I have two little girls that are dying to visit with each other and I have to understand multiple injection therapy before I will be willing to take on the task of caring for the child to make their visit possible. I was told that she receives Ultralente at night and then during the day she is only given Lispro if she eats carbohydrates. Do you know anything about this? Are blood sugars for an eight year old female that run from 27-600 mg/dl [1.5 -33.3 mmol/L] at any time okay? Is DKA [diabetic ketoacidosis] not a concern? I was told that in a child this young this is good control and complications like neuropathy and vascular problems and blindness are only of concern after puberty. This is all contrary to what I, as a nurse, have practiced and have taught patients for the past 20 years, but I am willing to learn about any new practice. Are there specific books that address this therapy?

Lots of questions so let me address them one by one:

Intensive multidose insulin therapy [MDI] is not one approach but a variety of approaches that focuses on blood glucose levels prior to meals, what happens after meals and ultimately tries to mimic what the normal pancreas might do. It’s very difficult to achieve, comes closest with appropriate insulin pump therapy because the basal and bolus mode of the insulin pump allows maximum adjustments. All such attempts at treatment are never as good as the pancreas so there are lots of ups and downs because insulin is not always absorbed the same from time to time, site to site — and food is not always absorbed the same — plus there are the effects of hormones, emotions and activity added to all of this vagary.

Lispro prior to meals plus Ultralente is one of the MDI regimens. We actually prefer an overlapping dose of Humalog and NPH at breakfast, lunch, supper and bedtime with an occasional fifth dose of Humalog at afternoon snack. We make all treatment decisions based upon blood glucose goals being achieved, desired, hypoglycemia safety issues and A1c levels as well as actual blood glucose profiles.

None of the MDI regimens is better or worse than any other. Our treatment should be to get the blood glucose levels as close to normal as possible but always without excessive or severe episodes of hypoglycemia.

The information about prepubertal years of diabetes not being important is outdated. Many studies (Donaghue et al in Australia, Dorchy in Belgium and Swift in UK as well as Danne/Weber in Germany being the most prominent) have disputed the original report from Pittsburgh that suggested the prepubertal years were unimportant. In fact, this was a misinterpretation of the data as originally presented. We know believe that all years of high sugars matter but that something occurs with puberty (growth hormone levels and/or sex steroid levels, for instance) that allows glucose-related damage to show up at or around the pubertal years. We practice as if everything counts and still try to get as close to normal as possible — while understanding we do not have the tools to always succeed — and always avoiding severe and recurring episodes of hypoglycemia. We succeed quite well most of the time with MDI and also with insulin pumps but always using lots of blood glucose monitoring, frequent visits (like in the DCCT) and hoping that this will make a big difference. My colleagues in Sweden (Ludvigsson et al) have already documented that such years of improved control have reduced kidney disease. Similarly, my colleagues in Belgium (Dorchy et al) have shown the same thing.

Ultimately, what you have learned and been taught still seems correct. High sugars are damaging to internal organs and, after many years, this damage produces the well known complications of diabetes. The better the control, the better the growth/height and the fewer the complications. No reason to believe anything else and no data to suggest anything else. If anyone suggest that is okay to have high sugars, ask them to show you the data — and also ask them how they would treat their own young child or themselves. Everyone, when asked this question, aims for the best possible glucose control with the least possible hypoglycemia. Enough said!

SB