My eight year old daughter has had type 1 dieabetes for two years, her A1c’s average 7.3%, and her average glucose is 165 mg/dl [9.2 mmol/L] over the last month. However, her individual glucose readings fluctuate widely ranging from extremes of 35 mg/dl 1.9 [mmol/L] to nearly 400 mg/dl [22.2 mmol/L]. Her highs are most common upon waking. I worry that she has too many extreme numbers and believe that the pump would alleviate the extremes and do a better job of controlling her overnight blood sugars.

Her current pediatric diabetes team set her target range at 100 to 200 mg/dl [5.6 to 11.1 mmol/L]. They are very concerned about the number of lows my daughter has and express little concern about her highs. They are slow to make changes to reduce highs. They tell me that they would be happy with A1c’s in the 8% range for her age, and they do not want her on the pump until she is at least 10, They insist that while we wait no long-term damage is being done with her A1c in this range.

I consulted with another pediatric diabetes provider who advocated blood sugars “as close to normal as possible” with an A1c goal under 7%. They were concerned more about her morning highs and were relatively unconcerned with her lows. They use the pump at age eight and lower routinely.

I understand that low blood sugars can cause brain damage, not to mention the immediate difficulties they cause, but I also thought that every high contributes to other potentially debilitating complications of diabetes even if A1c’s remain acceptable.

Can you offer a third point of view on what my daughter’s A1c’s and individual range should be? Are the dramatic swings and the individual high’s causing or contributing to long-term complications? Is the danger of low glucose at age eight enough to tolerate the risks associated with having many high’s? What is your opinion of using the pump at her age?

Nobody really knows the scientific answer to this dilemma. When one is doing a lot of blood glucose levels, it is quite common to see many up and down values all the time. If you are making corrections frequently with either food and/or insulin algorithms, then you will be able to keep the hemoglobin A1c from being very high since the amount of time your daughter has high sugars is being limited.

The data about hypoglycemia relates to severe and recurring episodes of hypoglycemia (unconsciousness and/or seizures) and nobody (also) knows any real risks from frequent hypoglycemia without such extreme lows.

You are correct that high sugars are associated with all of the long term complications (eyes, kidneys, nervous systems, blood vessels, etc.) so I would favor getting your daughter’s A1c as close to normal as possible and getting her average as well as individual blood glucose readings as close to normal as possible without severe or excessive hypoglycemia. This is virtually impossible even with multiple insulin injection therapy and is also virtually impossible even with an insulin pump.

We have many youngsters using insulin pumps since the pump relies on more reproducible fasting acting insulin (we recommend Humalog at present). The pump also seems to allow minimizing of hypoglycemia as well, (especially nocturnal hypoglycemia) since the basal rate can be adjusted in much finer fashion.

You will have to decide between the two different team approaches you have quoted — both very common — and see which one makes more sense to you, your daughter and your family.

SB
Additional comments from Dr. David Schwartz:

I agree with Dr. Brink. Please don’t lose track of your short-term and long-term goals. I would say that the HbA1c values that you report of 7-8% are excellent, especially for your daughter’s age, and such glycemic control, over the long haul, will greatly reduce the incidence of complications. There is no evidence that having her values at even lower values will eliminate complications (although that makes empiric sense, but tighter control will increase the risk of hypoglycemia and weight gain. So just focusing in terms of that, I see no medical reason to switch to a pump at this time, but there may well be social (including peace-of-mind for you) reasons to consider a pump. These are the factors that you will be weighing. In other words, right now, it does not appear that “things are broke” so there may be nothing that needs “fixing” at present.

DS