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December 4, 2006

Daily Care, Insulin

Question from Newcastle, New South Wales, Australia:

My son has recently been taken off the pump due to high blood sugar levels. He has been put on Protophane and Actrapid injections in the morning and evening and has NovoRapid as needed when he has blood sugars "2 x 15 mmol/L [270 mg/dl]." Is this an optimal regime for a three year old to gain better control? Is there a better one? Now, we are having trouble with low blood glucoses at bedtime and sometimes lows in the morning. He is on three units of Actrapid and five and a half units of Protophane at dinner. Is this too much? What would be his optimal bedtime blood glucose?

Answer:

To summarize, your three year old son was on an intensive insulin regimen using an insulin pump to provide continuous infusion of insulin but was taken OFF this, presumably by his Diabetes Team, because of poor control and high glucose levels. He has been placed on a very basic insulin plan using an intermediate (Protophane – NPH in the U.S.) and fast-acting (Actrapid, which is purified pork Regular insulin) twice a day PLUS some rapid-acting insulin aspart (NovoRapid; NovoLog in the U.S.) when he his glucose is more than 2 x 15 mmol/L (2 x 270 mg/dL or 540 mg/dL)!

You ask if this is optimal and for the best glucose at bedtime.

Number 1: You need to have a good, long conversation with your pediatric diabetes specialist. If you don’t have one, ask for a referral. If you do, then please get a good dialogue going. To go from an intensive insulin regimen via a pump to this twice daily plan because of high glucose levels, suggests some major poor control and regulation of glucose, meal planning, and corrections at home.

I am not saying that the current insulin plan is bad, but I would have expected wonderful glycemic control while on the pump. But, the pump is not for everyone and it requires a lot of work to manage the device, check glucoses very often, give extra amounts of insulin and track calories (“count the carbohydrates”) excellently. The new insulin plan is actually a very old, tried and true insulin plan. It does not allow as much flexibility as the pump plan as now your son is pretty required to take insulin at specific times of the day and eat designated amounts of food at specific times of the day. That may or may not be difficult for a toddler.

The amount of insulin on this type of insulin plan is variable, as it hinges on the meal plan and daily activity but, in general, one might estimate nearly one unit of insulin daily for every kilogram the child weighs. You didn’t really give a total of insulin dosing. But the average three year old weighs about 14 to 15 kg (31 to 33 pounds), so I might anticipate that your son would require about 15 units total of insulin daily.

If you are having wide, daily fluctuations in glucose, it suggests that there is an imbalance in meal planning relative to insulin and activity. Most commonly in my experience, it is from poor attention to meal planning.

Finally, I am a bit surprised at the “threshold” for which you have been told to give the NovoRapid. Again, you indicated extra for “2 x 15.” I assume that is 15 mmol/L glucose reading which translates to 270 mg/dL, which by itself is very high. And, you’ve been told to wait to give insulin until it is TWICE that.

I think a glucose target goal for a pre-schooler is about 100 mg/dl [5.6 mmol/L] to 200 mg/d ([11 mmol/L].

Please have an informed conversation for the specific diabetes plan for your child with your pediatric diabetes specialist.

DS