October 9, 2002
Question from Folsom, California, USA:
My 13 month old daughter is now on three shots of Regular and/or Novolog before breakfast, lunch and dinner and a shot of NPH before bed, and her doctor thinks we would have better control if we reduced this to only threeshots per day of NPH and Regular at breakfast, no shot before lunch, a shot of Regular before dinner and NPH at bedtime. I don't like the idea of NPH before breakfast because she often naps at noon. What do other parents with kids this small do?
There are so many combinations of insulin. I think the “right” answer for you depends on your child’s own glucose diary trends along with her activity and snacking patterns and your (and her) willingness to give shots. One must have a good understanding of the onset and peak actions of the various insulins, and based on your question, you do! If she takes NPH in the morning, yes, she could drop out low in the afternoon, if there is not enough food on-board.
Your question indicated that your physician thought the child could be in “better control” with a change of insulin regimen. but I did not see a hemoglobin A1c value. I am not certain that a 13 month old requires “tight” control. Ask your doctor what the goal is with a change: Better HbA1c? Less fluctuations/smoother glucose readings? Attacking a specific higher (or lower) pattern at specific times of the day?
You indicated that you currently give “Regular and/or NovoLog” with meals. How do you decide? Generally, NovoLog is given with every meal/snack. based on carbohydrate consumption. Do you carb count? Regular may be a good choice for the child who eats and then snacks rather consistently as the Regular can cover the meal eaten as well as the snack upcoming in the next 2-3 hours, but that snack, then, is generally required.
You consider changing to Lente (which works a bit longer than NPH) or even Ultralente which certainly lasts longer and is relatively peakless. I find that Ultralente often works well with toddlers. It must be given about 12 hours apart and functions as the long-lasting or basal insulin. Then the NovoLog (or Humalog or Regular) is given with the meal. The advantage is that NovoLog or Humalog can be given immediately after the meal, based on actual carbs eaten rather than the amount anticipated to be eaten. In addition, the short-acting insulins can be mixed in the same syringe as Ultralente.
[Editor’s comment: Sweet Kids: How to Balance Diabetes Control & Good Nutrition with Family Peace by Betty Brackenridge and Richard Rubin a great reference for managing kids this small.