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February 4, 2006

Daily Care, Other

Question from Elkins, West Virginia, USA:

My daughter, who is 6 in December, was diagnosed with type 1 diabetes in August of 2005. Since her diagnosis, her insulin needs have been really crazy. She weighs 44 pounds and is, as of yesterday, on half a unit of Humalog and four units of NPH in the morning; half a unit of Humalog and one unit of NPH in the evening. Her insulin needs change about every two weeks. Sometimes she starts having highs, so I have to increase her insulin and then she starts experiencing lows, so I have to decrease her insulin. This fluctuates back and forth all of the time. I was considering getting her an insulin pump, but don't know if it would be wise or not. Is this normal to have such a wide fluctuation in insulin needs all of the time? She is in Kindergarten and I send her lunch and monitor everything she eats. For breakfast, she has three exchanges; for lunch, three exchanges; for dinner, three exchanges and one and a half exchanges at snack times. Also, do her insulin needs seem to be appropriate for her age and weight? I was just concerned that there may be something else going on to cause her insulin needs to bounce out of control so often. I was also wondering why her insulin needs have not increased like I thought they would over time. Her last A1c was 6.5 and all of her blood work came back okay. She was tested for anti-gliadin and it was 52. Is that high? She was also tested for celiac sprue and it was okay. My mothers' intuition says that something is going on and I can't put my finger on it.

Answer:

Positive anti-gliadin with negative transglutaminase antibodies often indicate a wheat allergy rather than classical celiac disease. Many such youngsters in our practice have subtle or no symptoms on questioning and examination, but do remarkably well with a strict wheat avoidance dietary approach. It’s a difficult diet, but I think that they grow better and have fewer nonspecific complaints as well. Also, when we recheck the positive antibodies and they really are wheat free, after six to 12 months, the antibody titers decrease and normalize. I do not have term clinical data but suspect that subtle other problem such as osteopenia may also be prevented.

As far as insulin requirements, this is too individual to comment. We usually use a multidose insulin approach right from diagnosis and have stopped using twice-a-day Humalog or NovoLog with NPH. Rather, we use Lantus at bedtime and/or morning and bedtime for basal insulin needs, plus prandial analogs with adjustments based upon activity, carbohydrate intake and correction factors. This may help with your child as well, so you may want to discuss this with your diabetes team. Insulin pumps would be another excellent way to deliver such basal-bolus insulins when there is large day-to-day variability that is not caused by food inconsistencies themselves. If there is subtle bowel wheat allergy and/or variant celiac disease, then strictly avoiding all wheat in meals and snacks may also be very helpful.

SB