We give our eight-year-old son a shot of NovoLog only after he finishes eating, regardless of his level. We test his levels before a meal and, even if he is very high, i.e., 400 mg/dl [22.2 mmol/L], my wife insists on waiting until he finishes his meal before giving him insulin. Is this normal?

My wife gets up every night to check his blood sugar at 2 a.m. and then at 4 a.m. Is there any way this can be avoided and his levels be prevented from going low? The getting up every night for the last five years is telling on my wife’s health.

It is neither “normal” or “abnormal” to give the rapid-acting NovoLog after the meal. Rather, it is a style that your wife has adopted. A better question would be is whether this practice is “optimal.” It can be very adequate to provide insulin after the meal. This way, you can really assess how many carbohydrates were eaten, rather than guessing what the child might eat. I presume that you dose the child’s insulin based on what he actually eats. This is called “carbohydrate counting.” If you do not do this, then the practice of giving the dose after the meal is not optimal at all.

I also presume that you are giving your child insulin in “corrective” doses, also. By that, I mean you not only dose for the carbohydrate counting, but you also dose additional insulin for the current levels of glucose. Your child’s own pediatric diabetes specialist can help you determine a “correction formula” for you and your son, but if the dose for what he eats is four units (e.g., he takes one unit for every 10 grams of carbohydrates eaten), but his glucose before the meal was 400 mg/dl [22.2 mmol/L], then you must give extra insulin, otherwise, after the meal is done, you shouldn’t be surprised to see that the glucose level still around 400 mg/dl [22.2 mmol/L]. A common correction formula might be: [Current Blood Glucose minus Target Glucose] divided by Sensitivity Factor. The target glucose is the value that you are aiming for say about 120 mg/dl [6.7 mmol/L]. The sensitivity factor reflects how sensitive the child is to a unit of insulin. Does a single unit bring him down 50 mg/dl [2.8 mmol/L],75 mg/dl [4.1 mmol/L], or 30 mg/dl [1.7 mmol/L]?

For an eight-year-old, I’d start at a Target Glucose of 120 mg/dl [6.7 mmol/L] and a Sensitivity Factor of 50. If his glucose were 400 mg/dl [22.2 mmol/L] before the meal, then, after the meal, I’d give the amount of insulin the meal required (four units in my example above), PLUS another five and a half units for the correction.

Having said this, it probably is even better to give the dose before the meal, but it does leave the carbohydrate intake a little less precise.

I do not typically ask my families to check 2 a.m. (or 4 a.m.) glucoses routinely. It is not good for anyone’s health. Again, better questions would be: Has your son given you reason that he requires routine nighttime glucose checks? Has he been commonly low (glucose under 70 mg/dl [3.9 mmol/L], for example) during these times? Does he awaken with low glucoses? Has he had recurring hypoglycemic seizures? If the answers to these questions are generally “no,” then I don’t think that routine nighttime checks are required. But, you should ask your child’s primary diabetes specialist how they would want to proceed.

DS