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July 23, 2001

Daily Care

Question from a family physician in North Carolina, USA:

My son, diagnosed six months ago and still in his honeymoon, is taking 4 unuts of Lantus (insulin glargine) once a day and 1 unit of Humalog per 15-20 grams of carb. Due to fluctuations in his needs associated with the honeymoon, his requirements can change unpredictably and often. We have ordered an insulin pump which should help. For the last month, we've noticed a trend I can't explain or understand. My son will wake up with a reasonable fasting blood glucose (e.g., 130-150 mg/dl [7.2-8.3 mmol/L]) and then eats breakfast, but, even though we cover the carbs carefully, his two- hour postprandial is 200-350 mg/dl [11.1-19.4mmol/L], indicating we weren't even close. However, later on that same day, he responds to Humalog predictably and his control is great. Despite a normal fasting before-meal breakfast blood glucose, he seems to need even more Humalog for breakfast coverage than any other meal in the day. Why would this happen? It's an important issue because, when school starts again, we will have to make a critical decision about how to cover his breakfast so nothing bad happens at school.


We frequently see the need to use more insulin for the morning meal. Typically the carb ratio is maybe 30-50% greater for the morning (1 unit per 10 grams carb versus 1 unit per 15 grams carb). Give that a try, but remember that you don’t want to have the lunch glucose too low. Another approach, more complex carbs, but kids frequently won’t participate.

As a physician — I hope you aren’t the only doctor treating him — do have a good peds endo on the team.