Our five and one-half old daughter was just diagnosed with type 1 diabetes, which we found very early. We have thought back about the symptoms of diabetes, and she has not had any. We have started to monitor her blood sugar level, but have not started insulin. When should we start insulin and why?

The answer to your question rather depends on knowing on what basis the diagnosis was made and to answer this you really need to talk to your daughter’s doctor. A single fasting blood sugar on a five year old with no suggestive history and no glucose in a urine specimen can be misleading because glucose levels can rise significantly, albeit transiently, as a result of anxiety or illness. For this reason, some centers will now do a first blood glucose using one of the new almost painless meters and a hemoglobin A1c level. If these suggest diabetes, a fasting blood glucose level can then be confirmed with one of the new more accurate finger prick devices and an antibody test can be sent off. If the blood glucose and A1c results clearly suggest diabetes, then insulin in small doses would be started right away and an intense introductory education program started as well. In this situation, the primary role of the antibody test is to distinguish between type 1A (autoimmune) and type 1B diabetes which is antibody negative.

In your daughter’s case the initial fasting blood sugar may have been clearly abnormal, but the doctor may have wanted to wait for the antibody test to quite sure and felt that this was quite safe in the absence of any symptoms. A third possibility is that your daughter may be in what is called the pre-clinical phase of type 1 diabetes. This is a disorder of the immune system that takes a number of years to finally destroy the insulin producing cells in the pancreas, but in the last stages, an abnormal blood sugar can sometimes be detected before it is really neccessary to start giving insulin supplements.

DOB