My daughter is three years old and diagnosed with type 1 diabetes six months ago. She is on Humalog and NPH twice a day. What is the difference between conventional insulin therapy and intensive therapy? I have read the American Association of Clinical Endocrinologists Guidelines for the Management of Diabetes 2000, update. Is it better to begin a toddler on a more intensive therapy, for example, more than two injections per day or a basal amount of insulin with bolus of Humalog for meals and snacks. Our daughter runs high after lunch and often is 200-250 mg/dl [11.1-13.8 mmol/L] at afternoon snack. We are supposed to give her a snack anyway and then compensate at dinner with more Humalog.

There are conflicting recommendations for the treatment of toddlers with diabetes. Many people are very worried about hypoglycemic in toddlers because their brain is still developing. Others are more worried about the long term risks of hyperglycemia and complications clearly related to years of high sugars. We believe in striking a bargain looking for intensified treatment with frequent blood glucose monitoring, carb counting and multidose insulin regimens, even in toddlers, while always trying to prevent moderate and severe episodes of hypoglycemia. We believe we can accomplish this goal and usually use Humalog and NPH in overlapping doses four times a day.

However, it is absolutely critical to establish mutually acceptable blood glucose goals and work vigilantly to minimize hypoglycemia. Most hypoglycemia seems to occur from errors: omitted snacks or food, extra exercise not compensated adequately by less insulin or more food, late meals or snacks, dose errors.

We also belive strongly in individualizing insulin dose recommendations and use algorithms which are written and adjusted frequently at monthly intervals with our nurse educators and dietitians. We utilize the same protocols as were used in the DCCT with great success even in toddlers.

Having given you our own bias on this subject as well as the excellent outcomes we achieve, it will be very important for you to have this same discussion with your diabetes team to learn of their concerns, philosophy and rationale so that you can decide if this makes sense to you or not.

The AACE recommendations are mostly for adults and so must be adapted for children, especially the very young.

SB