My son was diagnosed with type 1 diabetes at 14 months and he is now almost three. We have no problem controlling his sugars. His A1c ranges from 6 to 7% and his endocrinologist is always praising us for doing a good job. But, when is comes to bedtime, he occasionally drops below 100 mg/dl [5.6 mmol/L]. My husband and I get up at 1 a.m., 4 a.m., and 7 a.m. to check him. He has a good bedtime snack with 40 ounces of soy milk mixed with four to six tablespoons of corn starch, which was recommended by his doctor to help with lows because it starts working about four hours after consumption.

If he falls asleep with a blood sugar around 200 mg/dl [11.1 mmol/L] and is about 150 mg/dl [8.3 mmol/L] at 1 a.m., we usually feel safe to sleep until 7 a.m., but, sometimes, not all the times we test at 7 a.m. and he’s been between 40 and 50 mg/dl [2.2 and 2.8 mmol/L]. Since we don’t know how long it’s been that low, what are the risks? Is there a theory about how low someone can be when asleep before it results in a coma or effecting the brain? Since the person is asleep and not active at all, can someone be that low for a period of time with no harm? I am just seeking your thoughts on this subject. We have given the exact same meals insulin dose trying, basically, to duplicate a day that was perfect and it’s never the same results. All in all, he is doing really well and if there’s anything out there that can make it a little better, we’d like to know and try it.

Recommendations for optimal glucose control for very young children with diabetes vary. Although we know that long-term high blood sugars are associated with a variety of complications with diabetes, our research and that of other groups, has documented subtle learning difficulties in children with diabetes diagnosed at very young ages (presumably related to repetitive episodes of low blood sugars). No one knows what the best approach is. Further studies on long-term outcomes in these smallest children are needed.

However, because we fear the effects of lows on cognitive development, our team has implemented a higher target range for children under five years of age than the targets you appear to be using for your child. We try to keep the blood sugars between 100 to 220 mg/dl [5.6 to 12.2 mmol/L] with a target of higher than 150 mg/dl [8.3 mmol/L] at bedtime. This usually translates into an A1c of around 8%, with about 10 to 20% of the blood sugars below the target, 40 to 50% in target, and 40% just above target.

Your note does not indicate what sort of insulin regimen your child is using. I would certainly recommend doing carbohydrate/insulin ratios and corrective doses at mealtimes, either with NPH as a “basal” insulin to help cover lunch and bedtime snack or with Ultralente or Lantus (with doses of insulin at each meal).

If you’re already doing ratios/corrective doses then you might want to talk to your physician about considering an insulin pump, to allow you to vary the insulin rates overnight. We have shown that very young children with diabetes need very little insulin overnight. It is very difficult to achieve this type of dosing with injections; sometimes a pump is preferable to avoid overnight lows.

LAD