June 12, 2002
Question from Warwick, New York, USA:
For the past two months, my three year old son's sugar levels have been very erratic. His diet has been pretty good with consideration to a typical toddler diet. He is very active also. He seems to be rising and crashing often no matter how I adjust his insulin. What can I do to help alleviate these terrible rate of sugar changes? His doctor would like him 90-200 mg/dl [5-11.1mmol/L], but his average is usually in the 200s mg/dl [11.1 mmol/L]. I also notice his disposition to be very good when he is in the high 100s - low 200s mg/dl [5.6-11.1 mmol/L]. The other problem I have been noticing is dinner time sugar levels may be in the mid 100s [mg/dl, 5.6mmol/L], and then when I check him at snack time before his bedtime he has either been low so I may give him a little juice as recommended, but an hour later he may skyrocket to over 400 mg/dl [22.2 mmol/L]. The psychological effects are very draining also. The constant worrying about the highs and lows are very taxing on myself and my mother who helps care for him while I'm at work. His doctor believes he would be a candidate for the pump, and I seem to be getting pressure from friends/relatives about it as well. I am not comfortable with this option, namely because I am unaware about how it is used and works in a child my age. I've heard wonderful things about it, and I've also heard not so wonderful things. I just can't seem to get a handle on the way his body is working and why this happening. What can I do to help alleviate these terrible rate of sugar changes?
Before worrying about whether an insulin pump will help, I would work with your son’s diabetes team to adjust his insulin to accommodate his food intake (through carbohydrate/insulin ratios) and blood sugars (through corrective dosing) and giving him his shots after he eats (once you figure out what his food intake has been). Toddlers can be quite unpredictable in their eating and activity habits, and this allows some flexibility and further parental control.
Our team has taken the approach that toddler blood sugars should be in the 100-220 mg/dl [5.6-12.2 mmol/L] range with numbers over 150 mg/dl [8.3 mmol/L] at bedtime. If you can keep 40-60% of blood sugars in this range, without many severe lows, his hemoglobin A1c will usually be around 8-9%, and you can know that you’re doing a reasonable job managing his diabetes. Fortunately, young children are relatively protected from the long term complications of diabetes.
If you test him within one to two hours after he’s taken juice or had a snack, his blood sugars will often be quite high. It’s best not to worry about those numbers falling within “average”. Just use them to make sure you’ve treated the low adequately. If he’s still high a few hours later, evaluate how much carbohydrate you’ve given him since some three year olds will not need a full 15 grams of carb to treat a low, depending on what their blood sugars have been and how low they were.