My 5 year old son, who weighs 46 pounds, has had diabetes for almost a year now. His last A1c was 6.2. He is on a regimen of Lantus (5 units at night), NovoLog and NPH in the morning (3.5 and respectively 2.5), and on a sliding scale of NovoLog starting from 2.5 at dinner. He may take up to 15 units of insulin a day. We know we cannot achieve the perfect control using this scenario of insulin, that he should be on four shots a day, but there is no one available to give him a lunchtime shot. Please help me with several questions below:

Is this too much insulin for a five year old?

Are his insulin dosages correct? I have read that Lantus should be half of his daily regimen, but we already consider downsizing from 5 units to 4 units because of the low blood sugars in the morning or in the middle of the night.

We are testing seven or eight times a day, a couple of times at night, and control is not that great, even with that much testing. How can we do a better job with less testing?

For a week with the same values at bedtime, same snack, he woke up within the range (around 140 mg/dl [7.8 mmol/L]). Last night, with the same scenario, at 2 a.m. my son was 66 mg/dl [3.7 mmol/L]. That was the first night in three months that I really thought that I could skip the 2 a.m. check. Does he still have spikes of insulin? How long will this last?

His diabetes team insisted that a carbohydrate to insulin ration cannot be made when he is using NPH, but I noticed that the following may be correct for my son: one unit of insulin lowers his blood sugar 100 mg/dl [5.6 mmol/L]; one unit of insulin needs to be given for every 50g of carbohydrates he consumes; and 1g carbohydrates will raise his blood sugar 10 mg/dl [0.6 mmol/L] at night 4 to 6 mg/dl [0.2 to 0.3 mmol/L] in the morning and 8 mg/dl [0.4 mmol/L] at dinner. Would this numbers be fair to consider? He eats about 48 grams of carbohydrates in the morning, 35g at lunch, 45 to 55g at dinner and 20g of carbohydrates for before bed snack (adjustable depending on his blood sugar).

Age, in and of itself, is not the major determinant of insulin needs: activity and food consumption are much larger players. I might estimate, for a five year old with diabetes for one year, the insulin requirements to be about 0.5 to 1.0 units for every kilogram the child weighs. At 46 pounds (21 kg), 15 units per day is 0.71 U/kg, and therefore, right on the money. But, your child may be leaving his diabetes honeymoon and his insulin requirements will go up, especially when he approaches middle-school and beyond.

Typically, the baseline insulin (which Lantus is) provides about 40 to 60% of total daily needs. It could be more, could be less, again depending on baseline activity, metabolism, etc. So, he may be a bit underinsulinized. Not uncommonly, younger children seem to be “fast metabolizers” of Lantus and the daily dose can be split up. Still that irksome issue of not supposed to mix Lantus with other insulins and therefore you talk about that many more shots….

Many, many studies have demonstrated that people with diabetes in good control test more often than those in poor control. When you test, you get information upon which you can act! The number of times that you test should be discussed with your own Diabetes Team physician and based on your confidence and anxiety level. An A1c of 6.2% suggests good control to me, especially for a five year old.

Your son may be having small “pulses” of his own insulin, but again, a year into the diagnosis, he likely is actually leaving the diabetes honeymoon. I often hear myself telling parents to try to see the “forest from the trees” in working with diabetes. In other words, I wouldn’t have you change his “routine” insulin doses based on isolated highs or lows. LOOK FOR RECURRING PATTERNS. For example, if he is mostly in the 140s mg/dl [7.8 to 8.2 mmol/L] at a certain time of the day but today he was 500 mg/dl [27.8 mmol/L] or 50 mg/dl [2.8 mmol/L], try to look for an isolated explanation (change in a meal, illness, change in activity). The A1c helps to see the forest. As for how long this will last, I don’t know. Special testing (for instance an I.V. glucose tolerance test or even an oral glucose tolerance test, for which there really would not be a strong clinical indications) could show you his “insulin reserve.” Other things can affect insulin SENSITIVITY, including other hormonal or metabolic irregularities that sometimes co-exist with diabetes. This would include, among other things, thyroid function, adrenal function, and celiac disease, all matters to discuss with his primary pediatric endocrinologist.

You need to discuss the insulin to carbohydrate ratio with your own Diabetes Team physician and nutritionist. You live with the child; you’re with him and monitoring his diabetes daily. Your Diabetes Team will not patrol at your house and oversee every meal, etc.

DS