My 21 month old son is on twice daily injections of NPH with Humalog. He normally wakes up in his target (150-250 mg/dl [8.3-13.9 mmol/L]), has breakfast, and then we give him his injection. One and a half to two hours later he has his morning snack, many times when I check is level then to see how he is doing, he is in the 300-500 mg/dl [16.7-27.8 mmol/L] range (with no ketones before his snack, and many times he is cranky. Then at lunch, (about an hour to an hour and a half later), he is normally back in his target range. I am assuming that this is because the Humalog has kicked in and brought him back down.

The doctor told me really the target is only for before meals, and his sugar levels will actually be all over the place during other times of the day. He said that we should not be alarmed by the high readings unless he has ketones.

Would going on a pump help to minimize these high readings?

Your doctor is correct in that current insulins do not have the ability to exactly match the body’s usual hormonal response to a meal (leading to the wide excursions in blood sugars that you’ve been seeing). An insulin pump would not make a difference, as the pump still delivers the same type of insulin, just in a different way. At present, general practice is to monitor and treat children your son’s age with these types of insulin in the way you’ve described. Hopefully, as he gets older the insulins we have available and the modes of delivery will improve to better mimic normal physiology.

LAD

[Editor’s comment: It appears that your son’s “target” is somewhat high. I would ask his diabetes team for the rationale. The ISPAD Consensus Guidelines for the Management of Insulin-Dependent (Type 1) Diabetes (IDDM) in Childhood and Adolescence (2000) state the following with regard to glucose targets:

For each individual the target should be the lowest achievable hemoglobin A1c without the occurrence of frequent or severe hypoglycemia.
A proportion of children should expect to achieve an A1c within the normal reference range at some time in the first year after diagnosis (during the partial remission phase)
The DCCT showed that as A1c rises above 7.5% (or more than approximately 120% above the upper level of the normal reference range), the risk of later microvascular complications increases steeply [In the DCCT intensive treatment group of adolescents, fewer than 50% achieved a mean A1c <8% (reference range <6.05%)]. I have a different opinion about the pump as an option. I have seen children this age who benefit from insulin pump therapy. Yes, the pump does deliver the same kind of insulin, but, because it is delivered in a more physiologic manner, it is be possible to fine tune basal rates along with bolus does in extremely small increments -- which you cannot do with injections. I think this is an option worth pursuing. SS]