Our daughter was diagnosed when she was two years old and she is now nine. She has been on an insulin pump for four years. For the past nine months, her A1c has not been under 9.3. I am concerned about complications, but her doctor doesn’t seem to be. Are there any tests that we should be having as a precaution?

You certainly should confer with your daughter’s endocrinologist as to why you and s/he do not seem to be on the same page. Does your child see a pediatric endocrinologist?

Most centers follow guidelines put forth by the American Diabetes Association regarding when and what to search for in terms of diabetes complications and associated issues. For instance, commonly screening for vision, kidney, and cholesterol issues are advised after the prepubertal patient has had diabetes after about five years; typically in the pubertal patient, one might screen every year. The common things to screen for annually, regardless, might be thyroid levels along with anti-thyroid antibodies and screen for celiac disease, commonly with anti-endomysial or tissue transglutaminase antibodies. Some centers will also screen for anti-adrenal antibodies for risk of adrenal insufficiency.

Screening for kidney involvement simply involves a random urine collection for the determination of small amounts of protein (“microalbumin”) relative to a normal kidney waste product, called “creatinine.” If the ratio of microalbumin-to-creatinine is elevated in a random sample, often a carefully timed urine collection overnight or for 24 hours is requested for a better quantified answer. See related questions at Ask the Diabetes Team on this web site.

Regardless, I would agree that for a person on an insulin pump, an A1c value of 9.2% is rather disappointing. Please talk with your diabetes team about methods to try to lower this value. Often, the child is skipping some meal boluses or is not estimating/calculating carbohydrate intake appropriately or needs an adjustment in the insulin- to-carbohydrate ratio. Perhaps some deeper parent involvement for several weeks is the ticket? Maybe the pump is not right for the child at this time and going back to individual injections for a time might be the jump start needed. This latter is especially pertinent during the summer when swimming and other water sports may make pumping a bit more of a hassle.

DS