My son has had type 1 diabetes since right after his third birthday. He has been on 4-5 injections per day. He is taking Humalog and NPH. We just moved to Alaska in July of 2003, and his diabetes is out of control, along with his asthma. We just got an endo in Anchorage but, so far, no one can really make sense of anything. He A1c is now 12%, while four months ago he was 9%. I am terrified for him.

I work on the medical-surgical floor with people who are very ill from their blood sugars being out of control. My son never had these problems in Texas. His A1c stayed in between 7-8% and we were getting ready to go to the pump. However, the doctor up here says he’s too young for a pump. I think he needs a pump. He is going to get worse if we can’t get his blood sugars down. I need some advice on what I can do? Can I demand an insulin pump?

First of all, your son is not too young to start an insulin pump. He may or may not be ready; he may or may not be responsible; he may or may not have the support he needs from family and health care providers (seemingly your doctor is not supportive) — but he is not “too young.”

Pump therapy requires an understanding that the pump is not an artificial pancreas: the pump will not automatically adjust the dose of insulin based on the blood sugar; rather, it adjusts the rate of the insulin based on time of day. Glucose levels must be checked multiple times and then extra insulin must be given based on food consumption. Therefore the pump provides insulin in what is called a “basal-bolus” manner: the “basal” is the amount of insulin that is continuously being infused, based on time of day while the “bolus” is the additional insulin required based on meal intake. Therefore it is important that calories be counted and thus insulin dosed appropriately accordingly. This type of basal-bolus therapy can also be done with insulin injections.

It does not sound to me that he is currently on a basal-bolus plan, although NPH plus Humalog can be used in this manner sometimes. He’s on 4-5 shots of insulin a day with NPH and Humalog? That seems a bit atypical to me – even for a basal-bolus plan. But I will add that other basal-bolus plans using Lantus and Humalog (or NovoLog or even Regular) do typically require multiple daily injections.

I wonder if some sessions with a counselor might be in order for the child: perhaps this move from Texas to Alaska has been more traumatic to his psyche than is appreciated. I wonder if there has been a larger change to the daily regimen of meals and activities.

I infer that the endocrinologist may not be a pediatric endocrinologist. A peds endo is not necessarily required but would be preferred, especially if that provider has little comfort level with pumps in children. If you have relocated to Alaska based on a military move, it may be possible to have peds endo consultations elsewhere.

Clearly there are issues here that cannot be addressed with an e-mail response. Please seek out the care of your diabetes team and relay all the concerns. You may have to really get back to basics to figure what has gone awry. A structured stay in the hospital may be required.

DS