I have two questions. One is about night time blood sugar testing and the other is about dead in bed (DIB), both due to concern and fear about possible risk for night time hypoglycemia.

My oldest child, my very responsible, very athletic, very beautiful 14 year old son, was diagnosed with type 1 diabetes almost seven months ago after I requested that my son’s urine be tested during a routine sick visit. What is your best advice and opinion related to night time blood sugar testing? Are there any situations that can concretely state that a parent can sleep 6-8 hours without worry?

Initially, our endo suggested to check one time between 2:00 or 3:00 AM, but only if we raised the evening NPH on that day. Other than that, I received no other initial suggestions as to when or what else warranted night time blood sugar testing.

I have learned a lot more since initial diagnosis through my own constant research, education and networking. I learned almost immediately there are plenty of other reasons to test during the night – not just only when the evening NPH is raised. I test if bedtime blood sugars are under 150, if my son is/was very active (which is daily during his current two basketball leagues) or if I awaken for some reason in between times I had intended to test.

In addition to the above question, are there any studies out there that provide any indication about the statistics and reasons for dead in bed? For example, I have noticed through one study I have read that the children/young adults who died from DIB ranged from 17-21 years of age. Could drinking alcohol, being alone, a cardiac issue or anything else be the underlying rationale or possibility for DIB? There has to be some sense we can make of this horrific syndrome that has lots of moms and dads worrying each night.

Yes, I can get hit by a bus tomorrow – but somehow I cannot compare that to DIB at this moment in time.

Hearing, “most kids will wake up” is not the same as hearing “all kids will wake up”. Twenty children under the age of 40 years out of every 100, 000 kids fall victim to DIB is way too high a number. One child is simply way to high a number for an unexplainable syndrome.

By far the best way to avert the complications and anxieties of hypoglycemia is by prevention. To this end I think that your first step should be to talk to your son’s doctor about changing his insulin regimen from regular and NPH twice a day to a a very short acting insulin like Humalog right after meals with a long acting basal insulin called glargine at bedtime. This is more demanding; but the number of insulin injections can be reduced to three a day by giving NPH with the breakfast short acting insulin and omitting the Humalog at lunch time. The glargine, for the most part, supplies a steady basal insulin need and can be calibrated against the pre-breakfast blood sugar. The very short acting Lispro or Humalog can be given right after the meal and the dose thus adjusted to the premeal blood sugar and the number of ‘carbs’ actually consumed.

The use of glargine for overnight control has been repeatedly shown to decrease the incidence of night time hypoglycemia. With a young person who is very athletic it is still possible that vigorous excercise in the aftternoon could produce hypoglycemia in the evening and rarely overnight; but the way to counteract that would be to do one or two 2 a.m. tests after excercise just to see if this is still a risk. I f you are still vey anxious about nocturnal hypoglycemia you might consider buying a Glucowatch. It is expensive both to buy and rather cumbersome to use; but with care it can reliably monitor blood sugars for a 12 hour period and it has an alarm. This instrument is likely to be superceded by one or more infrared devices in the near future and if you ar looking at a period of increased blood sugar monitoring you might also consider one of the new almost painless monitors, such as those by TheraSense.

The DIB or Dead In Bed syndrome has only fairly recently been described and as you have noted it is an event that occurs during the night in young Type I Diabetics and is thought to result from a cardiac arrythmia due to hypoglycemia or perhaps to an early autonomic neuropathy. It is nonetheless still a very rare event (see Dead-in-bed syndrome in young diabetic patients) and in this one study assessed at only 6% of all deaths in young diabetics.

I hope this has been of some reassurance.

DOB

[Editor’s comment: See our poll about nighttime blood glucose monitoring.

JSH]