Justin Delgado is husband to Kacie Doyle-Delgado, diagnosed at age 11. After more than a decade together, he considers himself to be an expert carb counter and Dexcom inserter. He graduated with his Master of Science in Finance from the University of Utah in 2013 and has been working in commercial banking since then. He attended his first Friends for Life conference in 2015 and is looking forward to volunteering with the teens.
December 2, 2007
Daily Care, Hyperglycemia and DKA
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.
Unless your kindergartener is very heavy or has other health problems, or is on some other confounding medications, I would be hard pressed to ascribe these higher readings to “daytime insulin resistance.” You did not indicate that OTHER glucose readings are so out of the target range.
I’d consider the following: if you are VERY confident in your carbohydrate counting skills and can’t explain her mid-morning highs on inadequate breakfast dosing, then I would increase the insulin to carbohydrate ratio some more. Try 1:7 or 1:8. Yes, the math is harder. I can’t see that you specifically indicated what type of insulin she gets with meals, but I will assume that it is Humalog, NovoLog, or Apidra. If so, then I think checking glucose levels two hours after a meal should be a “pretty good time” as these insulins typically have their maximal effects about 90 to 120 minutes after a dose. (If you use Regular, it might be a little too soon.)
I was uncertain of your correction of “1 for 120.” Typically, when I give a correction formula for patients, I give them a “target glucose” and a “sensitivity factor,.” then, give them the math equation to approximate the dose: (current glucose minus target glucose) divided by sensitivity factor.
For a five-year-old, I’d anticipate a target glucose of 120 mg/dL [6.7 mmol/L] and a sensitivity factor of 50 to 75 (but this can really vary person to person). So, if her sugar were 438 mg/dL [24.3 mmol/L], the correction would be about four units. Do you do something similar?
Do you have her checked for ketones when her glucoses are up? That could certainly explain tummy aches.
There is growing evidence that sporadic/intermittent high glucose values, and wide glucose excursions (big ups and low downs) are not good and can lead to diabetes complications. There is evidence that high glucoses MIGHT impair academic-type work and learning. But, there is clear evidence that LOW glucoses do this. So, I would also not be too quick to blame higher glucoses on poor school performance. On the other hand, if your child did not feel well (tummy ache, etc.) during the testing, that could certainly affect the work. I might suggest that you formally request an IEP for your child for the school. See our page on school Bill of Rights.
[Editor’s comment: One other option that you should discuss with your daughter’s diabetes team is the timing of the breakfast insulin, which you did not indicate. Some people have achieved blood sugars closer to “normal” by giving the fast acting insulin 15 to 20 minutes PRIOR to meals. Of course, you need to sure that your daughter is going to consume the carbohydrates you are going to give her.