Romanne Tan is five going on six and will be starting primary school next year. In addition to learning to handle money and buy food, she has also started learning how to prick her fingers to draw blood samples.
She suffers from Type 1 diabetes, a condition where one's body is unable to produce insulin, a hormone needed to regulate the amount of sugar in the blood. Several times a day, she uses a pen-like device called a lancet to extract blood samples.
Although she does not know how to monitor her blood glucose levels using the samples or inject herself with the correct dosage of insulin based on the glucose reading, her mother wants her to start learning to care for herself.
Ms Rosalind Goh, 37, worries that shy Romanne will not be able to tell her primary school teachers when she feels hungry, a sign of low blood sugar that she addresses by giving her daughter a glucose tablet or honey. If untreated, low sugar levels can lead to fainting or seizures.
Romanne also changes the disposable needles used for the injections.
Ms Goh, a nurse, taught her daughter these two aspects of her diabetes care last month, as a first step to preparing her for Primary 1 next year. She is hoping the girl will be able to check her sugar levels and administer her own insulin by the time she is 12.
Two types of diabetes
The symptoms of Type 1 and Type 2 diabetes are similar.
• Increased urination
• Sweet urine which attracts ants
• Blurred vision
• Fatigue or drowsiness
• Cuts or bruises which heal poorly
• Constant feeling of thirst
• Weight loss despite heavy eating (more applicable to Type 1)
• Nausea and vomiting
• Dry, itchy skin
• Loss of feeling in hands or feet
A blood test can confirm if a person has diabetes.
Both Type 1 and 2 diabetes, or diabetes mellitus, have a hereditary and a lifestyle component, but the contribution varies.
For Type 1 diabetes, the dominant predisposing factor is genetic. People with Type 1 diabetes need insulin injections to control their blood sugar level. It usually occurs in young people.
For Type 2 diabetes, though there is a strong hereditary component, a sedentary lifestyle with poor eating habits and excessive weight gain is a strong predisposing factor.
These diabetics can produce insulin, but their bodies do not use it effectively.
The condition can be controlled by diet, exercise and medicine. If these fail, insulin injections may be needed.
•Sources: The Diabetic Society of Singapore; Department of Paediatric Medicine, National University Hospital
For now, either Ms Goh or the family's domestic helper uses a glucometer to monitor Romanne's blood glucose levels. The five insulin jabs that Romanne, the younger of two children, needs every day are mostly administered by either of the two women. Her father, swimming coach Jimmy Tan, 37, pitches in sometimes when he is not working.
Romanne was diagnosed when she was three. Her mother says: "I'm now used to the pinpricks and injections. Emotionally, I can take it. In the past, it was heartache."
While she still tears up when talking about Romanne's condition, she is also optimistic about medical advancements, which have helped minimise the pain commonly linked to jabs. Romanne has a small injection port attached to her body, which allows her mum to inject insulin without having to puncture her skin for each shot. The girl says the injection port is not as painful as the syringes she used.
A demanding daily regimen such as hers is part and parcel of living with diabetes as a child. It is a diagnosis that parents and children often struggle with. Kids such as her face a lifetime of taking multiple daily doses of insulin.
Endocrinologist Ben Ng, a vice- president of the Diabetic Society of Singapore, who has a clinic at Mount Elizabeth Novena Hospital, says having a diabetic child can cause "psychological stress and conflict" within families or between parents.
He adds: "It comes from love. Why is the child's sugar levels so high? Why are they not taking the medication? The needs of other family members have to be met too.
"In Singapore, we're very good at the medical aspect of diabetes, less so the social and psychological support."
Since Health Minister Gan Kim Yong declared a "war on diabetes" last month, the focus has largely been on Type 2 diabetes, by far the more common form of the disease for Singapore's more than 400,000 diabetics.
Type 1 diabetes, an auto-immune condition which has no cure, is often hereditary, whereas people who are overweight and inactive are more likely to develop Type 2 diabetes, in which the body cannot use insulin effectively.
Losing a substantial amount of weight has been known to reverse Type 2 diabetes in some cases.
Dr Daphne Gardner, consultant at the Department of Endocrinology at Singapore General Hospital, says Type 2 diabetes affects up to 90 per cent of those with diabetes, while Type 1 diabetes is more often seen in childhood.
Although Type 2 diabetes occurs more in older people, rising numbers of children and teenagers are affected.
KK Women's and Children's Hospital, for example, has seen an average of a 60 per cent increase in paediatric patients with Type 2 diabetes in less than 20 years.
From 2000 to 2005, the hospital saw an average of 15 newly diagnosed paediatric patients a year. Between 2011 and 2015, this yearly average was 24.
For Type 1 diabetes, the number of newly diagnosed paediatric patients remained fairly constant at an average of 30 a year between 2000 and last year.
Two years ago, when Romanne was drinking a lot of water, waking up at night to go to the toilet and losing weight - all common symptoms of the illness - Ms Goh suspected it was Type 1 diabetes because of her medical training.
Yet she still found it hard to accept. "The first thing I thought was whether I had been giving her too much sugary stuff," says Ms Goh, even though she knew these were unfounded fears. There is no strong history of diabetes in her or her husband's families.
Making dietary adjustments was tough. She says: "It was difficult to explain to her that because she has diabetes, if her friends give her sweets or chocolates, she must tell them she cannot have them, she can have only sugar-free ones. I have to keep reminding her."
The amount of insulin measured out for each jab depends on the patient's blood glucose levels, which can be affected by the type of food consumed and the amount of physical activity.
Romanne was at first upset, but now mostly accepts her dietary limitations. She eats half a portion of cake at birthday parties and, instead of a scoop of ice cream, she can have just five teaspoonfuls.
Dr Gardner advises that the whole family be involved in making the lifestyle changes necessary to controlling diabetes.
She says: "Food choices would be better done in a family context rather than singling out the individual for an 'exclusion diet'."
As Ms Goh says: "I don't want Romanne to feel different from the family." Together with Romanne, she, her husband and their son, Romulus, eight, all eat white rice mixed with healthier oats or brown rice, and drink Coke Zero if they want soda.
Dr Yvonne Lim, associate consultant at National University Hospital's Division of Paediatric Endocrinology, says: "Parents of young children with Type 1 diabetes must overcome their own fears and administer injections to their kids. The other significant challenge is knowing when to allow the child to self-manage his or her diabetes with confidence."
Housewife Philomena Chew, 44, admits that her own fear of needles has influenced how she views her son's Type 1 diabetes.
She gave up work as an accounting executive to care for Raphael, 11, when he was diagnosed at five. "He's growing up, putting on more weight. The hospital staff kept telling me that he needed more jabs. I was not ready. I didn't want him to have more pain," she says.
It was only in November that she agreed it was time for her son to learn to inject himself. This was because Raphael, who has a six- year-old brother, was approaching adolescence. He is now in Primary 6. Until then, he had taken two insulin injections a day. From late last year, he started taking three jabs, and, last week, progressed to four.
Raphael, who enjoys taekwondo and basketball, says his mother's concerns sometimes "aggravate" any anxiety he might feel about needles.
However, he has a practical approach. When he injects himself in school in the early afternoon, he does not want people around, in case they brush against or distract him. "The needle is very fine. I'm scared it will break," he says. If low blood sugar levels make him hungry or uncomfortable, he addresses it by quietly eating sweets.
Not every young diabetic is level- headed like him. The teen years can be troubling for diabetics who might also be grappling with adolescent self-consciousness.
For example, convincing teens to exercise can be difficult, says Dr Ng from The Diabetic Society of Singapore, whose services include health screenings, diabetes management programmes and support groups.
For adolescents, "it's the support of their peers that helps", he says. "Those with Type 2 diabetes tend to be overweight. It's already a bit of a stigma. It's one more problem for them to be told to lose weight."
He has encountered girls as young as 13 who dangerously "manipulate" their disease by withholding insulin injections to lose weight.
When Type 1 diabetics skip or reduce their insulin intake, they run the risk of coma or even death, reports say. Blindness, amputations and kidney failure are some of the possible long-term complications.
Dr Gardner says parents can help their adolescents by "providing quiet and non-overbearing support".
"If someone would rather miss a dose of insulin to be out with friends, finding practical ways for them to administer insulin subtly would probably be more helpful than insisting they do it," she says.
Ms Nurul Jannah Buang, 21, had some difficulty after being diagnosed with Type 1 diabetes as she had to cut down on chocolates and fast food, normal fare for her teen peers then.
At 18, while out for a pizza, she drank four bottled sugary drinks and a blended ice drink, but these failed to quench her raging thirst, one of the symptoms that prompted her to go to the hospital. She was found to have a potentially fatal blood sugar reading of 40 millimoles a litre. The normal range is four to eight millimoles a litre.
Today, the preschool teacher has adjusted well. "I feel like I am just like other people. I need to stay healthy and exercise. What makes us special is the daily insulin."