April 26, 2001
Daily Care, Puberty
Question from Chesapeake, Virginia, USA:
My 10 3/4 year old daughter was diagnosed with type�1 diabetes at one year of age, and began insulin pump therapy a year ago. As a result, her blood sugars are falling in the normal ranges with her last HgA1c being 7.1%. Lately however, her blood sugars have been all over the place, and it has been difficult to treat since there is no pattern. Last week, her blood sugars ran low in the morning,and this week they have been over 300 mg/dl [16.7 mmol/L]and in one instance, 425 mg/dl [mmol/L] with large ketones. We followed the protocol for her pump, checked for problems, gave injections, and changed her infusion set, but unlike other times, she didn’t come down until late in the evening, even with the extra insulin recommended by her endocrinologist. Then, later when she did begin to come down, she went too low.
I am thinking that she could be on the verge of menstruating. She has been experiencing lower abdominal pain or cramping over the last couple of weeks. Is there any way to find out if her period is coming and if this is the culprit? I am not sure when I started. I just remember it was a “typical” age.
This story is not an uncommon one, and whilst this may be related to puberty, I think that the connection is likely to be an indirect one. My first guess would be that the overnight basal rates are set too high, and this is producing hypoglycemia in the middle of the night with a rebound hyperglycemia due to counterregulatory hormones that may raise the early morning blood sugars. I would suspect too that the cause of this is vigorous activity in the afternoon with perhaps some inconsistencies in suppertime and bedtime snacks.The irregularities in the morning blood sugar in turn relate to the timing and extent of the exercise and to any eccentricities in the diet.
The first suggestion then would be to do a number of blood sugars at about 2.00 am to see if this could be the case and then, if this turns out to be what is happening, try to relate the overnight blood sugar pattern to exercise and dietary factors. After that, it should be possible to obtain a more even morning blood sugar level by adjusting the overnight basal rates according to exercise patterns with additional adjustments to food intake at supper and bedtime as seems indicted. I am sure it would help to work on this with the nurse educator in your daughter’s diabetes team.
Also it just might be worth writing to Cygnus to see if one of the ten centers where the GlucoWatch device is going to be available now that it is FDA approved, is near at hand. It would make the whole business of really knowing what blood sugars are doing overnight so much easier.
[Editor’s comment: Your daughter’s situation might well be clarified by monitoring sugar levels continuously for several days to try to sort out what’s happening in more detail. See The Continuous Glucose Monitoring System, and ask her diabetes team about using it.