The Paediatric & Adolescent Endocrinology & Diabetes Society – South Africa (PEAD-SA) share their position statement on children with Type 1 diabetes mellitus returning to school.

All children should return to school in accordance with government guidelines. Type 1 diabetes mellitus (T1DM) does not seem to increase the risk of acquiring infection or of having COVID-19 severe disease in children and adolescents. Our position as PEAD-SA is that children and adolescents with T1DM should not be prevented from returning to school.

Background

The pandemic of infection with coronavirus (SARS-Cov-2), which has caused corona virus disease since 2019 (COVID-19) has affected all aspects of life throughout the world.

South Africa has not been spared and we are now in the early stages of this epidemic. The carefully considered and courageous decision by government to call for a lockdown was timely and necessary as is the easing to the different levels.

As part of this change, it has been recommended that children and adolescents begin returning to school. Considering concerns raised by numerous people, PAEDS-SA is presenting our position on this aspect of the epidemic.

What does PEAD-SA know about children and infection with SARS-Cov-2?

What we do know comes from very limited information from other countries and from limited local experience.

1. Children (under 20 years) do get infection with SARS-Cov-2. In most countries, children make up a small fraction of all the people with infection. Thus, it seems that children and young people don’t contract COVID-19 at the same rate as adults. In China and Italy, children less than 10 years were only 1% of all cases, and those between 10 and 19 years were 1,2% of all cases. In the USA, children and adolescents (under 18 years of age) were 1,7% of all cases reported^1,2,3.
2. Children do not seem to get severe infection very commonly. This may be the reason why children make up such a small fraction of people with infection, because in most countries, people are only tested when they are ill. It is thought that most children get infected but do not have symptoms. Children rarely require hospitalisation or have severe disease⁴. (1,1% of cases are critical, 2,2% of cases are severe)⁵(5,7% of children hospitalised US)³
3. Very few children have been seriously ill or have died from this condition. To date, it is thought that 30 children have died from COVID-19.
4. Children do not seem to be responsible for the major spread of infection to others. Most children are infected by adults rather than from each other.
5. It is not clear that children have the same risk factors as adults for serious illness e.g. hypertension, lung disease, Type 2 diabetes, etc. Reports from colleagues suggest that children with T1DM do not contract Corona virus infection more frequently than other children² and do not have more severe forms of COVID-19 disease than other children. In China and Italy, no-one under 25 with T1DM landed up in hospital or with severe disease (needing ICU).²
6. In South Africa, we are starting to see a few children with COVID-19 disease and the pattern does not seem to have changed from the rest of the world.
7. We are seeing increasing numbers of children with stress, anxiety and other psychological, social and emotional issues because of the lockdown.

Conclusion

PEAD-SA, therefore, have taken the position that children and adolescents with T1DM should not be treated any differently from other children in terms of going back to school.

All usual advice for the care of children and young people with T1DM remains valid:

• Better control means better health, particularly in winter when everyone gets sick.
• Children with T1DM should have a flu vaccine.
• Any illness will affect glucose control, which then needs extra attention.
• If children are ill, they or their caregivers should not delay in contacting their healthcare provider because they are afraid of COVID; unmanaged DKA is far more dangerous.
• Hypoglycaemia remains the most urgent problem that must be treated immediately, including at school.

PEAD-SA will continue to monitor reports from international organizations (WHO, ISPAD, ADA), colleagues and from across the world and update this statement promptly as new information becomes available.

Click on the video below to hear The International Society for Paediatric and Adolescent Diabetes (ISPAD)  statement on COVID-19 and children with diabetes.

REFERENCES: 

1. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in ChinaSummary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention Zunyou Wu, MD, PhD; Jennifer M. McGoogan, PhD JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648
2. Summary of recommendations regarding COVID‐19 in children with diabetes: Keep Calm and Mind your Diabetes Care and Public Health Advice | International Society of Pediatric and Adolescent Diabetes (ISPAD) | Ped diab 2020;21(3):413-414 doi.org/10.1111/pedi.13013
3. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. 422 MMWR / April 10, 2020 / Vol. 69 / No. 14. CDC COVID-19 Response Team 
4. SARS-CoV-2 Infection in Children Xiaoxia Lu, Liqiong Zhang, Hui Duet alNEJM 18 Mar 2020
5. Clinical Manifestations of Children with COVID-19: a Systematic Review Tiago H. de Souzaa, MD, PhD; José A. Nadala, MD, MSc; Roberto J. N. Nogueiraa et al

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Mommy, what are we eating for lunch? A question that most mommies have heard a lot during the lockdown period. Donna Van Zyl, a dietitian, shares a few lunch ideas for the family

School-going children generally have a routine and other activities that makes diabetes management a bit easier than children at home during lockdown. They may be sleeping late at night, waking late morning, and eating at irregular times. The lack of routine may contribute to irregular blood glucose levels.

In addition, we find ourselves walking far more to the cupboard or refrigerator due to boredom and we catch ourselves snacking slightly more. Boredom eating is one of the bigger challenges in lockdown and therefore routine should also be established like the school day at home with breakfast; school work; snack and lunch time. However, eating at home or school; a diabetic lunch is no different to a healthy lunch that every child should eat.

A healthy balanced lunch will ensure that your child gets the right amount of nutrients and energy they need to concentrate or perform optimally. A balanced lunch consists of a wholegrain/unrefined low-GI carbs, protein, fats, fruit, salads and vegetables.

 Tips for lunch or lunch boxes

• For those who are carb-counting, a good tip is to write down the total amount of carbohydrates on a sticky note, paste inside the lunch box so that it is easier for your child, or the school nurse, to count carbs at school. Preparing portioned foods can also aid your child at school, or at home, when carb counting.
• Prepare or pack a healthy lunch you know your child will eat. Otherwise your child may enjoy swopping his or her food with friends or end up not eating. It is important to switch up the foods regularly. Let your children try new foods over the weekend or at night, so that you know whether you can prepare or pack the food in for them.
• Allow your child to help you prepare the lunch or pack the lunch box. At the same time, you can teach your child how to do the carb counting or even some culinary skills. Often children who take responsibility for preparing the meal establish healthy and good eating habits.
• Always provide a low-carb option, such as a protein or fat snack. See options listed below.
• Always have a snack available to pick up a low blood glucose level; longer life options, such as a packet of raisins, can be kept close by just in case.
• Prepare food in advance and freeze or prepare more portions the evening before so that leftovers can be used for lunch the next day

Use leftovers

How to use leftovers the next day; and if there are no leftovers what can you serve for lunch tomorrow?

Snack items

For those children heading off to school, a lunch box can include a few more snacky items; especially when lunch is generally served at home. You can include the following:

• Proteins

Scrambled egg muffins; or lean meat, such as beef strips, chicken breasts strips, sosaties (mini), biltong, salami slices/sticks, meatballs (chicken or beef), cheese: wedges, blocks of cheddar cheese, cottage cheese or cream cheese, yoghurt, smoothies.

• Starchy food

Whole-wheat/rye bread, whole-grain Provitas, wraps, brown rice, quinoa, barley, baby boiled potatoes/sweet potato with the skin, and durum wheat pasta.

• A good helping of salad, vegetables and fruit

Fresh fruit is easy to pack; or chopped fresh strawberries, pineapple fingers, apple slices, orange or naartjie wedges. Remember to count the fruit towards your carbs.

Raw veggies, such as carrot sticks, cherry/Rosa tomatoes, mini cucumber or sliced, gherkins, mini corn, corn on the cob, capsicum strips are all popular to add colour to the lunch box and can always be served with a dip: sour cream/hummus or guacamole.

Nuts and seeds or unsweetened nut butters can also be added as an additional treat.

The actual lunch box

• Ensure it is a strong container that will protect the food from being squashed.
• Have smaller containers available for dips, sauces or cut-up fruit.
• When choosing a water bottle, make sure that it will be easy to clean. Some juice containers have a removable ice pack that you can use to keep the water cold. This is also great for milk or smoothies.
• You can use a soft cooler bag for food that needs to be kept cool.
• And remember to wash out the lunch box daily.
  

We hear Youth with Diabetes’ position statement on whether sending your child with diabetes back to school is a good idea.

Two large studies from England have just been released on COVID19 and diabetes. Because of this new information, Youth with Diabetes is adjusting our recommendations about going back to school. Please use this new advice to help you decide if you will be sending your child back to school.

The studies show that people with Type 1 diabetes are more at risk of dying from COVID-19 than those with Type 2 diabetes.

After taking into account age, sex, heart disease, socioeconomic status and race, people with Type 1 diabetes are almost three times more likely to die from COVID-19 than those without diabetes. (Hazard ratio of 2,86).

If your HbA1c is more than 10,0%, you are twice more likely to die than if your HbA1c was less than 7,5%. (Hazard ratio of 2,19).

It is important to note that age is the most important risk factor, even if you have diabetes. In these studies, no one with Type 1 diabetes under the age of 50 has died. Most of the COVID-19 deaths in Type 1 diabetes have been in the age group of over 70 years.

Other risk factors that contribute to increased risk of death for people with Type 1 diabetes are obesity and chronic kidney disease.

All this information means that you can reduce your risk by getting your blood glucose level under control and losing weight if you are obese.

Here are the links to read the full research articles:

https://www.england.nhs.uk/wp-content/uploads/2020/05/valabhji-COVID-19-and-Diabetes-Paper-1.pdf

https://www.england.nhs.uk/wp-content/uploads/2020/05/Valabhji-COVID-19-and-Diabetes-Paper-2-Full-Manuscript.pdf

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Esther Rodrigues, a T1D Mom, shares the joys of seeing her son, Mikyle, celebrate his 21^st birthday.

Esther Rodrigues stays in Cape Town with her husband, Antonio, and  their three children, Kelsey, Mikyle and Jayden.

I am a T1D Mom, who is exceptionally proud of my son, Mikyle Rodrigues, who turned 21 on 20 May 2020.

Mikyle is a strong T1D Warrior who never gives up. In his quiet confidence, he has the strength of a lion, a will to survive and a burning desire to overcome all obstacles in his way.

Currently, my son’s life consists of studies, exercise, eating lots of food, playing PS4 and managing his Type 1 diabetes.

Our family and friends are supportive and assist us wherever possible. Two and a half years ago, Mikyle fell in love, and that gave him reason to live, reason to fight and unconditional love.

Diagnosis

Mikyle was diagnosed at the tender age of 10 in August 2009. I did not know anything about Type 1 diabetes. I was completely dumbfounded with the diagnosis. In the blink of an eye, without any warning, our lives changed forever. Nothing can prepare you for this…Google became my best friend.

As a T1D Mom, I did not know how I was going to do this. I felt as if there was a huge hole in the centre of the earth and I was being sucked in. It was only once we came home, with all the reading and research I did, that I realised what Type 1 diabetes was all about.

The first few years were fine until puberty struck and caused havoc in our lives. We pushed through as best we could but we were advised to look at an insulin pump. Pumps are very expensive and while trying to save towards one, Mikyle was gifted with his first insulin pump by another T1D Warrior, Rowena Carmyn Webb. Rowena gave it to Dr Tracy Janse Van Rensburg, Mikyle’s doctor at the time, to bless a child with it and Tracy chose Mikyle. Sadly, Rowena, an incredibly generous woman, passed away on 22 June.

Eating habits changed as a family

As a family, we love eating. We celebrate with food. Eating habits had to be altered, sugar was removed from our household and sugar-free drinks were bought. Xylitol was used for baking, because Mikyle has a sweet tooth.

I remember the highlight of his school camps were ending the day with hot chocolate topped with marshmallows. So, I searched high and low and made sure that I packed his sugar-free hot chocolate and sugar-free marshmallows when he went on school camps. I did everything in my power to convert the things he liked into sugar-free treats!

Insulin

Mikyle uses a Medtronic insulin pump and Humalog insulin. To test his glucose levels, he uses a Freestyle Optium Glucometer with Freestyle testing strips.

What Mikyle enjoys

Mikyle enjoys exercise, with his favourite being weight training and recently he started taking interest in cardio, specifically boxing.

Since he has joined the gym, he heals faster, and his immune system is much stronger. The blood glucose control is also much better.

Mikyle enjoys eating food. If you want to steal his heart then cook for him. He enjoys most foods, with emphasis on healthy foods. He is currently studying Dietetics (2^ndyear) at Stellenbosch University so he knows the importance of consuming healthy foods.

Most of the time, he is playing games on his PlayStation, driving and spending time with his girlfriend, Tamia.

Lessons learnt

I was prepared to help my son grow into a strong, independent young man who could do anything he puts his mind to, but it turns out that he is stronger than I could ever have imagined. With many prayers and the grace of God, he celebrated his 21^stbirthday with us as a family.

I believe that God gives his hardest battles to his strongest soldiers, and took some of the strongest women and made them T1D Moms.

My hero calls me mom.

Images by RE Photograghy.