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December 22, 2003


Question from Sao Jose do Rio Preto, Sao Paulo, Brazil:

My 16 month old daughter, diagnosed at 10 months, takes 3.5 units of NPH (Novolin N) in the morning and 0.5 unit NPH before bedtime, and eventually 0, 5 Humalog when she's over 400 mg/dl [22.2 mmol/L]. The morning NPH seems to be acting a lot longer than it should, producing peaks (often with hypos) 14 to 16 hours latter, often between 12:00 pm and 2:00 am, and having her with readings around 100 mg/dl [5.5 mmol/L] even when she didn't have her 9 pm night shot (which seems to be bringing her to the 100s around noon the next day). However, her readings in the afternoon and before dinner are constantly above 400 mg/dl [22.2 mmol/L], but will go down to around 200 mg/dl [11.1 mmol/L] at 1:00 am, so we never use Humalog after 5 pm. Is NPH possibly having an extra-long action on her metabolism? Does it happen frequently with toddlers? Is there any other insulin we could expect to have intermediate action between Humalog/regular and NPH that she could use to cover between 12 and 7 pm and still be sure its action is over by bedtime?


I really understand your deep concern regarding your small daughter’s blood sugar levels sudden fluctuations. These fluctuations are generally only linked to that given disease management and appropriate measures must be taken in close collaboration with your daughter’s diabetes team. The ultimate aim is to better handle those fluctuations trough proper education towards appropriate self management approach.

I think she would probably benefit in terms of blood sugar stability from the new basal insulin glargine. It’s a very good insulin and you even don’t need to stick to a fixed time of its injection as it’s possible to use it over a longer range of time during the day with Humalog before each meals that may be given with much more flexible time. This new insulin assures quite often the same metabolic control as insulin pumps do. The bad side is that its use is not FDA approved for children under 6 years of age. That said, the only advice would be to reduce the dose of Novolin N in the morning around 1 UI and to increase it at bedtime around 3-4 UI based on blood sugar monitoring with the Humalog as an extra 0.5UI when blood sugar is above 300 mg/dl [16.7 mmol/L].