My 10 year old son swings between high and lows daily. After three years, I would have thought we could have hit on the correct insulin for him. He is only happy to inject twice per day, and we have used several different premixed insulins. He eats correctly, does plenty of exercise, and checks four times per day. We feel quite disappointed that despite our 100% efforts, we haven’t got things under control. How normal is it for active children to have not settled to a good daily set of readings after this long?

To begin with, the hemoglobin A1c level should be used as a judge of how much the fluctuations of blood sugar levels will count towards complications. Of course, the A1c reflects only mean blood sugars so that a good level is still compatible with wide swings.

I wonder if, with the help of his doctor, you could do some bargaining with your son. You would ask him to agree to three shots per day. One right after breakfast would be the long acting insulin Lantus with a second shot at the same time of Humalog together with enough NPH to cover lunch with the third shot just after supper of Humalog again. The Humalog injections could be calibrated to the pre meal blood sugar and the number of carbs actually consumed. In return, you would undertake to use a device that essentially make the injections painless.

DOB
Additional comments from Dr. Andrea Scaramuzza:

Managing diabetes with only two shots per day is not very easy. There are so many factors throughout the day that can could influence the blood glucose levels, so it is not strange for me to read that your child is having so many fluctuations.

For a better control and more blood glucose stability, you can ask his
doctor to switch to Lantus. However your son would have to inject Humalog

or

NovoLog

three times per day before meals (breakfast, lunch and dinner). If if you don’t want to switch to this new insulin , I think he might have better results by introducing a third shot before lunch.

AS
Additional comments from Dr. Larry Deeb:

I have only seen two shots work with the most regimented families (very similar meals and set meal times). Otherwise the vagaries of insulin activity and childhood activity won’t mesh.

LD
Additional comments from Dr. Stuart Brink:

If he has typical type 1 diabetes, premixed insulins often don’t work unless there is a lage amount of food and timing regimentation. Many centers around the world have “given up” on forcing food to work against insulin peaks and valleys and have substituted a much more flexible multidose insulins regimen that uses insulin analogs before meals and snacks (boluses) and supplements these boluses with several types of longer-acting analogs (ie. Lantus once or twice a day, Lantus at bedtime and NPH at lunchtime, etc.) to provide

basal
insulin function. Coupled with frequent blood glucose monitoring this allows greater flexibility and timing of meals, amounts, sports activity bursts, etc. We have used such an approach for the past twenty years with great success, little severe

hypoglycemia,
and excellent A1c levels.

The price one has to pay, however, is more insulin injections to get more flexibility and improved glucose control. The more the glucose control improves and the fewer the wide blood glucose swings, the greater likelihood that A1c will be lowered and therefore long term complications, growth problems, etc., all will be less likely. Many pediatric diabetologist think that this should be the way to start treatment for type 1 diabetes so that you do not get into battles with youngsters about taking more injections but there are different opinions about this. The number of injections is not the key issue but how to control Blood glucose variability from day today is the key decision point.

You should go back and discus this with your diabetes team and see if you can problem solve the situation with them. The teaching manual

Insulin-Dependent Diabetes in Children, Adolescents and Adults,

by Dr Ragnar Hanas

(available on this web site as well as at web-based bookstores like Amazon) have excellent chapters describing such an approach and how it works for children. It is conceivable that you will also have to “pull rank” and decide the number of shots of insulin needed on his behalf if he balks too much.

SB