February 25, 2002
Question from a nurse who is a Certified Diabetes Educator in Waterloo, Iowa, USA:
I am currently assisting a mom of a one month old who has hyperglycemia, and I have never worked with a child this young. The doctor is treating with diluted (1:1) Ultralente and Regular every 12 hours and feels the hyperglycemia may be due to immature pancreas as child was born one month premature and small for gestational age (weight 2 pounds, 13 ounces at birth, now up to 4 pounds). Any helpful hints in how to have mom cope at home, detecting low blood sugar, how often to test without being obsessive compulsive about numbers, how frequently to check ketones? Any information on immature pancreas would be helpful.
This is certainly challenging. Is the child being followed by a pediatric endocrinologist? With a baby of this age and diagnosis, I would almost insist.
To me, the foremost concern is that people should have realistic expectations for glucose control for this infant. I would not aim for “tight” glycemic control: 150-200 mg/dl [8.3-11.1 mmol/L] should be very adequate. The combination of Ultralente and Humalog seems a good choice to me, with Humalog dosed on carbohydrate counting.
The family needs to be prepared to look for lows. This infant indeed may have few symptoms. The family should not focus on individual numbers, but rather to look for patterns. I would ask that the family check glucose before meals, when they lay the infant down for the night, and when they go to bed themselves. I think that it would be prudent to check this baby more often rather than less often. So a glucose check with a night-time feeding is appropriate. Perhaps a few times a week, they would check the glucose readings two hours after a meal. If the baby feeds every three to four hours, they’d really be doing that anyway.
In this infant, if I am assured that Ultralente is being given (My experience is that Ultralente needs to be given twice daily with many children), then I am less concerned with DKA [diabetic ketoacidosis]. I would be more concerned with hypoglycemia. Families should know to check urine for ketones if the glucose is more than 250 mg/dl [13.9 mmol/L] and should know how/when to give glucagon.
There is a rare form of neonatal diabetes that sometimes resolves in infancy. It actually can be looked for with special genetic testing.
[Editor’s comment: Check to make sure that the meter this mother is using is approved for use in neonates since it may otherwise yield inaccurate readings. If it is not, this mother should get a meter that is.