I am taking care of a two week old neonate who is HIV exposed whom we have since diagnosed with neonatal diabetes. Abdominal ultrasound is suggestive of an atrophic pancreas. The baby is on soluble insulin at 2U/kg. Glycemic control is still poor. Why?

Neonatal diabetes is extraordinarily difficult to manage, especially when coupled with HIV infection adding extra metabolic stress, no doubt. There are many ways to manage such insulin regimens in such small babies. Many use insulin pumps, if they are available, since this would allow optimum adjustments of basal insulin needs plus boluses as often as needed for correction. The more regimented can be the food intake, the better at being proactive and predicting insulin bolus needs, of course. If insulin pumps are not a possibility because of financial concerns or supply availability, then a multi-dose insulin regimen using Humalog or NovoLog as prandial bolus insulins, probably diluted 1:10 so that 1/10 unit doses, can be administered accurately with one-half unit marked syringes. This can be coupled with Lantus insulin once or twice daily. Sometimes, it is best with babies for morning Lantus not bedtime Lantus; sometimes morning and bedtime Lantus. If Lantus is unavailable, then overlapping small doses of NPH can also be utilized; we used to use three or four such NPH overlapped doses coupled with boluses of prandial rapid-acting analogs that were adjusted by algorithms.

The key to all of this is frequent blood glucose monitoring so that guesswork is minimized and ongoing adjustments can be made multiple times each day. This also will allow identification of hypoglycemic episodes, probably unavoidable, but, in this fashion, identified so that they do not become convulsive episodes.

I would be glad to provide ongoing assistance and support if specific questions arise with this most difficult medical problem.

SB