My six year old daughter, diagnosed about eight months ago, is on Regular with NPH in the morning, Regular at supper time. and NPH at bedtime. The problem is lately though we have tried everything it seems, going up on the Regular at breakfast times made her bottom out when it got to be around 10-11 am even though she had a morning snack. We even increased her grams of carb at breakfast, and by 10 she was hitting the low 70s [mg/dl, 3.9 mmol/L].

So, her doctor dropped her back from 4 units of Regular with 7units of NPH in the morning to 3 units of Regular with units of NPH in the morning which has stopped her from bottoming out but by supper time (5-6 pm), she seems to be running 200-300 mg/dl [11.1-16.7 mmol/L]. We give her 3 units of Regular at supper, and sometimes she hits the low 70s mg/dl [3.9 mmol/L] before bedtime (8:30 pm) and sometimes she is still high. Then she gets 5 units of NPH at bedtime, and by morning she is still in the 200s mg/dl [11.1 mmol/L].

I don’t know what is going on with my daughter’s blood sugars, and it’ s upsetting all involved. The doctor just keeps changing the insulin and doesn’t seem to know what is going on with her either. What are your suggestions?

I was not completely clear on the perceived issues but as I understood, your daughter, diagnosed with type 1 diabetes about eight months ago, is currently on mixed doses of NPH and Regular in the am, a dose of Regular with the evening meal, and a dose of NPH at bedtime. The doses are being adjusted because she is awakening with higher glucose levels before breakfast, and has higher glucose levels before the evening meal, but has an easy tendency to drop to lower glucoses in the mid-morning and sometimes also at bedtime. She is on three meals and three snacks.

You sound very frustrated. I do hope you are not looking for “perfect” glucose readings, but it is perfectly acceptable to shoot for “very good” glucose readings.

I’d want to take a step back and look at the fundamentals: a normal glucose is 60-110 mg/dl [3.3-6.1 mmol/L], although we don’t really get excited about a diabetes value unless the fasting glucose is more than 125 mg/dl [6.9 mmol/L]. Please do not get a “normal” range confused with a “target” range. For a six year old, I’d have a goal of about 80-180 mg/dl [4.4-10 mmol/L], or maybe a little lower. Your daughter’s doctor may suggest a different target. Certainly, I would not get excited about a glucose value “in the 70s [mg/dl, 3.9 mmol/L]” since that is perfectly normal! In addition, if it is occurring just at the time of a scheduled meal or snack, then wonderful!

Typically, I like my patients to go to bed with a glucose reading over 100 mg/dl [5.6 mmol/L]. You did not clearly note the time between the dinnertime glucose check and insulin dose and the bedtime check/snack/dose.

Given what I think you are relaying, I’d suggest that the easiest thing is to increase her bedtime NPH in order to bring the glucose levels down by breakfast and perhaps increase the morning NPH to help bring down the evening glucose readings, remembering that NPH begins to work about two hours after a dose but has it’s maximal effect about six to eight hours later, while Regular begins to work about 30 minutes after a dose and has its maximal effect about three to our hours later.

There are other options that might include giving Lente rather than NPH as it may last a bit longer or you could discuss switching to an insulin regimen to more mimic natural physiology using what is often referred to as a “basal/bolus” insulin plan using very long-acting insulins (such as Lantus or Ultralente) and then dosing with a short-acting insulin with every meal with her doctor, but that would require multiple daily injections and carbohydrate counting skills.

Diabetes management is not constant, unfortunately. It is very fluid based on activity, meals, insulin absorption, etc. Making adjustments in the doses is exactly what the doctor is supposed to help you do. You may wish some more sessions with the Certified Diabetes Educators within your daughter’s diabetes team.

DS