My 11 year old son has had type 1 diabetes for two years. He takes two combination shots of insulin R/N in the A.M. and dinnertime. Over the past year I’ve noticed days where his blood sugars elevate for no apparent reason. The insulin is good, not ill, no major changes in eating pattern or activity. These elevated days last for 2-5 days and occur once a month or sometimes twice a month. We manage these days like sick days with insulin increases, but he is not sick. My diabetes team tells me this “just happens.” Another diabetes educator agrees with me that these are likely related to growth hormone spurts. What is your opinion?

I am not sure that I agree with the concept of ‘growth hormone spurts’: I think it more likely that these erratic blood sugars are associated with some form of stress at school or dietary malpractise. If his control is generally good and his A1c is around 7% (i.e., near the upper limit of normal) then I would not be concerned. If this is not the case, then it might help to have the medical social worker in the diabetes team talk to your son; a really experienced person can often uncover a problem that may not be apparent at home very quickly. If there turns out to be no evidence of a psychosocial issue and the A1c suggests less than good control it would be worth discussing with the endocrinologist whether a more intensive insulin regimen is needed or whether perhaps it might be time to consider a insulin pump.

DOB
Additional comments from Dr. Lebinger:

Although I agree that often when you look closely, you may find “hidden” reasons for “unexplained” changes in blood sugars, in my experience, often no reason is found. There have been many theories to explain these erratic blood sugars, such as erratic absorption, or binding of insulin to proteins (protein bound insulin is inactive) which is then released, but no real reason has ever been found.

Many years ago, studies were done with a machine called a Biostator, which was basically an external “artificial pancreas”, the size of a TV. Patients would be studied sometimes for several days in clinical research centers. Patients were hooked up to 2 IV’s. One IV drew blood to measure the blood sugar every minute. Another IV gave insulin and or glucose to keep the blood sugar at a preset level (the preset level could be low, normal, or high) The amount of insulin and glucose given was determined by computer generated mathematical formulas. Patients were hooked up to IV’s so they had very little variation in day to day exercise and were given hospital food with the same amount of carbohydrate, protein, and fat each day. One interesting finding was that although most people could be controlled with the mathematic formulas used, there were 5-10% of patients that couldn’t be controlled with the formulas that worked for the majority of individuals. Another interesting finding was that day to day variation of insulin requirements (in adults who were not growing) could be as much as 5 units a day in some individuals on exactly the same amount of food and controlled exercise (one cannot completely control the day to day variation of stress even in a metabolic research ward).

In my opinion, these studies documented my personal observation that some people are just more difficult to control for unexplained reasons even though they may be very compliant. I have always felt that more research needs to be done to further explain this.

TGL