My 11 year old daughter has type 1 diabetes, has been menstruating for a year, and is now having a hard time with control. She is currently on 24 units of NPH with 12 units of Humalog at breakfast, 12 units of Humalog at dinner, and 26 units of Lantus (insulin glargine) at bedtime, along with a sliding scale on the Humalog for higher than normal values. The current trend we are seeing is normal at breakfast, low-to-normal two hours later at snack, low at lunch time, high two hours later at snack, and the highest value of the day is at dinner time. Bedtime and 2:00 am values are normal. What can we do to get those afternoon values down and our lunch time values into normal range?

Certainly you want to confer with your daughter’s diabetes team, but I might have you consider the following:

Since her readings two hours after breakfast are normal-to-low, that sounds pretty good and suggests that the dose of Humalog at breakfast is covering her well. So why is she eating the snack? Remember, Humalog peaks about 90 minutes after you give it so by mid-morning you are losing its peak effect. Perhaps she gets the snack to prevent a low before lunch? If she is high in the mid-afternoon and dinner, it suggests that the dose of morning NPH is inadequate. Is she getting a mid-afternoon snack? That might add to higher readings towards dinner. I do not like to limit food, if the child is hungry, but I see no reason to “force food” if the child does not want a snack if the child is receiving Humalog.

So here are some considerations:

Limit or stop the afternoon snack.
Increase the morning NPH to attack the afternoon readings and lower the morning Humalog to smooth out the lower readings before and at lunch.
Switch to Lente rather than NPH at breakfast since it peaks a little later, but you still might need to adjust the dose.
She is already using multiple daily injections, although perhaps a non-classic basal/bolus routine given the use of NPH. Are you sure you’re carb counting well and using the correct insulin-to-carb ratio? You probably are at breakfast, but maybe a higher ratio towards lunch and use of Humalog then might help.
She could progress to using an insulin pump.
Keep talking to your daughter’s diabetes team.

DS