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September 11, 2003

Daily Care

Question from Tampa, Florida, USA:

My seven year old son has had diabetes for about four months and is very good about checking his blood sugar and helping counting his carbs. When he was first diagnosed his dose was 1 unit of Humalog with 7 units of NPH in the morning, and s 1 unit of Humalog with 6 units of NPH in the evening. He has have had a lot of lows in the morning and at bed time, so they discontinued the Humalog. He eats three snacks a day (mid-morning, afternoon, and bed time), and his levels are always good when we check before meals and at bed time. However, I checked him several times after his mid morning snack, and he was in the 200s mg/dl [11.1 mmol/L]. is this because the insulin has not kicked in yet? I questioned the diabetes educator who said not to worry about it because it's is not a normal time to check is blood sugar. However, I thought we were trying to keep his levels 80-150 mg/dl [4.4- 8.3 mmol/L]. What will happen if he continues to have these levels and we don't know about them? I know you can't check his levels all the time.


Your child is probably still in the honeymoon phase thus explaining the normal glucose readings toward lunch, despite the spikes of hyperglycemia after the meal. Yes, if you do not give a very short-acting insulin such as Humalog or NovoLog with a meal, you should expect a higher glucose two hours after the meal. If you are not giving a fast-acting insulin, then I would not ask you to check the two-hour after-meal glucose level.

Is the spike harmful? Perhaps. Some data in adults suggest these high glucose excursions are not optimal. Even people who don’t have diabetes get a small peak of glucose after a meal.

Additional comments from Dr. Donough O’Brien:

I think levels in the 200s mg/dl [11.1 mmol/L] soon after his midmorning snack was a function in part that the morning NPH had not yet begun to have its full effect, and in part that it may have been taken too soon after his snack. However, don’t let anyone persuade you that you shouldn’t know the reason for a high blood sugar because it wasn’t taken at a conventional hour. Being concerned about this level of reading is quite proper, but if other blood sugars are mostly within acceptable limits, then you really have to rely on a quarterly hemoglobin A1c level for an overall assessment of control.

In the meantime, there are the beginnings of systems for continuous monitoring and indwelling subcutaneous sensors. One day the hope is that these latter devices will be reliable and accurate enough to control a insulin pump.