May 27, 1999
Question from Ohio, USA:
We have a 5 year old son with type 1 diabetes, diagnosed about 2 and 1/2 years ago. All in all I think his control is relatively good, his last HBA1c was 7.2. However, he still has wide variations in his numbers. We have a particular concern with his post meal numbers, they often range in the 300 to 400 range an hour or so after eating.
Our son is about 44 inches tall, weighs about 44 pounds, and is in generally good health. We use the carb counting system for his diet, we also track and control the fats and proteins. His normal insulin dosage is: 7NPH, 1Humalog, 1 and 1/2 Regular in the morning and 1 NPH and 1 Diluted Regular at night. We do not have an exercise program that we plan and do every day, we just try to work it in as we can.
We visit with a pediatric endocrinologist at Children’s Hospital every 3 months, and call anytime we have a concern. We are in general very pleased with the advice and service we receive from our doctor. He sometimes however seems to be conservative and doesn’t always seem receptive to new things. We were on the no sugar added diet for a year, his office is just now learning the carb counting system. We learned the carb counting system on our own, with a help from a local dietitian.
We are very active in trying to do the best possible for our son. We have been considering taking our son to a visit with perhaps the Joslin Diabetes Center to review our ‘plan of attack’, glucose and HBA1c readings. More or less just to see if we missing something that might improve our son’s numbers. Should we have an exercise program in place? Are his after meal numbers something to worry about? Is his meal plan sufficient? and so on?
What is your opinion of this? Would it be a waste of our time and money? If you think this is a reasonable thing to do, do you have any recommendations on where we should look for such a review?
At first glance your son is being extremely well cared for and although I don’t know the A1c normal values for the laboratory a value of 7.2% is only a modest degree above the usual upper level of normal. His height and weight are very normal for his age; but for someone who has had diabetes for 2.5 years his total insulin dose of about 0.5U/kg body weight seems low, the normal being about 0.7U. I imagine though that in the past he has been very sensitive to short-acting insulins and that you are all anxious to keep the safe side of serious hypoglycemia even if it means high postprandial blood sugars and an A1c that you would like to see a little lower too.
Just the same I think you might talk to his endocrinologist, and perhaps you have already done so, about very cautiously increasing the Humalog I don’t think this would be technically difficult as you already seem experienced with giving very small amounts of Regular insulin. The other point to discuss would be whether to give the short acting insulin mixture after the meal. This would mean that you could learn to adjust the dose to the pre-meal blood sugar and to appetite. Increasing the Humalog might then be more effective in reducing the post prandial rise in blood sugar and the delayed dose should not prevent the small amount of regular bridging the gap to lunchtime and helping avoid a third injection for the time being. If the night time dose is in fact before supper there might again be a case for using Humalog in the same way after the meal leaving the bedtime snack to make sure there is no early morning hypoglycemia.
There is no doubt that a pattern of lifetime exercise is of great importance in sustaining immaculate control. This can be difficult with a five year old boy; its not that they aren’t inexhaustible, its that they need leadership. By this I mean joining a soccer group, participating in whatever the school may offer, and trying to make sure that activity is year round.
As an additional prop you might like to look at or even download Peter Chase’s book Understanding Insulin-Dependent Diabetes.
The Joslin Clinic is an excellent resource and going perhaps once or even once a year to one of the established children’s diabetes centers can help in a number of ways. Not least it may confirm that your son is doing very well indeed; but just as important it is an opportunity not only to have another physician’s opinion but to go over more practical details with a nurse educator, a nutritionist and perhaps a medical social worker or a clinical psychologist, all very experienced with this age group. It would also be a chance to review what the future holds in terms of pumps and other forms of intensive therapy, of non-invasive blood sugar monitoring, etc.