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July 6, 2006

Hypoglycemia, Insulin

Question from Mt. Pleasant, Texas, USA:

My 11 year old son was diagnosed when he was two years old. We've had our ups and downs, but, overall, have never experienced major complications. I credit this to our structured approach over the years of maintaining good carbohydrate counts, a healthier diet/exercise, and a good control/testing of blood sugars for my son. But, there are a couple of questions lingering on our minds now and we'd like your opinion. About five months ago, my son's insulin regimen was changed from NPH/Humalog to Lantus/Humalog, mostly because he was suddenly recording higher and higher overall blood sugars. This change produced greater control in his A1c, from a high of 8.5 to 7.5. This was done as a suggestion from a new endocrinologist and we were very pleased with the results. Over the past two weeks, he has been experiencing lows when waking up (40 to 60 mg/dl [2.2 to 3.3 mmol/L]) and after eating breakfast, with no Humalog whatsoever. We've even given bedtime snacks, up to 20 g of carbohydrates to try to avoid the morning low. Now, we are playing an insulin game, to the extent that it is becoming a risk to give Humalog, as normal, at breakfast, because of the lows he is continuing to experience. We went through the honeymoon period years ago when he was a baby, and from all my research, it seems that it is not possible for his body to begin producing insulin again, assuming all islet cells are now destroyed in his body. Call it mother's intuition, but something is going on here. Are there any cases ever documented, worldwide, that the body could indeed produce insulin again, even small amounts, after nine years of type 1 diabetes? My second question is regarding his growth. He is entering the puberty phase, beginning with the tale-tell pimples on the face. We have been very concerned over the growth of his penis, as his is smaller than his six year old brother's and much smaller than the average boy his age, which has already resulted in teasing. We've been told time and time again that this is in no way related to diabetes. But, since the change in insulin management, his overall growth in height/weight jumped in just three months. Maybe this was happening due to normal growth patterns, but are there any cases where diabetes caused any decreased blood flow to the male genital area, causing growth problems? I read about the impotence in men and see that other parents share my concern about their own preteen boys. What kind of questions should I ask my doctor? They generally dismiss this, but should I have anything checked - growth hormones, thyroid, etc.? As a woman, I have no idea what predicates the size of a man's penis, but am genuinely wanting to do whatever possible at this stage to ensure his best chances at a "normal" growth.

Answer:

The issues related to his growth and recent improved glycemic control can be related. In a simplistic manner, if his glucose levels are better (as reflected by the lower A1c), then he is (literally) not “pissing away” calories (glucose).

Puberty hormones more commonly cause higher glucose readings, not lower. I would not expect diabetes to lead to diminished blood flow to the genitalia. The male genitalia respond to testosterone and similar hormones, primarily. I’d expect a pediatric endocrinologist to have inspected and even measured the young man’s genitalia; there are normative data and charts for the wide range of normal penis growth before and after puberty.”True” puberty, as reflected by increases in testicular size and penile development, may not occur in a teenage boy until about as late as 14 years. Simply raise the question to your child’s pediatric endocrinologist.

The recent “increased sensitivity” to insulin is indeed surprising and should be investigated. Are you sure of the dosages of insulin? Who is measuring it? Who is giving it? Is it being supervised or witnessed? Other, not-so-uncommon metabolic derangements can evolve with type 1 diabetes and your pediatric endocrinologist will likely want to search for issues with the young man’s levels of thyroid hormones and adrenal cortisol, and screen for intestinal celiac disease.

DS