From Sao Paulo, Brazil:
I am writing to you on behalf of a cousin of mine who is a pedriatrician in Sao Paulo - Brazil. He asked me to help him via INTERNET with what he thinks is a very rare case of diabetes with a two month old baby. I am not a doctor but a professor of business strategy and I will try my best to comunicate with you. My apologies!
A two month old male baby with diabetes ketoacidosis, who has insulin dependent type I diabetes. The laboratory tests showed high levels of glycemia (400 mg/dl), acidosis and high potassium. His diagnosis: diabetes insulin dependent type I.
The patient was in coma in the hospital until yesterday. He managed the situation but he needs help.
- Is there any medical literature about how to treat diabetes in a such young patient (two months of age)? The doctor insists that the guidance he needs should be related to diabetes in such a young patient.
- Is this a rare patient case? Do you have information about research in this field related to patients of this age range?
- How should he treat this patient until he reaches a later stage of life? He means, ok, he is not in coma any more, but what specific care does he need? Are there any peculiarities about the suitable treatment related to his age?
The pediatric endocrinology programs in the US see such cases occasionally, though it's extremely rare.
A two-month old with diabetes definitely should be followed by a pediatric endocrinologist, not only by a general pediatrician.
- In general, treat him like any other kid with diabetes. Because of the risk of hypoglycemia, a safe target range for the blood sugar levels would be about 100 - 200 mg/dl.
- Let the infant eat whatever whenever. Breast feeding is okay.
- Either 2 or 3 or shots daily. Usually NPH alone at this age; these infants are very sensitive to Regular insulin. Sometimes Regular is needed, however.
- Dose changes are usually made in half-units; may need about 2 units/day total, depending on blood sugar.
- Diluting the insulin to get more accurate doses might be helpful: both Eli Lilly and Novo-Nordisk have the diluent.
- Frequent monitoring of blood sugars: before meals at least; anytime the parents have a question, they need to check the blood sugar.
From Tessa G. Lebinger, M.D., Pediatric Endocrinologist
28 February 1996
As a Pediatric Endocrinologist in Private Practice I have cared for a few babies this age and several infants under 1 year of age. Their care is similar to older children with diabetes, but there are some differences. First of all, babies this age are more prone to low blood sugars at night as they "metabolize" their food more quickly than older children. I usually encourage parents to test every four hours during the night, and to encourage them to try and continue feeding the child frequently during the night until they are sure they will be able to sleep through the night without going low. (They should also have glucagon for injection available for emergencies.) Although it is very hard to regulate what a baby eats, I encourage the parents to try and be as consistent as possible in the timing of the feeds, and in the amount of carbohydrate, protein, and fat at each meal. Breast feeding should be encouraged, but you have less an idea whether the baby is eating more or less than usual. When the baby graduates to formula or baby food, American baby food companies can supply the nutritional breakdown of all their products. I don't know what products are available in Brazil.
I have also found it necessary to dilute the insulin. I have given babies as little as 1/40 of a unit of regular at a time to control their blood sugar. There is no one insulin regimen that will work with every baby. If the child is very erratic with eating, you might want to consider very small amounts of regular insulin with each feed along with a small amount of longer acting basal insulin (NPH, Lente, or Ultralente) once or twice a day. Other children will do well with just an intermediate inuslin (lente or NPH) twice a day with or without regular as needed. I have also found that many young children will have low blood sugars before lunch even if no regular is given with the morning lente or NPH. Sometimes lowering the dose of Lente or NPH, and adding or substituting a longer acting insulin such as ultralente will help. (Don't mix NPH and Ultralente in the same syringe.) Remember the baby's food and insulin requirement may change rapidly with growth.
The most important thing is to individualize and be creative to try and match the insulin with the child's schedule as much as possible. Although you want to keep the blood sugar as close to normal "as possible", this is of difficult without avoiding severe lows. There is some information that the brains of babies may be more susceptible to the effects of low blood sugar and that there may be an increased chance of learning disabilities later on if they have had many severe low blood sugars.
Original posting 19 Feb 96
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