Question from San Jose, California, USA:

Since the start of school this year, my kindergartener has had high/out of range blood sugars every day at school. Her range is supposed to be between 100 mg/dl [5.6 mmol/L] to 200 mg/dl [11.1 mmol/l] for her age. She is normally tested at 10:20 a.m. each day, which is prior to snack time. Consistently, her readings are between 200 mg/dl [11.1 mmol/L] to 300 mg/dl [16.7 mmol/L], usually around 200 mg/dl [11.1 mmol/L] to 250 mg/dl [13.9 mmol/L], but at times have even been over 300 mg/dl [16.7 mmol/L].

I’ve spoken with her diabetes management team about what we can do to bring her blood sugars down. She wakes with readings within range (thus adjusting her Lantus at night is not necessary). Her insulin to carbohydrate ratio is 1 for 10 at breakfast (1 for 15 for lunch and dinner) and is pretty aggressive already. I try to give a lower carbohydrate breakfast most days (around 24 grams), but still she will have a reading around 200 mg/dl [11.1 mmol/L] to 250 mg/dl [13.9 mmol/L].

If she wakes with a high reading, I give no carbohydrates and only give a correction injection (1 for 120). Even then, her reading is 200 mg/dl [11.1 mmol/L] to 250 mg/dl [13.9 mmol/L] when they check. One factor I think is that she gets tested usually exactly two hours after finishing breakfast, which I think may be too soon to check (that is what her endocrinologist says). However, that is the time of snack and I prefer not to postpone the testing/snack because then she will miss snack time (and feel left out/different) and have to eat alone while the rest of the class is working again. Giving breakfast earlier would mean getting up earlier and this is not an option as I don’t want her to lose sleep. What other options do we have?

Also, would having readings consistently between [11.1 mmol/L] to 300 mg/dl [16.7 mmol/L] cause her to not be able to focus or do poorly in school? At our most recent parent/teacher conference, the teacher suggested that I show her below grade level progress report to her endocrinologist and ask what we can do. My gut tells me that her blood sugar is not affecting her performance and that the teacher is using her diabetes as an excuse for her being below grade level. She does not have proof that her blood sugar readings are causing her to perform poorly. Also, when I asked to have her retested because her blood sugars were not in range when the testing was done, she agreed, but then again tested her without notifying me, so her blood sugar again was not in range. So, we have no way of knowing if the out of range blood sugars are a factor.

The care team at the clinic does not have any further suggestions and they suggest that she is probably having insulin resistance, which is common in the waking hours. I have verified this on the weekend by checking how long it takes for the insulin to start bringing down her blood sugar and it has taken up to two hours or more. This is probably what is happening on school days; her insulin does not take affect until after two hours or more and the time they check her is usually around two hours after injection.

Is there really nothing else that I can do to have her within range? The only thing that I can think of is NO carbohydrates at breakfast, but I know this will cause food battles with my five-year-old and I don’t want this.

I’m also worried about whether or not this is contributing to her below grade level performance. Is there a way to verify it? I have already requested retesting when she is within range, but I’m wondering if on a day-to-day basis this is affecting her and don’t know how to find out if it is. Five-year-olds do not have the capacity to know if it does, so speaking to her about it does not get me very far. She does sometimes complain that she doesn’t like school because she always has a stomachache there.