My 12 year old daughter was diagnosed with type 1 diabetes three months ago, has just switched from twice daily NPH with Regular to Lantus at bedtime with Humalog at breakfast, lunch and dinner and was eating three meals and three snacks on her previous insulin regimen. Now, since she gets the Humalog before meals to cover the food she’s eating right then, but what about snacks? Will the Lantus cover any snacks? If so, how many carbs?

The premeal Humalog with bedtime Lantus (insulin glargine) approach to meticulous control has been a major step forward, but, as you might expect, it is already beginning to be modified and improved. To begin with, the profile of Humalog action is so similar to that of after meal glucose levels that you don’t really need snacks, except perhaps after very vigorous exercise. There may be some exception to this in the case of a bedtime snack which should still be given if the blood sugar is less that 100 mg/dl [5.6 mmol/L]. For some children, this snack is part of a goodnight ritual, and, in this case, it may need to be covered with a small amount of Humalog which of course means counting the carbs and giving another shot. The number of ‘carbs’ is not all that critical because they can be matched to an appropriate amount of extra insulin to cover, judged on the basis of experience.

There are some other variants you might want to talk to your daughter’s diabetes team about such as giving the Humalog immediately after a meal rather than before so that you can take advantage of the premeal blood sugar reading and appetite. Another variation is to give Humalog and some NPH at breakfast, Humalog at supper and Lantus at bedtime which may still give very good control, and at the same time avoid the need for an injection at school.

The last thing to say is that the teen years are looming, and in our experience, there can be a very significant fall off in control. Diligence at this time and the single most important factor in preventing this is that you stay involved.

DOB