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July 12, 2019

Blood Tests and Insulin Injections, Daily Care

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Question from Detroit, Michigan, USA:

My young granddaughter has just been diagnosed with type 1 diabetes, was hospitalized for three days. When I was at the hospital, the nurse would give my granddaughter her insulin two hours after she ate. Should I be giving her insulin after two hours? Someone told me you should give the insulin a half-hour after eating.

Answer:

It is always best, whenever possible, to obtain care for young and especially very young children from someone experienced in the care of children and toddlers living with type 1 diabetes (T1D). That individual or center can best provide guidance in not only insulin timing, but other issues specific to children and toddlers with T1D. Such a program of individual will know more specifics about an individual child/family from which to make the best recommendations for that child.

In general principle, although experienced providers may recommend different amounts (if any) to wait after giving (or taking) insulin before beginning to eat, the recommendation from ISPAD (International Society for Pediatric and Adolescent Diabetes) in their 2018 Guidelines is that, whenever it is safe and possible, give the insulin before eating. Depending on the type of insulin and other factors it can take from 5 or fewer minutes (analog insulins) to 45 minutes or longer for Regular insulin. Some pediatric diabetes specialists recommend giving some of the insulin ahead and some after completing the meal depending on how much a toddler will reliably consume.

There may, however, be some confusion as to what was said in that 2 hours is essentially how long analog insulin lasts and the time after which most recommend that one can give additional insulin for correction of an elevated glucose level that is above target to bring the glucose level into the desired range. That range is also recommended in the ISPAD 2018 Guidelines, which can be found online at no cost.

Additional response from Dr. Stuart Brink:

It seems like you have not received appropriate education about toddler diabetes. Insulin should generally be given about 1/2 an hour before meals, in addition to some type of long-lasting (basal) insulin such as glargine or levemir. This attempts to mimic the usual way the pancreas produces insulin based on eating patterns, consistency possible with toddlers and actual blood glucose results. The best teaching book is by Ragnar Hanas, Type 1 Diabetes in Children, Adolescents, and Young Adults. I would genrally recommend going to see a board certified pediatric endocrinologist/diabetologist rather than a PCP since such types of education lapses are less lilkely. Also, with such a very young child, it is importnat to make sure that this does not represent a type of diabetes called monogenic diabetes. Free testing is available from ISPAD website if your insurance doesn’t cover this expensive genetic testing, which is available at specialty centers in U.S., too.