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May 23, 2005

Hypoglycemia, Insulin

Question from Riverview, New Brunswick, Canada:

My nine year old daughter has been diabetic for about two and a half years. I have been diabetic for over 24 years. Not too long ago, my daughter's blood sugars were running very high due to illness. This was to be expected as it was a combination of the flu and the cold. However, for the past four days, she has been experiencing consistent lows. My wife and I have cut her carbohydrate ratio in half in some cases. from one unit per 10g to 0.8 unit per 10g in mornings and from 0.8 unit per 10g to 0.4 unit per 10g in the evenings. Her blood sugars are running consistently below 3.5 mmol/L [63 mg/dl], no matter how much she eats. Granted, she has been a little more active with the nice weather, but not so active that she should take a dramatic turn such as this. Today, she woke up 2.4 mmol/L [43 mg/dl], ate her breakfast after we addressed the low, and had 9.5 units of Humulin NPH and only had 5.5 units of Humalog insulin (70g of carbohydrates at 0.8 unit per 10g). The 5.5 units of Humalog is the ONLY fast acting insulin she has had all day. She has been running mostly below 3.0 mmol/L [54 mg/dl] all day with very little activity. I have never experienced anything like this in my 24 years as a diabetic. I am at a loss to explain it. We have spent the whole day feeding her to correct the lows. We gave her lasting carbohydrates like bread and crackers and fruit. This evening, after 9 p.m., after she ate supper, popcorn and had NO fast-acting insulin, she was 3.2 mmol/L [58 mg/dl]. Do you have any explanation for this? She does see her diabetic specialist on June 16 and we will call him before then. However, as you can probably guess, we are worried.

Answer:

I do not know if I have THE right answer, but I have seen this many times.

Often, this unanticipated change with enhanced insulin effect is associated with some recent (or soon-to-manifest) gastrointestinal illness.

Remember that, fundamentally, one’s glucose level is primarily controlled by the interaction and balance of insulin, activity, and meal planning. Yes, her activity has increased, but not so much as you recognize. Depending on the nature of the “flu and cold” that she recently experienced, there may be some incomplete recovery of the intestinal digestive function whereby she is not optimally absorbing calories and food well.

Other things, some of which are not uncommonly associated with type 1 diabetes, can also affect insulin sensitivity. Your diabetes team may wish to assess your daughters thyroid and adrenal function and consider screening her for an intestinal disorder called celiac disease.

In the meantime, talk also with your diabetes team about, for the time being, decreasing her usual, background insulin doses somewhat.

Let us know what you might learn.

DS