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June 28, 2011

Daily Care

Question from Mendoza, Argentina:

My wife and I are concerned about the amount of insulin and carbohydrates that our 20-month-old son needs to consume to manage blood glucose levels of less than 200 mg/dl [11.1 mmol/L]. Currently, we are living in Argentina and have very good doctors to assist with his diabetes. However, as this is our first child, we want to be sure that his overall health is not affected by consistently higher sugar levels (i.e., 180 to 320 mg/dl [10.0 to 17.8 mmol/l]). We were informed that, for infants and toddlers, maintaining slightly higher blood sugar levels is necessary for the child's growth when the child has been recently diagnosed (ours at 17 months old). Please let us know what is considered safe and normal in terms of transitioning to levels below 200 mg/dl [11.1 mmol/L]?

Answer:

You ask a great questions but there are no easy answers. The goal is always to get blood glucose levels as close to normal as possible but always at the same time also without excessive or severe hypoglycemia. This is a delicate balancing act since insulin is not always predictable in its effects and similarly activity, stress, illness and even food have variable effects on blood glucose levels. The key is to use either an insulin pump or a multidose insulin (MDI) regimen with fast acting analog insulins given before eating plus basal insulin. Usually the basal insulin is either by pump or by some other basal insulins given once or twice-a-day. Blood glucose results should be your best guide as well as working closely with your diabetes team and watching the A1c levels. Watching the A1c results also gives you a guide to how you are doing. For those, especially the very young, who have severe or recurring hypoglycemic episodes, target goals must be raised for safety reasons. So, these goals must always be re-evaluated. Some can aim for premeal values of 70 to 140 mg/dl [3.9 to 7.8 mmol/L] and postmeal values that raise to 160 mg/dl [8.9 mmol/L] with overall target values of 100 mg/dl [5.6 mmol/L] while, for others, this is too strict and too risky because of hypoglycemia. If you are using higher target levels for a toddler and are ready to attempt stricter control, then slowly lowering the target ranges is reasonable.

SB

[Editor’s comment: Though the overall goal is to maintain blood sugars below 200 mg/dl [11.1 mmol/L], even below 150 mg/dl [8.3 mmol/L], one of the reasons parents are advised to keep the child at a higher level is that younger toddlers are not able to verbalize when they feel low. And, it can take months, maybe years, for them to recognize lows.

One way to achieve lower blood sugars is to administer fast acting insulin about 20 minutes before the meal/snack. However, given that toddlers often do not eat what we expect them to eat, parents of toddlers may wish to consider dosing fasting acting insulin AFTER the meal. This way you have a better estimate of how many carbohydrates were consumed. Please talk to your diabetes team about insulin dosing and timing. They know your child and his diet better and should be able to advise you about this.
BH]