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May 24, 2007

Diagnosis and Symptoms, Insulin

Question from Syria:

My 18-month-old son was diagnosed with type 1 diabetes when he was 13 month old after an ear infection. We give him NovoRapid and NovoMix. His reaction to insulin is very high; two units may cause him to drop from 400 mg/dl [22.2 mmol/L] to 70 mg/dl [3.9 mmol/L]. All our efforts to keep his blood sugar within 100 mg/dl [5.6 mmol/L] to 150 mg/dl [8.3 mmol/L] are in vain. Initially, the results of his GAD test were negative. A second test, last week, was also negative. Both tests were performed at the American University Hospital in Beirut which is handling my son's case. A doctor took blood from us (parents) and my son to find out the gene responsible; the test is to be conducted in aLondon laboratory. The doctor advised us that the treatment will be the same, that these tests will help him managing his diabetes in the future. I have three questions: Regarding Lantus type insulin: The doctor advised us that Lantus will work perfectly for our case. However, this type of insulin is not approved by the FDA for kids under eight years old, but he said we "may" use it; but he never say I can use it, as he cannot take responsibility for it. Can we use Lantus for our son? If not, how can we manage our son's diabetes without having blood sugars of 40 mg/dl [2.2 mmol/L] to 50 mg/dl [2.8 mmol/L] at 2 a.m.? With respect to the GAD testing: if the results were negative, twice, doesn't that mean he does not have type 1? If he does not, what treatment approach do we take? We are willing to travel anywhere we need to go! Regarding chromium: The doctor said that he had another same case which parents gave the kid a chromium supplement without the doctor's advise and, after two months, they reported to the doctor that the kid is insulin free! Would a chromium supplement help our son? If so, at what dosage? What kind of foods could we feed our son in order to give him chromium naturally? Are there any side effects? What is the latest finding?

Answer:

I will address the easier questions first: chromium is unlikely to work in type 1 diabetes, so, generally, it is not used and not advised. I suspect that another child treated with chromium just entered a honeymoon phase of partial beta cell response.

Antibody tests are notoriously inaccurate for very young children. So, islet cell or GAD65 antibody tests, if positive, confirm autoimmune type 1 diabetes; if negative, they are unhelpful. I assume that the special genetic tests went to Dr. Hattersley’s laboratory working in cooperation with ISPAD. I am the current ISPAD president and know about this excellent collaboration around the world. If the genes are abnormal, then insulin could be stopped and another medication called a sulfonyurea substituted for improved glucose control and, of course, no need for insulin. All will depend upon the genetic test results.

As far as Lantus, we and many others use it in very young children for the past five years without obvious problems. You can also use detemir in similar fashion to Lantus. You are correct that it is not officially approved, but there are many such medications which are used without formal approval and that seem to work. Our routine would be to use small doses of Lantus morning and late evening and then boluses of NovoLog (or Humalog) before breakfast, before lunch, before dinner and before snacks. All should be based upon actual before and after blood glucose readings. Fast acting insulin can also be diluted, either with the company’s own diluting solution or with normal saline to allow smaller doses to be used at any given moment.

SB

[Editor’s comment: Make sure you discuss blood sugars and the timing of shots of short acting insulin, such as NovoRapid, with your diabetes team. Often, toddlers are picky eaters who may have better blood sugar control getting insulin after they eat.

BH]