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From Manama, Bahrain:

Our two-year-old daughter was recently diagnosed with type 1 diabetes and we would like a second opinion. Her random blood sugar was 28.7 mmol/L [517 mg/dl], according to laboratory blood work, so she was put on Regular and NPH insulins. Her A1c was 9.0. Other laboratory results included urea - 3.5 mmol/L; sodium - 128 mmol/L (range 140-148 mmol/L); potassium - 4 mmol/L (range 3.6 to 5.2 mmol/L); chloride - 95 mmol/L (range 100 to 107 mmol/L); and bicarbonate - 11 mmol/L (range 21 to 30 mmol/L). Her C-Peptide was 0.35 (range 0.12 - 1.25 nmol/L), free T4 was 14.3 pmol/L; and her TSH was 4.3 (range 0.25 to 5 uIU/ml).


It looks like she was not ill for very long with only a modest increase in her hemoglobin A1c at diagnosis. This is an older form of insulin treatment regimen using Regular and NPH twice-a-day. It often does not work very well and forces parents and children/toddlers to be extremely strict about timing and amounts of food since there are big peaks and valleys of insulin. It also causes more middle-of-the-night hypoglycemia because of the peaking of the suppertime NPH dosage. Many of us using intensified insulin regimens stopped using such insulin regimens about 15 years ago and now use basal insulins such as Lantus or Levemir instead of NPH because both Lantus and Levemir have fewer peak effects and more physiologic delivery of insulin. This involves using fast acting analogs such as Humalog, NovoLog or Apidra 15 minutes before each meal and more blood glucose testing than you are currently doing so that you always know the starting point of current blood glucose levels, then make a correction (i.e., one unit of fast acting might compensate for 5 mmol/L of blood glucose elevation in a toddler). This would mean the fast acting dosage is always adjustable according to how many grams of carbohydrate are to be eaten and whether or not you are close to your target blood sugar goal (say 5 mmol/L [90 mg/dl to 6 mmol/L [108 mg/dl]) before meals. Insulin pump treatment is another option for toddlers. Both the multidose regimen (MDI) using six or so injections each day around meals coupled with basal Lantus or Levemir twice-a-day or the insulin pump require much more testing and analysis.

Your daughter's thyroid functions were normal. Her salt levels were fine. Antibody results were not provided but may be negative in a toddler even though this sounds like classical type 1 diabetes. The only other test that we would routinely do is a test for celiac disease using transglutaminase antibody as a screen.

It is most important that you work closely with your pediatric diabetes team and find out what other insulin options are available in Bahrain. To improve overall glycemic control and minimize hypoglycemia, as well as some of the day-to-day variabilities, consider changing to Lantus or Levemir for basal insulin effect, probably twice-a-day coupled with meal-time analogs and consider increasing blood glucose monitoring to pre breakfast, two hours post-breakfast, pre lunch plus two hours post-lunch, pre dinner and two hours post-dinner with occasional late night and through-the-night blood sugar monitoring as well.

The diabetes teaching books, Understanding Diabetes, 11th Edition by H. Peter Chase and Type 1 Diabetes in Children, Adolescents and Young Adults, Second Edition by Ragnar Hanas would also be extremely valuable and can be ordered online to give you the latest information about toddler diabetes issues and treatment.


Original posting 2 Dec 2008
Posted to Diagnosis and Symptoms


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Last Updated: Tuesday April 06, 2010 15:10:18
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