated with more miscarriages and smaller babies. In asking the question we suspect that you already know the answer – take insulin and give up smoking. There is also more recent evidence to link even modest regular alcohol intake in pregnancy with an unfavourable outcome as far as the baby is concerned, so we suggest that you should stop drinking alcohol until the pregnancy is over.

Why must I ensure that my diabetes control is perfect during pregnancy?

This is to ensure that you reduce the risks to yourself and your baby to an absolute minimum. If you are able to achieve this degree of control from before the time of conception through to the time of delivery, you can reduce the risks to your baby and these risks will be virtually indistinguishable from those to babies born to women without diabetes. On the other hand, if you do not control your diabetes properly and pay no attention to it, then the risk to your baby increases dramatically.

 

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(35) Diabetes

Gestational Diabetes during Pregnancy (Video)

Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the postnatal period

Diabetes35

Pregnancy management

When I was 7 months pregnant, I developed diabetes. I had 8 units of insulin a day. After my baby was born, the tests were normal so I stopped taking insulin. I would now like another baby.  My doctor says I could develop permanent diabetes. Another doctor, however, says this is very unlikely – please could you advise me?

You have had what we call gestational diabetes (i.e. diabetes that occurs during pregnancy and then goes away again when you are not pregnant). The chances are that this will recur in all your sub-sequent pregnancies. You may well find that at some stage it doesnot get better at the end of the pregnancy and that you then have permanent diabetes. Even if you do not have further pregnancies, you are a ‘high risk’ (greater than 1 in 2) case for developing diabetes at some stage in the future. Your pancreas produces enough insulin to cope with everyday life but the extra demands of pregnancy are more than it can manage, hence the need for extra insulin. You should pay particular attention to your diet and fitness, and keep your weight at even slightly below your ideal weight for your height. The decision about further pregnancies with the greater risk of developing permanent diabetes is one that you and your partner must make after you understand the facts.

When I had my first baby, I was in hospital for the last 2 months and I was given a caesarean section after 36 weeks of pregnancy. My baby weighed 3.7 kg (8 lb 4 oz) even though it was 4 weeks early. During my most recent pregnancy I was allowed to go into labour at 39 weeks and the baby weighed 3.2 kg (7 lb) – I spent absolutely no time at all in hospital other than going into hospital as I went into labour. Why was there such a big change in treatment?

The last 15 years have seen a dramatic change in our attitudes to the care of pregnancy in women with diabetes. Good blood glucose control is the most important goal and with home blood glucose monitoring this can be achieved in the majority of women without the need for admission to hospital at any stage. It sounds as if your control was worse during your first pregnancy than your second. Early delivery by caesarean section was decided on because the baby had already grown to 3.7 kg by 36 weeks and the doctors were worried that it would become even bigger if left to 38 or 39 weeks. The heavier baby in the first pregnancy was because the high blood glucose you were running resulted in more fat being laid down on the baby. However, during your second pregnancy, when your control was clearly a good deal better, the baby grew at a more normal rate, so that it was at the correct weight when you went into labour at the end of pregnancy.

During my last labour I was given a drip and had an insulin pump up all day. Why was this necessary?

Strict blood glucose control during labour is very important to ensure that you do not put your baby at risk from hypoglycaemia in the first few hours of life. If there is any possibility that your labour may end up with an anaesthetic (e.g. for forceps delivery or possible caesarean section), then the simplest way to keep your diabetes well controlled is with glucose being run into your circulation and matched with an appropriate dose of insulin. With the pump this means that – should an emergency arise – you will be immediately ready.

During my pregnancy I found attending the antenatal clinic a nuisance and I did not like to keep my diabetes too well controlled because, if I did, I had many hypos. Labour and delivery seemed to go quite normally but my baby was rather heavy. He was 4.2 kg (9 lb 4 oz), and had to spend a long time in the Special Care Baby Unit because they said he was hypoglycaemic – how do I avoid all this trouble in my next pregnancy?

If you want to go ahead and have further babies, then it is essential that you change your attitude to the antenatal clinic and to controlling your diabetes throughout the pregnancy. The trouble that your baby had from hypoglycaemia was a reflection of the fact that he had been exposed to a very high glucose concentration throughout pregnancy and had had to produce a lot of insulin from his own pancreas to cope with this extra load of glucose from you. Immediately after birth he no longer had the glucose coming from you but still had too much insulin of his own, hence the hypoglycaemia.

You can prevent this risk in future pregnancies by ensuring that your control is immaculate. This will require you to attend the antenatal clinic on a regular basis and to do frequent blood glucose monitoring to ensure that your control is excellent. If you can do this you should be able to eliminate any risk of hypo-glycaemia in your baby.

Is it all right for me to breastfeed my baby if my blood glucose is too high?

Breastfeeding is generally encouraged these days for all women with babies. There are no special difficulties for women with diabetes and the presence of a slightly raised blood glucose need not worry you too much, provided that your control of your diabetes is not too bad. For the best results with breastfeeding, keep up a high fluid intake and keep an eye on your diabetes, making appropriate adjustments to your insulin dose if necessary.

Breastfeeding is a demanding process in terms of increasing nutritional requirements for anyone, so make sure that you eat regular amounts of carbohydrate to minimize the risk of hypo-glycaemia. If you find this all too much, it is perfectly all right to bottle-feed. Do not breastfeed whilst having a hypo – feed your-self first, so that you and your baby will both be satisfied! Always seek medical advice if you are in any doubt.

My diabetes was fairly easy to control during my pregnancy, but since the birth of my baby it has been more difficult to control, and I am needing much less insulin. I am breastfeeding – could this have anything to do with it?

Various hormones are produced during pregnancy and these lead to an increase in your insulin requirements and alter your body’s metabolism in such a way that obtaining good control is usually easier. After the birth these hormones decrease which means that you need much less insulin, and in many people this dose is even lower than was required before pregnancy. When you are breastfeeding, the dose usually drops even more and you should be prepared to lower your dose of insulin should hypos occur.

I am married to a man who takes insulin to control his diabetes. I have just fallen pregnant, so what special things do I need to do during pregnancy to ensure that it goes smoothly and without complications?

You need take no special precautions other than those taken by all pregnant women, as the fact that your husband has diabetes does not put your pregnancy at any particular risk. It is only when the mother has diabetes that strict control and careful monitoring of blood glucose become essential.

I have been told that I must keep my blood glucose levels as low as possible during pregnancy. Please can you tell me what they should be?

Your blood glucose before meals should be 4–6 mmol/litre and 2 hours after meals no higher than 5–8 mmol/litre.

I am frightened of having hypoglycaemic attacks especially as I have been told to keep my blood glucose much lower during pregnancy. What should I do?

All people treated with insulin should be prepared for a hypo whether or not they are pregnant. Carry glucose or dextrose or something like a mini-Mars bar on you at all times. Most convenient are Dextro-energy tablets. Some people prefer to carry small (125 ml) cans of Lucozade or Coca-Cola (not the diet variety).

Will any hypoglycaemic attacks that I might have during pregnancy harm the baby?

No. There is no evidence to suggest that even a very low blood glucose in the mother can harm the baby.

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(36) Diabetes

Gestational Diabetes during Pregnancy

Diabetes and Pregnancy

Diabetes36

Pregnancy management – complications

 My second son was born with multiple defects and has subsequently died. I have been on insulin for 14 years (since the age of 10). Are women with diabetes more likely to have an abnormal baby?

The secret to a successful pregnancy is perfect blood glucose control starting before conception and continuing throughout pregnancy. There is good scientific evidence to suggest that multiple developmental defects are caused by poor control in the first few weeks of pregnancy and that the risk of this can be avoided by ensuring immaculate control at the time that the baby is conceived. The risks in terms of multiple congenital defects seem to be confined to the very early stages of the pregnancy.  This is hardly surprising because this is the stage when the various components of the baby’s body are beginning to develop and when other illnesses such as German measles (rubella) also affect development.

Good control is also needed for the rest of the pregnancy because the gradual development and growth of the baby can be disturbed by poor control. In particular, with poor control, the baby grows rather faster than normal and is large in size, although the development of the organs remains relatively immature in terms of their function. This does not happen with well-controlled diabetes. Because the baby is large, the mother has to be delivered early and, because the baby is immature, it is susceptible to a number of added risks immediately after birth.

I have read that the babies of mothers with diabetes tend to be fat and have lung trouble shortly after birth and also there is a risk of hypoglycaemia. Is this true, and if so why does it happen?

We know that, if the mother runs a high blood glucose through-out pregnancy, glucose gets across the placenta into the baby’s circulation and causes the baby to become fat. This is because the baby’s pancreas is still capable of producing insulin even though the mother’s cannot. As a result of this, the baby grows bigger during pregnancy and delivery has to be carried out earlier to avoid a difficult labour. This used to be carried out most commonly by caesarean section at about 36 weeks of pregnancy. One of the complications of this method of delivery is lung trouble in these babies, known as the respiratory distress syndrome (RDS), caused by the fact that the babies were born before their lungs were properly developed.

If the mother’s blood glucose levels are kept strictly within normal limits during pregnancy, babies do not grow faster than they should and pregnancy can be allowed to continue for the normal period of 40 weeks. This avoids the risk of caesarean section in the majority of women and RDS is rarely seen because the babies are fully mature when they are born.

Low blood glucose (hypoglycaemia) during the first few hours after birth is a result of the fact that the baby’s pancreas has been producing a lot of insulin during the pregnancy to cover the mother’s high blood glucose, which was passed across the placenta to the baby. If the mother’s blood glucose is strictly controlled during pregnancy and delivery, hypoglycaemia in the baby is much less of a problem.

My baby was born with jaundice. Are babies of mothers with diabetes more likely to have this?

Babies born to mothers with diabetes are more likely to be jaundiced. This is partly because they tend to be born early, but we do not know why a mature baby is jaundiced, though the problem is usually mild and clears without treatment.

I developed toxaemia during my last pregnancy and had to spend several weeks in hospital even though control of my diabetes was immaculate. Luckily everything turned out all right and I now have a beautiful healthy son. Was the toxaemia related to me having diabetes? Is it likely to recur in future pregnancies?

Women with diabetes are more prone to toxaemia. You are not more likely to develop toxaemia in your future pregnancies - indeed the risk is less.

During my last pregnancy I had ‘hydramnios’ and my obstetrician said that this was because I had diabetes. Is this true? And is there anything that I can do to avoid it happening in future pregnancies?

Hydramnios is an excessive amount of fluid surrounding the fetus and it is, unfortunately, more common in mothers with diabetes. It does appear to be related to how strictly you control your diabetes throughout your pregnancy. Our advice is that you can reduce the risk to an absolute minimum in future pregnancies by aiming to keep your HbA1c and blood glucose levels completely normal from the day of conception.

During the recent delivery of my fourth child (which went quite smoothly) I had an insulin pump into a vein during labour. I had not had this in my previous three pregnancies, despite having diabetes. Why did I need the pump this time?

We now know that it is very important to keep your blood glucose within normal limits during labour to minimize the risk of your baby developing low blood glucose (hypoglycaemia) in the first few hours after birth. This is most effectively and easily done using an intravenous insulin infusion combined with some glucose given as an intravenous drip. This means that your blood glucose can be kept strictly regulated at the normal level until your baby has been delivered. It also ensures that should any complications arise and something like a caesarean section be required, you are all ready immediately for an anaesthetic and operation.

My first child was delivered by caesarean section. Do I have to have a caesarean section with my next pregnancy?

It all depends on why you had the caesarean section. If it was performed for an obstetric reason that is likely to be present in this pregnancy, then the answer is yes. If it was performed because the first baby was large or just because you have diabetes, the answer could be no.

Some doctors do consider it safer to deliver a woman by caesarean section if she has had a caesarean section before. Others would allow you a ‘trial of labour’. In other words, you would start labour and, if everything was satisfactory, you would be able to deliver your baby vaginally in the normal way.

My doctor tells me that I will have to have a caesarean section because my baby is in a bad position and a little large. What sort of anaesthetic is best?

Nowadays approximately 50% of women who have caesarean sections have them under epidural anaesthetic rather than under general anaesthetic. If you have an epidural anaesthetic your legs and abdomen are made completely numb by injecting local anaesthetic solution through a needle into the epidural space in your spine. You remain awake for the birth of your baby and therefore remember this event. In most cases an epidural is preferred because your baby receives none of the anaesthetic and therefore is not sleepy.

If you are interested in having your baby this way, you should discuss it with your obstetrician.

My baby had difficulty with breathing in his first few days in the Special Care Unit. They said this was because my control of my diabetes was poor – why was this?

It sounds as if your baby had what is called respiratory distress syndrome (RDS) which occurs most commonly in premature babies and was discussed in an earlier question. It occurs in babies of mothers with diabetes where the baby has grown too quickly because of the mother’s poor blood glucose control, and so the baby is born before it has become fully mature. It used to be a relatively common cause of death in the babies of mothers with diabetes but now, because of stricter control and super-vision, the mother does not have to be delivered early, so the baby is fully mature when it is born. It is now uncommon and indeed you can probably completely prevent it if you control your blood glucose throughout your pregnancy, thus allowing it to proceed for the normal 40 weeks.

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(37) Diabetes

Developing Diabetes In Pregnancy Increases Risk For Autism In Babies Up To 63%

DIABETES IN CHILDREN

Diabetes37

Diabetes in the young

Diabetes in young people is divided naturally into three main age groups: babies, children and adolescents.  Diabetes on babies and children consist of questions asked by parents and the answers are naturally directed at them. Diabetes on adolescents is for both young people and their parents. We have listened to hundreds of parents who have felt the despair of finding that their child has diabetes and then overcome their fears to allow their child to develop to the full. Mothers and fathers usually end up by being especially proud of children who have diabetes. We hope to pass on some of this experience to those parents who are still at the frightened stage.

The baby with diabetes

My baby developed diabetes when she was 4 weeks old. She is now 6 weeks old and looks very healthy but I would like emergency advice in order to protect her life. What food and treatment should I give her?

You must be relieved that your baby is better now that she has started treatment, but worried about the difficulties of bringing up a child with diabetes from infancy. Diabetes is very rare in infants less than 12 months old, so you will not find many doctors with experience of this condition. However, the general principles are the same for all infants with diabetes and there is no reason why she should not grow into a healthy young woman.

Diabetes UK has produced a special youth pack for children under 5 years old, which contains many useful documents including a booklet about babies with diabetes. Diabetes UK might also be able to put you in touch with other people who have had the same problem. Practical advice and reassurance from these people would be more use than any theoretical advice.

Like all babies, your daughter will be fed on breast or bottle milk. For the first 4 months frequent feeds are best – 3-hourly by day and 4-hourly by night. Bottle-fed babies usually need 1 scoop (168 g of milk per kg of body weight) each day (21⁄2 ounces per pound). Some babies grow very rapidly and need more milk than this, while others may need solids earlier than 4 months. This may be a help in babies with diabetes as the solids will slow down the absorption of milk. It is important to wake young babies for a night feed to avoid night-time insulin reactions.

If there is any doubt about this, do a blood glucose check while your baby is asleep. If her blood glucose is low an additional 5–10 g carbohydrate (100–200 ml milk) should be given.

My little boy is nearly 12 months old and has been ill for a month, losing weight and always crying. Diabetes has just been diagnosed. Does this mean injections for life?

Yes. We are afraid it does literally mean injections for life. The thought of having to stick needles into a young child quite naturally horrifies parents, but with loving care, explanations and playing games like injecting yourself (without insulin) and a teddy bear (using a different needle) and perhaps some bribery, most children accept injections as part of their normal day. Young children grow up knowing no other way of life and they often accept this treatment better than their parents do. Encourage your child to help at injection time by getting the equipment ready or perhaps by pushing in the plunger and pulling out the needle.

How can I collect urine for testing from my 18-month-old son?

It is not easy to get clean samples of urine from babies in nappies. Many infants will produce a specimen by reflex into a small potty when undressed. You can also squeeze a wet nappy directly onto a urine testing stick. But be warned – washing powders or fabric softeners in the nappies alter the urine test result.

Diastix or Diabur-Test 5000 can be used for testing for glucose, whilst Ketostix or Ketur Test are used to test for ketones. Keto-Diastix and Keto-Diabur tests for glucose and ketones. Infants are much more likely than older people to have ketones in the urine. This is because they rapidly switch to burning up fat stores in the fasting state. It is important to check on ketones and try to keep his urine ketone-free, although you should not worry if ketones appear for a short time.

You will also have to do blood tests on your son. Parents expect children to find these painful but blood tests taken from a finger, heel or ear lobe are surprisingly well accepted by young people. They enable you to check accurately what is happening if your son feels unwell or looks ill. Urine tests provide only a guide about the state of his diabetes since his last urine specimen. The blood test confirms what is happening at that very instant. It is the only reliable way of deciding whether your son is hypo or just tired and hungry. Blood glucose measurements are also necessary to check the overall control of his diabetes and to help you decide on the dose of insulin if his blood glucose rises during an illness. Blood samples should be obtained with an automatic finger pricker – the Autolet (Owen Mumford [Medical Shop]) has a special platform for children, but the Soft Touch and Softclix (Roche), the Glucolet (Bayer Diagnostics), the BD Lancer (BD) and the Monojector (Tyco Healthcare) are all suitable. There are new blood glucose meters on the market that need only a very small amount of blood for the test. For instance, the OneTouch Ultra works on a tiny blood sample and comes with a new lancing device, which is adjustable. The small blood volume means that only the shallowest skin puncture is needed. Adults can check their glucose by sampling from their arm and it is virtually painless. Such a meter would be ideal for a baby or young child.

My 2-year-old daughter has diabetes and makes an awful fuss about food. Meals are turning into a regular struggle. Have you any suggestions?

Food is of great emotional significance to all children. If meals are eaten without complaint, then both mother and child will be satisfied. All children go through phases of food refusal because of a need to show their growing independence, their ability to provoke worry or anger in parents and their attempts to manipulate the situation. Food leads to the well-known battleground, which occurs in all families at some stage. The only way for you to win is to remain in control of the weapon. Usually when young children begin this phase (at 10-18 months), they dislike being told to leave the table and go away. They often return and eat rather than remain alone and hungry.

The battle is even more difficult for parents like you where the child has diabetes - your daughter has some explosive weapons!

However, you must stay in control: try distracting her attention away from food by toys, music, talk or your own relaxed approach to eating. You may have to send your daughter away from the table if she is refusing to eat properly. Hypoglycaemia often provokes hunger and, anyway, a couple of mild hypos due to food refusal are a small price to pay for better behaviour next time. Be prepared to modify the type of carbohydrate within reason if she consistently refuses the diet recommended by the hospital. Bread, potatoes, biscuits, fruit juices and even ice cream can be offered as alternatives.

Susie Orbach has written an excellent book called On eating. The box reprints the advice that was given in The Guardian (reproduced with permission from AP Watt Ltd on behalf of Susie Orbach).

FOOD AND YOUR CHILDREN

Dos and don’ts for babies and toddlers

• Do introduce your baby and toddler to the mashed-up version of the foods and tastes you relish, including the herbs and spices.

• Do clip a baby seat on to the table if possible so that the baby can be part of family eating and have her interest in what you are eating stimulated.

• Do respect your baby or toddler when they say ‘no’. When they turn away from eating, offer them some other food and if it doesn’t hit the spot, allow them to stop eating. They will soon let you know if they are hungry again.

• Do let your baby and toddler muck about with food and make a mess. Food is a source of creativity as well as fuel.

• Don’t encourage them to eat five more spoonfuls for grandma, or the starving children elsewhere, or play games that trick them into eating. Show them your relish in food. Dos and don’ts for primary-age children

• Do put lots of different kinds of food out and let the children choose what they fancy.

• Don’t differentiate between kids’ and adult food. Children’s tastes will be as complex and sophisticated as the foods they are exposed to.

• Do value foods equally so that broccoli becomes no less of a special food than ice cream.

• Do let children see you stopping when you are full and leaving food on your plate.

• Do let children leave food when they’ve had enough or when they are compelled to rush off to do something more interesting than eat. If you are worried they have not had enough to eat, make sure there is food around for them to come back and refuel on.

• Don’t ever reward them for eating their greens by offering those sweets or ice cream or cake. Do let them eat in whatever order they like including having dessert first if they are desperate for the carbohydrates.

• Don’t cheer them up or jolly them out of a sad or angry mood with food unless you know they are hungry. Do let them tell you how they feel without shushing them or humouring them out of their upset. If they tell you and get their feelings out in the open, the pain will dissipate faster.

Dos and don’ts for adolescents

• Do expect them to eat fast food. It’s a sign of independence, of showing how different they are from you, of making it with their peers. If you’ve fed them interesting food all along, don’t despair, they won’t be able to eat KFC or Wagamama every day.

• Do sit together around the table several nights a week. If they’ve stocked up on food after school and aren’t hungry, let them sit with you while you eat so that they get accustomed to being around food and only eating it when they are hungry.

• Don’t have fights while eating together. It fuses food and conflict together.

• Do have tons of food in the house and expect erratic eating. Teenagers have fast metabolisms and many need to eat lots more than adults.

• Do tolerate their cooking even if their experiments violate your basic principles in the kitchen.

• Do discourage them from dieting. Set the example by never doing it yourself.

• Don’t have a corner for ‘junk’ food. Disperse it among the foods you consider good.

 

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