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April 26, 2002

Daily Care

Question from Reddington Shores, Florida, USA:

My 11 year old daughter, who has had type 1 diabetes for about one and a half years, has had a problem getting her sugars under control since her diagnosis. They are consistently high no matter how we count carbs or withhold sugar. To maintain her sugar at a reasonable level, she basically has to starve herself. We were given the guidelines for 60 grams of carb for meals and 30 grams of carb for snacks. If she eats this amount of carbs her sugar will run 400-500 mg/dl [22.2-27. 8 mmol/L] or more, and even with a minimum of 25 to 30 grams of carb for meals her sugars still run around 200-300 mg/dl [11.1-16.7 mmol/L]. We have tried everything. Yesterday, all she had to eat was five sausage patties with sugar-free syrup (about 6 grams of carb, no sugar) for breakfast, peanut butter on wheat bread (about 45 grams of carb) for lunch, and a hamburger with cheese, lettuce, pickles, mayo, ketchup and mustard (about 30 grams of carb) for dinner, which resulted in a bedtime blood sugar over 400 mg/dl [mmol/L], and she had large ketones. I am lost as to what we are doing wrong. If she were to eat the amount of carb she is supposed to her sugar would be off the scale. She is supposed to have a certain amount of carb for proper growth and at her age (she will be 12 in three months), and I worry about anorexia. She knows if she eats her sugar will be high. I would appreciate any help or suggestions you might have to offer me. I am afraid she is going to end up back in the hospital.

Answer:

You should be working very closely with your daughter’s diabetes team since this problem requires close collaboration. Sounds like she needs more insulin. In puberty, sometimes the insulin doses need to be significantly higher because of something called insulin resistance. If she is not using more than two shots a day, she may need three or four. We would make such changes based upon actual blood glucose readings, ketones levels, and hemoglobin A1c, and then try to match insulin to blood glucose readings very specifically.

SB

[Editor’s comment: There are several things to consider here:

As Dr. Brink has pointed out, impending puberty could be a culprit.
Could there be a problem with the insulin you are using at home? Opened vials of insulin need to be discarded monthly, and unopened vials should be kept in the refrigerator. Discard the vials of insulin you are currently using and change to new ones that have not expired.
Look at her injection sites carefully. If there are puffy or indented spots, this means your daughter has some lipohypertrophy or lipoatrophy. If this is the case, insulin injected into these areas will not work properly. She’ll need to use other sites.
If your daughter is currently giving her own injections, I think you should do them for a while to see if this makes a difference in her control. If it does, you will then need to explore why the insulin does not work when she self-injects.
I agree that a face-to-face visit with a pediatric diabetes team is needed. If you cannot locate one in your immediate vicinity, I’d suggest taking a trip to a center somewhere to get to the bottom of the problem.
SS]