My four-year-old daughter has had diabetes for more than two years and has been pumping for about a year. Her blood sugars are much more variable that I would like to see. I test her six to eight times daily. In a normal week, she will have about three 400+ mg/dl [22.2 mmol/L] readings, seven 300+ mg/dl [16.7 mmol/L] readings, three readings in the 60s mg/dl [3.3 to 3.8 mmol/L], and one reading in the 50s mg/dl [2.8 to 3.2 mmol/L] (excluding any retests within a couple of hours or tests that she might have had less than two hours after meals). She’ll have a 500+ mg/dl [27.8 mmol/L] and a below 49 mg/dl [2.8 mmol/L] reading about every other week. Her A1c is about 7.4 on average (low 6.9, high 7.9), and she’s within range (70 to 200 mg/dl [3.9 to 11.1 mmol/L]) about 50% of the time so her diabetes care team is not concerned. I don’t like to see her levels swing so fast and so often. I would think that since she is on a pump, her blood sugar readings should be more stable. I am careful when I count carbohydrates, often using a kitchen scale and carbohydrate ratios. Are these swings normal?

Her diabetes team wants me to aim for an A1c of about 7 and has me do nighttime pump corrections to 100 mg/dl [5.6 mmol/L] rather than the more conservative 150 mg/dl [8.3 mmol/L] or so that I would feel more comfortable with (I don’t like correcting to 100 mg/dl [5.6 mmol/L] at 11 p.m.!). They think I’m doing a good job caring for my daughter though. I feel more comfortable with an A1c of 7.5 to 8 because she has fewer lows that way and because her blood sugars are so variable. Am I being unreasonable?

For a four-year-old, the American Diabetes Association advises to target the HbA1c between 7.5% and 8.5%. Why? In part, because there is the concern that overzealous glycemic control might lead to a serious hypoglycemic or other sudden untoward event (such as “Dead in Bed Syndrome” – the nature of which is unknown but is hypothesized to be linked to nocturnal hypoglycemia).

I think there are pediatric endocrinologists who would target an HbA1c in this age group lower and their approach could be supported. As a child gets older, the target for HbA1c gets lower toward 6.5 to 7%. But your letter confounds me a bit: You write that “Her A1c is about 7.4 on average (low 6.9, high 7.9), and she’s within range (70-200 mg/dl [3.9 to 11.1 mmol/L]) about 50% of the time so her diabetes care team is not concerned.” You then write “Her diabetes team wants me to aim for a A1c of about 7.” So, are they happy or are they not?

I think your instincts are not at all unreasonable. I do NOT advise my younger patients to target a glucose correction to 100 mg/dl [5.6 mmol/L] at nighttime. Indeed, I generally target glucoses to 120 mg/dl [6.7 mmol/L]. Amongst my reasoning is that such a value is low enough to prevent symptoms of excess glucose (increased urination and thirst), and is high enough that if they do “overshoot”, there is plenty of room to go before I would expect hypoglycemia symptoms. There are some children, typically thin and younger ones, whom I target at 150 mg/dl[8.3 mmol/L].

As for your wanting to limit the wide fluctuations, I’m sure your diabetes team would agree with that, too. You sound like you well understand pumping and that an insulin pump is in NO WAY an artificial pancreas. But, one goal of pumping is to limit the degree of the fluctuations so that the highs aren’t so high and the lows aren’t so low. If one is expecting a super-tight range, especially in a preschooler, then I think they might be deluding themselves.The so-called Un-tethered Regimen” might be helpful. I think it is often terrific. It also helps avoid those instances when the insulin infusion gets interrupted during the night (kinked tube, catheter issue, pump failure, etc) and the patient awakens very hyperglycemic and ketotic. Please discuss this with your diabetes team.

One of the new technologies that can assist with limiting the wide fluctuations is the use of a continuous glucose sensor. Whether using a CGM is right for you and your child (and in your budget) is another matter. For a four-year-old, you will probably battle insurance companies. Also discuss this with your diabetes team.
Great job with that A1c! Teach your child good habits now for a long LIFETIME of diabetes control.

DS