Our son was recently placed on a "mix your own" insulin program. The odd thing about it is it is not what people refer to as "sliding" - that is we do not determine his insulin dose according to his readings. Rather he is on a set dose of insulin (presently 1R/3N am, 1R dinner, 1N bedtime) regardless of his current blood glucose readings. Is this the norm for a child of 2 3/4 years?
What we don't understand is if he is experiencing a high of say 21 mmol, and we go ahead and administer his usual dose (or give him no extra if it is a lunch reading for example) how does his body cope with bringing itself down to an acceptable level if the insulin dose is intended to cope only with his food intake? One day he ran at 21.x all day from 8 am to 8pm.
Also, what do you think about an insulin program that requires three shots a day as indicated above. Our thinking is that he is going to be getting a lot of needles in the next 20 years and one extra a day makes for a lot of extra "holes" in his arms and legs. Also his tolerance for these needles may become frayed with the increased frequency. Why not give the N at dinner along with the R? (see clinics justification below)
Also, the clinic we are dealing with insists that Novolin N insulin peaks in 8 - 12 hours whereas Dr. Chase's book indicate it peaks in 6-8. This is of some concern to us because the clinics justification for giving him his N shot at bedtime (8pm) is so that it won't peak until the "dawn effect" or possibly when he is up the next morning for his breakfast. But according to Dr Chase it could peak as early at 2am which could cause some concern for night time lows (The clinic indicates this is why they do not want his N shot at dinner (5pm) because it will peak through the night.)
This type of question is probably the hardest that we get at children with DIABETES. If you put 100 paediatric diabetologists in a room, lock the door and tell them not to come out until they have agreed the best insulin regimen for the under 5 year old child, they will all die of starvation.
What they will agree on, however, is that the main aim is a happy, healthy and growing child who has reasonable blood sugars most of the time and does not have frequent or severe hypoglycaemic episodes. The lessons of the Diabetes Control and Complications Trial cannot be translated directly to this age group and there is some evidence that bad hypos may be more dangerous in very young children. This doesn't mean that blood sugars should be deliberately run high. I could fill a book with arguments in both directions about the number of injections that a small child should have per day. My own preference is for two (before breakfast and evening meal) but there are many proponents of one, or even 4 or 5 injections (the latter mainly in Scandinavia).
As for peak action and duration of action of insulin these are only indicative numbers and, as with everything else in diabetes, trial and error is the only way of tailoring a treatment package for an individual child.
I understand your concern about not apparently paying any attention to your son's blood sugar before giving a "standard" insulin dose. However, particularly with young children, it is a fruitless exercise to "chase the blood sugar". What usually happens if you do this is that his blood sugars will go on a roller coaster with fluctuations between highs and lows. It is better to view the pattern of blood sugars over several days before making any changes to regimen. This, of course, doesn't apply if he's ill.
Young children are typically fussy eaters and have enormously variable activity - perfect blood sugars for more than a day at a time are rarer than pink elephants.
Relax and talk to your Diabetes Team.
Original posting 22 Jul 96
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