Our two-year-old son was diagnosed with type 1 about a month ago. His insulin to carbohydrate ratio is currently 1 to 45 with a half a unit Lantus daily. He weighs 38 pounds.

It seems that at night, starting from about 10 to 11 p.m., his blood sugars go up about 100 to 150 mg/dl [5.6 to 8.3 mmol/L] until about 3 a.m., then go back down about 100 to 150 [5.6 to 8.3 mmol/L] by 7 a.m. Although he ends up with about the same numbers in the morning, it would help to know the cause. Last night, he was 144 mg/dl [8 mmol/L] at 10 p.m., 301 mg/dl [16.7 mmol/l] at 3 a.m. and down to 101 mg/dl [5.6 mmol/L] at 8 a.m.

Although it seems he is currently in the honeymoon stage as his insulin needs have lowered since originally diagnosed, it doesn’t seem to be connected because this has been going on since we left the hospital.

You did not clearly indicate the time of day that the Lantus is given, and that might make a difference. Although Lantus is essentially “peakless,” it does have a time to onset of action. It is the clinical experience of many that younger children are “fast-metabolizers” of Lantus so they are often given Lantus twice daily, sometimes in a 50:50 split, sometimes about 75:25, with the larger dose as the “first dose.” Very often, Lantus is given at bedtime, but if you are providing it in the morning, then it is possible that by the middle-of-the-night, the dose is waning some, but the glucose levels are returning to acceptable targets in the morning because your child is only a couple of months into the diagnosis and is likely “honeymooning.”

If you are giving the Lantus at bedtime, then the elevated glucoses you see at 3 a.m. may indeed reflect that a little more insulin (short or rapid or even intermediate-acting, depending on the timing of the last non-long-acting insulin dose and meal/snack) is required. But, as a clinician, I’d ask: WHY? The glucose values are normalizing. What is the A1c, which is reflective of the “great majority” of plasma glucose values? You could strive for “perfect” levels but: 1) you will ‘NEVER’ achieve them and then 2) you will be disappointed or frustrated. Follow the glucose trends and you will see the wiser and see the “forest from the trees” and not get fixated on any particular number. At this age, it is certainly advisable to avoid hypoglycemia.

By the way, when I prescribe Lantus at bedtime for young children, I typically mean the PARENT’s bedtime. You should discuss specifics with your child’s own pediatric endocrinologist.

DS