Recently, our specialist has changed our routine at school during my daughter’s 10 a.m. check. In the past, I had set up a chart indicating how many grams of carbohydrates she was to eat based on her blood sugar. I think it had worked great. However, the specialist thinks it is best to eat the same amount of carbohydrates each day at 10 a.m., no matter what her blood sugar is. For a blood sugar of 350 mg/dl [19.4 mmol/L] and up, 8 grams. For a blood sugar under 350 mg/dl {19.4 mmol/L], under 15 grams. Today was the first day of trying it. Maybe it will work in the long run, but today she came home at 3 p.m. with a blood sugar of 323 mg/dl [17.9 mmol/L]. To me feeding the fire is not the way to go. What is your opinion? In the past, she has come home at 3 p.m. with blood sugars ranging from 90 to 250 mg/dl [5.0 to 13.9 mmol/L].

My opinion is that it really hinges on your comfort levels and philosophy.

One school of thought is that it may be inappropriate, in the long run, to “teach” a child with diabetes to manipulate the blood sugar by withholding food. There is concern that this may breed an eating disorder later on. I have not seen long term studies that substantiate that claim, but I know I personally have seen it happen (as I know many of my colleagues have as well). This occurs later in life, especially in teenagers (girls and boys, but perhaps more so in girls). Therefore, the idea is to allow the child to eat and learn to either burn off the extra calories or supply more insulin. This is part of the wave of basal-bolus insulins, such as with multiple daily injections or insulin pump therapy, whereby one learns to calculate an amount of extra insulin to correct a sporadic high glucose. I don’t think this works as well when on split doses of NPH and short-acting and a “sliding scale.” After all, in the non-diabetic, if somehow the glucose began to rise high, after a jelly donut, for example, they would make extra insulin. So, that is somewhat what you were doing before: higher glucose, then eat less. It does make sense. Does that sporadic high glucose in the 300s (mg/dl) [16.7 to 21.5 mmol/L] cause problems? Probably not in of itself. It mostly seems to be sustained higher glucoses that lead to diabetic complications. But, there are some clinicians who do worry about high glucose excursions. The majority of the data indicate that, as long as the overall A1c is within your target, then you need not fret too much about the sporadic highs except in the presence of ketones.

The last thing I will ramble about is the following: You did not indicate what insulin regimen that is used at home. Depending on the regimen, perhaps a snack is not even required! The dogma of snacking came about when people indeed only had NPH and Regular insulins, with their varying onset and peak actions. The snack was timed to correlate with the peak effect of those insulins in order to avoid hypoglycemia. If Regular is not used, then perhaps a snack is not necessary. If the child is already on a basal-bolus regimen, then I’d not consider a routine snack, unless the child wants one, and then one would probably bolus insulin, the way a non-diabetic would release insulin for the food intake.

DS