August 23, 2003
Daily Care
Question from Las Vegas, Nevada, USA:
My two year old son was diagnosed with type 1 diabetes eight months ago. He is only receiving one shot per day in the morning (6 Units of NPH with 1 Unit of Humalog), and he is often low prior to lunch. The only way to avoid the lows is to give him a big midmorning snack. Decreasing the Humalog only made him run high until snack time, and I was not happy with a 250 mg/dl [13.9 mmol/L] reading three hours after breakfast. From what I understand about the insulin, I’m confused as to why he needs such a big snack (sometimes as much as 30 grams of carbohydrate) to keep him going until lunch. I’ve tried giving him more simple sugars at snack time thinking that perhaps I had been giving him snacks that were taking longer to process, but we get the same result still happens. What is going on?
He receives his insulin in the arm at about 7:45 am and then eats 40 grams of carbohydrate for breakfast (which takes him about 30 minutes). I check him at 10:30 am mainly to give him the appropriate snack to keep him going until lunch. If he’s in the low 100s mg/dl [5.6 mmol/L], he needs about 25 grams of carbohydrate. If he’s below 100 mg/dl [5.6 mmol/L] (not very often), he needs about 30 to 35 grams of carbohydrate, and if he’s in the 200s mg/dl [11.1 mmol/L] then a regular 15 grams of carbohydrate snack. Lunch is at 12:00 noon, and his blood sugar is usually 80-100 mg/dl [4.4-5.6 mmol/L]. He eats 30 grams of carbohydrate for lunch, 10-15 grams of carbohydrate for afternoon snack, and 20-30 grams of carbohydrate for dinner.
The doctor suggested waiting giving the shot after he eats breakfast, but I just don’t see how this could work. He also suggested decreasing the NPH which I tried, but then he is often in the high 100s mg/dl [5.6 mmol/L] to low 200s mg/dl [11.1 mmol/L] three hours after lunch. Our schedule seems to be working, but I just don’t understand why the insulin is so hard at work midmorning. Should I change our breakfast or lunch times? Does this happen to others?
Answer:
The intensity of treatment required for patients with type 1 diabetes must reflect mutually desirable goals (family, patient and physician). These goals may change depending on age (most important) and other factors. So in a little child as your son, the goal could be a blood sugar level around 120-150 mg/dl [6.7-8.3 mmol/L] in order to avoid hypoglycemia, in a patient who has an very instable life (exercise, quantity of foods eaten per day, etc.).
Nevertheless, in answer to your question, I think that waiting to give him the shot after he eats that important for glycemic control. In addition, because his problem is a low blood sugar two to three hours after breakfast, moving the shot will only save 15-20 minutes.
In my experience, it is easier to control a child so young with a three a day shot per day regimen rather than only one shot per day. In fact, with the three injections scheme, you can do a shot of Regular (or Humalog) before breakfast (1/2 or 1 Unit), before lunch (1 or 2 Units) and a shot of Regular with NPH before dinner (1-2 Units of Regular with 2-3 Units of NPH). If you want a small change to what he is getting now, you can diminish the Humalog to 1/2 Unit and see if the blood sugar level is better before lunch and if he will not require such a large mid-morning snack.
AS
