My six year old daughter, diagnosed with type 1 diabetes about eight months ago, is on Humalog with NPH before breakfast, and she eats approximately 45 grams of carb for her main meals and 15 grams for her snacks. Her A1c was 6.6% three months ago, but recently it has gone up to 7.3%. During this interval, she had a bout with illness, we saw a gradual need for more insulin, and she is growing normally for her age.

I have checked her blood glucose levels two hours after breakfast to make sure she wasn’t going low, and, she is still always high at lunch. I know that if I gave her more of Humalog in the evening it would kill her, so it terrifies me to send her to school every morning after giving her but if anything she does seem to need more Humalog in the morning.

We are working with our diabetes team to get to an appropriate dose of insulin. We are gradually raising the NPH, and she seems to have good numbers before breakfast, after school, and before dinner, and bedtime, but she’s still very high before lunch. At home on the weekends I have checked her blood glucose before morning snack and sometimes it is very high as well which is unacceptable. It is like the Humalog doesn’t even work half the time in the morning, and this has been going on for about a month. Why does it take far more Humalog in the morning than at night, for the same amount of carb consumption?

Well I think the answer is two-fold, but the primary answer is right in what you wrote. Some might point to the

dawn phenomenon that, due to more morning hormones produced naturally (like growth hormone and cortisol), we all have higher glucose values in the morning so we might need more insulin to “cover breakfast.” I have many patients who dose insulin based on carbs, and they require more fast-acting insulin at breakfast than at other meals. However, I think the more definite answer is in knowing how the insulin works: the Humalog you give at breakfast peaks about 90 minutes later and then has a mild residual effect for a bit longer. So in essence, it “covers” breakfast. The NPH you give at breakfast has its peak effect later in the afternoon, so it is covering lunch and a potential after-school snack. Your child is high at lunch. So why are you giving a mid-morning snack? It’s likely because you were told to! However, that “three-meal/three-snack” regimen evolved from our use of NPH and Regular insulin which begins to work about 30 minutes after breakfast and peaks about two-three hours later –between breakfast and lunch. So, in order to be certain to avoid a mid-morning low, people prescribe a snack!

I think your options are multiple:

Less protein at breakfast
Cut back or out the morning snack.
If your child wants the morning snack, then can either:

give another dose of Humalog using carb counting to guide how much insulin to give

OR

give Regular at breakfast instead of Humalog. The Regular could cover breakfast and the snack to come. The potential disadvantage here is now the snack should not then be missed.

Please do not make any significant changes in meal planning or insulin dosing without input from your daughter’s diabetes team.

DS