My 14 year old son was diagnosed one year ago with diabetes. He has been on insulin only as needed since two weeks after he was diagnosed. Lately, in the morning, his sugar is in the 200 mg/dl [11.1 mmol/L] range. He takes 2 units of Regular and, by midafternoon, even with a snack, he is hypo. Often falling in the 30-50 mg/dl [1.6-2.8 mmol/L] range. His night time reading is in the normal range. What could be causing his blood sugar to go up in the middle of the night? We live three hours from his doctor and have not been able to get any answers about why this is happening.

At this stage, I think it is important to discuss with your son’s doctor exactly what kind of diabetes he has and whether in fact he needs any insulin at all. It is just possible that he has type�1A, (autoimmune) which is the most common form in Caucasian children in the U.S. and is one of the very few that have a prolonged honeymoon period. I think this is very unlikely because it seems that he was not insulin dependent in the very beginning. If, however, he had a positive antibody test at the onset, this would be confirmed, and, ultimately, he will require much larger doses of insulin. He might also be a very mild case of type 2. This is increasingly common in children and would be suggested if he had been overweight or if there had been a family history of obesity and type 2 diabetes. It would be confirmed by a near normal or even slightly elevated blood C-peptide test. Finally, he might have type�1B which normally has an early acute insulin dependent phase, but is often followed by a period when insulin is not required. There are also some other very rare possibilities.

I question whether he now needs any insulin since the very small present dose induces a measure of hypoglycemia in the middle of the day. The fasting morning blood sugars are also only marginally abnormal and might be categorised as ‘impaired glucose tolerance’ rather than frank clinical diabetes. I would suggest to the doctor that your son gets a hemoglobin A1c test which will indicate whether the average daily blood sugar has been running significantly above normal. There are tests that could be done now such as an intravenous glucose tolerance test with insulin or C-peptide levels to show, more decisively, whether his insulin secretion is marginal or not. My own inclination though would to either try him on a long-acting insulin like NPH instead of the Regular which might well take care of both the hypoglycemia and the slightly elevated morning blood sugars, and, if his A1c stays close to normal, I would then try to manage him without insulin and just on diet, exercise, and, perhaps, Glucophage [metformin, a pill for type 2 diabetes].

DOB