Safe Ramadan Fasting for Kids with Diabetes – PediaCast 577

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Description

Dr Leena Mamilly visits the studio as we consider safe Ramadan fasting for kids and teens with diabetes. Ramadan is a time of fasting, prayer, reflection, and community… but the fasting part can bring challenges for families impacted by diabetes. Tune in as we explore safe ways for kids to fast. We hope you can join us!

Topics

Ramadan
Fasting
Diabetes

Guests

Dr Leena Mamilly
Pediatric Endocrinology
Nationwide Children’s Hospital

Links

Endocrinology at Nationwide Children’s Hospital
Fasting Guidelines for Diabetic Children and Adolescents
Muslim Pediatric Fasting Practices Among Diabetic Children: A Mixed Method Approach
How to Observe Ramadan Safely With Type 1 Diabetes

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast is brought to you by Pediatric Endocrinology at Nationwide Children's Hospital. 

Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads.

This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. It's episode 577.

We're calling this one safe Ramadan fasting for kids with diabetes. I want to welcome all of you to the program. So today we are tackling an important topic for many families, Ramadan fasting, and how it impacts children with diabetes.

Now, Ramadan is a sacred month for Muslims around the world, marked by fasting from dawn to sunset, prayer, and reflection. For many families, it's not just about fasting, it's also a time for community, faith, and togetherness. And while fasting is a spiritual and cultural tradition, it also presents unique challenges for kids with diabetes.

Managing blood sugar, avoiding dehydration, making safe decisions, those are all key concerns. And parents may wonder, is fasting safe for my child? What precautions should we take?

How can we make this a positive experience while also prioritizing health? We are going to break it all down with expert guidance, who should and should not fast, how to prepare, what adjustments may be needed, and when to seek medical advice. Our goal is to provide practical evidence-based information so families can make informed decisions while balancing their faith and their health.

And to help us with the conversation, we have a fantastic guest joining us. Dr. Leena Mamilly is a pediatric endocrinologist at Nationwide Children's Hospital. So, if you have a child with diabetes and you are considering fasting, then this episode is for you.

And even if you don't have a child with diabetes, or you are not Muslim and you're not fasting for Ramadan, I think this will be a really interesting conversation as we all strive to understand each other and different cultures and the challenges that families who are different than ourselves have. And so, I think it will be great, I hope you're able to stick around and listen. I do want to remind you the information presented in every episode of PediaCast is for general educational purposes only.

We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you're concerned about your child's health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

So, let's take a quick break. We'll get Dr. Leena Mamilly settled into the studio, and then we will be back to talk about safe fasting during Ramadan for kids with diabetes. It's coming up right after this.

Dr. Leena Mamilly is a pediatric endocrinologist at Nationwide Children's Hospital and an assistant professor of pediatrics at The Ohio State University College of Medicine. She has a passion for supporting kids and families impacted by type 1 and type 2 diabetes, and this includes children and teenagers whose families celebrate Ramadan. Why is this an important consideration?

Because Ramadan involves fasting, which can make managing type 1 diabetes challenging but not impossible. That is what she is here to talk about today, safe Ramadan fasting for kids with diabetes. But before we dive into our topic, let's offer a warm PediaCast welcome to our guest, Dr. Leena Mamilly. Thank you so much for visiting the studio today.

[Dr Leena Mamilly]
Thank you for having me.

[Dr Mike Patrick]
Yeah, we really, really appreciate you stopping by. Let's first just kind of define for the audience, what exactly is Ramadan? I think most of us have heard of it, but maybe not understand exactly what it is or why this is an important time for Muslims.

[Dr Leena Mamilly]
Thank you. Ramadan is the ninth month in the Islamic calendar. It is the most important month out of the Islamic calendar year, which actually follows a lunar timing, meaning that it follows different times of the regular calendar year, usually 11 days earlier each year.

The month is considered one of the most important times of the year for Muslims because it's a month of not only fasting, but it’s also a month of worship, it's a month of meditation, self-improvement, and even celebration for families and getting together with families and community.

[Dr Mike Patrick]
Yeah, yeah. And so, when you say the Islamic calendar, how does that compare to the calendar that we follow month to month? How is it different?

[Dr Leena Mamilly]
So, a lunar calendar follows the appearance and disappearance of the crescent moon in the sky, and that usually happens every 29 to 30 days. So, each month begins when the crescent moon appears again in the night sky. And that's why now, because it happens every 29 to 30 days, usually the entire year will be 11 days shorter than your regular calendar.

[Dr Mike Patrick]
Great, good to know. And then the fasting part of it, let's talk a little bit more about that. What are the times that fasting takes place, and how long of a period do folks have to go while fasting?

[Dr Leena Mamilly]
So, the fasting happens every day for the entire month. It begins right before sunrise, so that's dawn time, and it ends at sunset, meaning people can eat or drink between pre-sunrise to sunset, but then they can eat between sunset and pre-dawn. And usually, it lasts anywhere between 10 or 11 hours to sometimes 18, 19 hours, depending on the time of the year.

So, this year in particular, we're fasting for about 13 hours every day, but sometimes it's longer when the month falls in the summertime. Yeah.

[Dr Mike Patrick]
So, it's almost better when it falls in the middle of winter, because then the fast doesn't have to be as long. And when I say better, I mean for the health of kids who have diabetes, and fasting may create some issues with their blood sugars. So, this is just kind of medium this year.

And then what do you have to refrain from during the fast?

[Dr Leena Mamilly]
So, it's mainly food and drink, but not only that, oral medications are usually not allowed during fasting. Even some, if it's nutritive IV medications, Muslims are expected to refrain from wrongdoing in general. So, from getting angry or using profanities, or also intimate relations are prohibited during fasting hours.

[Dr Mike Patrick]
Now, you mentioned medicines. For the most part, especially if we're just talking a month out of the year, kind of moving medicine schedules so that you're taking them when the sun is down, that seems like it wouldn't be too much of an issue. Although for kids with diabetes or something where you're really managing a number, that becomes a little bit more difficult, correct?

[Dr Leena Mamilly]
Correct. So, insulin in particular is a subcutaneous injection. And so, it is allowed during fasting, but if they have to take something that's nutritive, like glucose or oral glucose tablets, it is not allowed.

And then oral medications for sure for patients with type 2 diabetes. So, we either move the medication to when they are able to eat, or they will not be able to fast.

[Dr Mike Patrick]
Okay. And then what about water? Is water allowed during a fast?

No, not allowed. Okay. And then are children expected to follow these rules as well?

Is there a particular age when it starts or is this observed from everyone right from birth?

[Dr Leena Mamilly]
It is not from birth. Usually, children are not required to fast. And fasting technically is required at puberty onset.

So that's usually during teenage years. Young children are not required to fast. But what happens is that they sometimes like to practice when they're on the older side.

[Dr Mike Patrick]
Yeah. I imagine if they see their mom and dad doing it and the parents of their children and folks that they worship with, they probably, if I know kids well, want to jump in and be a part of that. For the younger kids that want to jump in and do it, is it safe for kids in general to fast or is that something that parents really should only let their kids do it for a particular amount of time?

And I'm talking about the prepubescent children.

[Dr Leena Mamilly]
Fair enough. So, I mean, the short answer to your question is that we don't necessarily know what the exact right age that is safe for fasting in children. However, what we know is that usually before elective surgical procedures, children are required to be fasting so that they don't have complications from anesthesia.

And in those studies that looked at children who fasted before surgical procedures, children were found to have no problems with low blood sugars or dehydration when they fast, you know, overnight, which typically is 11, 12 hours. What we see is that some studies that looked at very young children, meaning toddler ages, found that there might be a risk of hypoglycemia or low blood sugar during fasting before procedures.

[Dr Mike Patrick]
Yeah. And that makes sense for me working in an emergency department. Sometimes we'll have kids come in and they'll have a low blood sugar, and they haven't necessarily been vomiting a lot.

They just weren't eating very much. But then again, those are sick kids and they're probably, it makes no difference whether the sun is up or down as to whether they are, you know, fasting or not. They're just sick and not eating and their blood sugar goes low.

But I can see where that could be a potential issue, especially for the younger children. Let's turn our attention now to kids with diabetes and what special concerns arise for those kiddos if they want to fast?

[Dr Leena Mamilly]
So, there are different aspects to looking at fasting in children with diabetes. The most important one is that they are at risk for high blood sugars, low blood sugars. They are at risk for dehydration because the high blood sugars come with increase in the frequency of their urination or peeing.

And that usually, you know, may result in dehydration. So, they're not allowed to drink. They might be at risk for dehydration.

And then, of course, we also have to consider what medications they're on, if they're on oral medications, whether or not it's safe for them to forgo this medication for the duration of fasting.

[Dr Mike Patrick]
Are there specific guidelines out there that are published somewhere? I'm sure that there are primary care pediatricians out there who have families in this situation. And certainly, hopefully those families also have a pediatric endocrinologist to guide them.

But if there are providers out there who may not be familiar with things that we're talking about, is there something out there that they could find that provides some guidance?

[Dr Leena Mamilly]
Absolutely. Actually, luckily, there is multiple resources. And those guidelines are usually made by the collaboration between international specialists in the field and then even religious authorities and physicians that care for very sick people.

So, the one that pertains to diabetes, management of diabetes during actually any religious fast, not just Ramadan, is the International Society of Pediatric and Adolescent Diabetes, ISPAD. They have guidelines that pertain to type 1 diabetes. And then there is also the International Diabetes Federation that gave guidelines for anybody with type 1 or type 2 diabetes.

And then they specified certain recommendations for children. There is also the American Diabetes Association, which also put out guidelines for fasting and people with diabetes. But those are mainly for adults.

So, they pertain to your older teenager.

[Dr Mike Patrick]
Sure. And we'll put a link in the show notes for folks. Actually, we'll have several links to resources.

So, providers and also families, if you want to learn more about this, just visit the show notes over at pediacast.org. This is episode 577, and you will find those resources there. I want to talk about insulin a little bit more.

So, insulin is allowed because it is a subcutaneous injection. It's not nutritive. However, insulin has the effect of lowering your blood sugar.

And so, if you are fasting, it would seem to me that you need to make some adjustments in how you're using your insulin to avoid going low. Talk a little bit about what's expected in terms of changes in insulin administration during this time.

[Dr Leena Mamilly]
Absolutely. Yes, you're right. Insulin is usually given under the skin, whether it's shots or through an insulin pump.

It's always under the skin, so it is allowed during fasting. What happens is, normally, children will respond to insulin just like your any other day, but because of the risk of low blood sugars. Normally, when we have children whose blood sugars are right within target range, we try to make sure that their sugars are a tad higher than their usual level so that they have a lower risk of low blood sugar.

Now, for children who have higher blood sugars before fasting, we have to think about first whether the blood sugars are too high to fast, which happens also all the time. But if it's not too high to fast, maybe we continue to have the same amount of basal insulin during Ramadan, and they will normally see better fasting blood sugars during the month.

[Dr Mike Patrick]
Yeah. And so this really does sound like something that families should do with the help and guidance of their pediatric endocrinologist to help guide them on exactly what they should do, because it also sounds like maybe it's going to be a little bit different from one kid to another, depending on what the numbers look like and each individual disease and how their body responds, whether it doesn't respond to insulin versus not making any insulin, and the difference between type 1 and type 2. Families really ought to have that guidance from someone who has expertise in managing diabetes, right?

[Dr Leena Mamilly]
Yes, I agree. There are actually studies that showed that providing standardized advice as well as personalized to each kid with diabetes before Ramadan, those studies looked guidance a month or two before Ramadan starts, and they had very good success rates, meaning kids were able to safely complete very good number of days of fasting. So, guidance certainly makes a difference.

[Dr Mike Patrick]
Yeah. Now, what warning signs are there that things might not be going well during the fast and would make a family concerned that the blood sugar might be going too low and that maybe we need to stop the fast to get the blood sugar back up to where it's supposed to go? What are those warning signs that families should be watching for?

[Dr Leena Mamilly]
So, the most important thing is to keep an eye on the blood sugars. In these days, the availability of continuous glucose monitoring devices has made it easier for us to keep a very close eye on the blood sugars or continuous monitoring of those blood sugars. So, before I talk about the signs, I want to make sure that I convey the message that use of CGM is extremely helpful for kids who are fasting and actually for any child with diabetes.

Now, during the fast, usually families are instructed to look for signs of low blood sugar, signs of high blood sugar, and sometimes it's harder to figure out that children are having high blood sugars just from symptoms, but usually if they have increase in urination or increased thirst than normal, then this might be a sign that they have a high blood sugar. Stomach pain and vomiting are not normal. Usually, they might indicate that kids are starting to develop ketones.

So, we're looking for low blood sugars, we're looking for ketones, and then any other symptoms and signs that tell us that they might be significantly dehydrated, like dizziness or increase in their heart rate, are good to watch for.

[Dr Mike Patrick]
So, you're really watching for symptoms, and hopefully, especially since we're mostly talking about kids after puberty, so teenagers here, hopefully, I mean, not that we wish ill on anyone, but they've probably experienced low blood sugar in the past. And so if you kind of know how you typically feel when you're going low, I would think that could be helpful in, hey, we need to check what is my blood sugar right now, check my urine for ketones, and then if those are in warning, if there's any ketones present or our blood sugars drop below a threshold that we've determined with our pediatric endocrinologist, then that would be an indication to go ahead and break the fast for health reasons, and that sort of thing is allowed, correct?

[Dr Leena Mamilly]
Absolutely, yes. Whenever there is any sign of danger, whether it's low blood sugars, high blood sugars, dehydration, or any other significant symptoms, it is very important that the child breaks the fast immediately. And this is something that we not only discuss with our families, but we also give this guidance to school nurses who might be watching the kids while they're in school.

[Dr Mike Patrick]
Yeah, yeah. Are there strategies in terms of when to have meals with the fast? Like, then do you want to get up early and have a good breakfast before the sun comes up?

I mean, are there strategies for doing this safely, and in particular for kids with diabetes?

[Dr Leena Mamilly]
Absolutely. So, I'm going to go back to that monitoring and remind everybody that monitoring is key. You know, when we don't use CGM if it is feasible, but if CGM is not available, we usually ask our kids to monitor the blood sugars at least every two to three hours while they're fasting.

And then meals are also an important component of blood sugar management. Traditionally, a fasting child will have a meal at sunset, and then they will have another meal before sunrise, and maybe one or two meals in between, depending on what the family usually does. We mainly advise them to drink a lot of fluids, particularly water, because it's a carb-free fluid.

When we're eating our meals, we want to make sure that we balance our carbohydrates, and especially simple carbohydrates like, you know, juices and sugary foods with other components like protein in the meal, and that way we don't have very high sugars after the meals, and we keep our blood sugars steady.

[Dr Mike Patrick]
Yeah, yeah, very important. You talked about school nurses. What can schools do?

So, what is their role in supporting these kids and families?

[Dr Leena Mamilly]
Nurses have a very important role, because they are, you know, keeping an eye on the kids while, you know, they're in school, while they're fasting. What we normally do, we encourage families to let us know ahead of the month, so that we send proper communication with their school nurses. We have actually standardized communication with school nurses that we can tweak for the needs of particular patients or kids, and we can tell them, you know, to first of all notify them that the kids might be fasting, and they might be fasting some days and some days not.

So, school nurses need to know, and then they will help kids monitor their blood sugars. They will know to watch for signs and symptoms of low blood sugar and check their ketones if they have any symptoms of a stomachache or vomiting, or if they have a high blood sugar.

[Dr Mike Patrick]
Yeah, it seems like this is a great opportunity for in-school education of staff and school nurses. I know here in Columbus, in our Columbus public school system, we have a lot of schools that actually have Nationwide Children's Hospital clinics in the school, and I would suspect that if that's the case, you're in a great place in terms of doing this safely. But in schools that maybe don't have that resource, and maybe they just have a part-time school nurse who's not even on the grounds at that particular school, you know, the entire time that school's in session, I would imagine this is a great opportunity for education of school personnel in terms of what to expect, what are the signs of low blood sugar, and you know, maybe even something that ought to happen on a regular basis. Is that something that, you know, across the country there are educational programs like this?

[Dr Leena Mamilly]
I'm not aware of educational programs that pertain to fasting in particular around the country, especially for kids. But you know, here at Nationwide Children's Hospital, we're working on updating our website with some information in regard to fasting, and then we have a sort of a kit that we provide to those nurses that don't have, you know, Nationwide Children's staff in the school so that they have the resources available.

[Dr Mike Patrick]
Yeah, and we will put a link in the show notes to endocrinology at Nationwide Children's Hospital. And so, folks, there is a way to contact your group through that site if folks had questions or, you know, wanted resources. And of course, we'll also have some resources in the show notes over at pediacast.org episode 577. Tell us a little bit more about the diabetes team at Nationwide Children's Hospital and how you guys offer support for fasting kids.

[Dr Leena Mamilly]
Yeah, so we are very, very happy to be able to offer support here at Nationwide Children's. And we've been offering for the last few years now. We can offer pre-Ramadan assessment, so that requires usually looking at blood sugars, medications, other, you know, health conditions.

We offer counseling through our diabetes educators or providers. We have; we can offer nutritional recommendations for kids who choose to fast. And then we also offer communication with school nurses.

We even have resources for carb counts for different, you know, cuisines around the world so that when kids, you know, choose to, you know, eat certain, from certain cuisines, carb counting is not so challenging.

[Dr Mike Patrick]
And then what final advice do you have for families that are considering this? So, you know, maybe they've had a kid who's fasted, but not the entire time. They are teenagers now and they're getting ready to do their fast for the very first time.

What advice do you have for those families?

[Dr Leena Mamilly]
I will start by saying that fasting is feasible with type 1 diabetes, but it's not for everyone. Some kids have a higher risk than others and will be asked by their doctors not to fast. And that's usually even an exemption from an Islamic standpoint.

For those who are deemed to be safe to fast, they need to plan a month or two ahead at least by contacting their endocrinology team, sending their blood sugars in, getting their technology if it needs updated or reinstating it. It's very important to share those plans with the diabetes team and know that Nationwide Children's Hospital is ready to help you. And during the month of Ramadan, it's very important to monitor constantly and be prepared to decide to break the fast for the child if they have signs and symptoms of complications.

[Dr Mike Patrick]
And again, we will have a link to endocrinology at Nationwide Children's Hospital and lots of resources in the show notes. What other disorders are treated by endocrinology at Nationwide Children's? You guys take care of a type 1 and type 2 diabetes.

What are some of the other conditions that you treat?

[Dr Leena Mamilly]
Absolutely. So, this is going to be a very long list, so I'll try to keep it to the highlights. We see kids with growth and puberty problems.

We see kids with thyroid disorders, with adrenal problems, including Addison's disease or congenital adrenal hyperplasia. We see kids with pituitary disorders and pituitary tumors. And then we see kids also with type 2 diabetes, also some bone disorders.

So, it's a very long list, but those are the highlights.

[Dr Mike Patrick]
Yeah. And we are so fortunate to have you guys, and you do so many great things for so many kids and I really appreciate all your work and efforts. I have been mentioning links in the show notes.

I want to get a little more specific now. Again, we will have a link to endocrinology at Nationwide Children's. There's an article called Fasting Guidelines for Diabetic Children and Adolescents from the Indian Journal of Endocrinology and Metabolism.

We'll have a link to that in terms of guidelines. There's also a great article from the American Academy of Pediatrics that was published in the journal Pediatrics in 2021. It's called Muslim Pediatric Fasting Practices Among Diabetic Children, a Mixed Method Approach.

So that's an interesting one for providers out there. And then for families, we do have a link to an article called How to Observe Ramadan Safely with Type 1 Diabetes. That is from type1better.com and we'll have links to those in the show notes over at pediacast.org.

Once again, this is episode 577. So, Dr. Leena Mamilly with Pediatric Endocrinology at Nationwide Children's Hospital. Thank you once again so much for visiting us and sharing your expertise with us.

[Dr Leena Mamilly]
Thank you for having me. It's been a pleasure.

[Dr Mike Patrick]
♪ Once again, to all of you for taking time out of your day and making PediaCast a part of it, really do appreciate that. Also, thanks to our guest this week, Dr. Leena Mamilly, Pediatric Endocrinologist at Nationwide Children's Hospital. Don't forget, you can find PediaCast wherever podcasts are found.

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