June 3, 1999
Daily Care
Question from Bangor, Northern Ireland:
I have recently moved to Northern Ireland from Canada. My daughter is 4 years and 9 months old and was diagnosed with Type 1 diabetes four days before she turned 3. She weighs about 20 kg. and goes to school every day 9-1:45. Her current insulin regime is R2 or 2.5 and N 15 in the morning, R 1.5 at supper time, and N 2.5 at bedtime. However, for the past 7 months I have had great difficulty in keeping her suppertime blood glucose in the target range, having to steadily increase the amount of N with little lasting effect. For instance, this past week’s readings have ranged from 16.0 to 27.6 at supper time; these readings have been climbing up but have occurred without any corresponding increase in food consumption from eight weeks earlier when N 14 worked just fine. Last August she only received N8 in the mornings.
I don’t understand why 2 units of R is enough to cover a small breakfast and a good snack (when I go to the school to test her at lunch she is usually close ! to her morning reading in the 4-8 range), but 15 units of N doesn’t come close to covering a small lunch and an afternoon snack. When she originally was started on insulin she received 2 R and 3N in the mornings. Her R hasn’t changed but the N has gone up 500%. Although she is only 4, she takes great interest in drawing up her needle and gets upset when her dose is increased.
Can you comment please? We have lived in 3 places since she was diagnosed and I have had little direction except to increase insulin slowly and watch for changes for 3 days.
P.S. One mom I met said that her doctor said that her 7 year old son was resistant to N and temporarily put him on pork insulin. When he returned to Human, it was much better.
Answer:
Things are not so easy for children with Type 1 diabetes over a relatively long period of time, i.e., after the honeymoon period which can be quite short among toddlers and young children.
It seems that any NPH insulin generally works much worse than any Regular/lispro insulin, either because of a much more irregular and unpredictable absorption from the injection site or because of a unphysiological action profile over the day compared to that of the more “natural” Regular.
You’d need to discuss your insulin regimen (especially morning/bedtime NPH insulin, which I’d switch towards lunch/bedtime because the morning period is already covered, as you noticed, by the previous night NPH injected at bedtime: perhaps a larger dose I’d guess) with your team and also speak to a dietitian regarding what your son eats over the afternoon, at dinner and at bedtime. Any snack over the afternoon is not easily managed with the lunch Regular/NPH mixture, which needs to be finely tuned to accomplish it and to avoid late afternoon hypoglycemia. Sometimes, a small dose of Regular insulin before the afternoon snack makes diabetes management much easier than NPH distributed during the day.
That’s diabetes in childhood and sometimes it seems to be difficult, but that doesn’t mean you should give up. It requires diligence and teamwork: good education, family, and a diabetes team devoted to children.
MS
