My nephew, weight 28 kg [61.6 lbs], was diagnosed with type 1 diabetes in the second week of August 2020 with a HbA1c value of 14.5%. A doctor from a government hospital prescribed him Mixtard 30 HM injection with 12 units every morning and 12 units every evening. During the first week, his fasting sugar level remained near 150 mg/dL [8.3 mmol/L] while after breakfast and controlled diet, his usual levels were in the 350 to 500 mg/dL [19.4 to 27.8 mmol/L] range. His daytime sugar levels are not in range despite the doctor increasing the units from 12/12 to 15/20. Even after changing dosages, 2 hours after breakfast and 2 hours after dinner, his sugar levels were still 300 to 500 mg/dL [19.4 to 27.8 mmol/L]. Currently, his doctor advised 26/26 units of Mixtard 30 HM, but we are seeing no improvement. Please suggest what should we do to get his sugars to target and is it okay to give a child 52 units in a single day? Please advise.

It is most important for your nephew and his parents to get him to a real diabetes doctor. Medical schools and larger hospitals will have such specialists since your nephew doesn’t just need more morning insulin but the insulin given in a twice or three times/day regimen.

Mixtard for teenagers usually needs to be given before breakfast and before dinnertime and often with some plain NPH at bedtime, sometimes Mixtard all three times. It depends on how well his food intake is balanced and available since food excess or increases will need more insulin and so day to day consistency is important. In many places in the world, Mixtard is still used in children and adolescents while in high resource places, we have stopped premixed insulins and use the more expensive insulins since we can then make more adjustments every day based on blood glucose monitoring. The key is to get your nephew also to a diabetes specialist who can do detailed food teaching and carbohydrate counting. If money and food is not always available to ensure consistency, then a diabetes specialist, nurse and dietitian will also teach how to make adjustments for when there is more or less food. Similarly, activity consistency will be important on a premixed insulin combination. You can also go to the Changing Diabetes In Children website and look at the resources available (free PDF download) that discuss such difficulties in under resourced communities. Also, the International Society for Pediatric and Adolescent Diabetes Guidelines available on the website and the Life For A Child Pocketbook Guidelines also discuss issues like this. The Pakistani Diabetes Association may also have some recommendations for current and ongoing care as well as suggestions for support for blood glucose testing, insulin, syringes and education.