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February 26, 2010

A1c (Glycohemoglobin, HgbA1c)

Question from Chippewa Falls, Wisconsin, USA:

Why is it acceptable for a 10-year-old to have an HbA1c of 8? Our pediatrician does not want us to try to get this down. I fear my son will suffer the horrific consequences of type 1 diabetes if we do not work really hard to get this down. She says that if we are at the recommended percentage, we should not worry about it. Am I wrong for being concerned? Also are there any free pump classes in Wisconsin?


From: DTeam Staff

In other parts of your communication, you did not indicate how long your 10 year old has had diabetes mellitus other than it has been “for less than 10 years.” You also did not indicate how long he has been using an insulin pump. You did indicate that his diabetes care is being overseen by a general pediatrician. I will conclude from this that your son does not see a pediatric endocrinologist routinely. (Has he ever?)

Current recommendations from the American Diabetes Association (ADA) for pediatric-aged patients with diabetes mellitus promote HbA1c values at the following targets: 7.5% to 8.5% in children under the age of six years; < 8% for children aged six to 12 years (no lower limit); and < 7.5% for children aged 13 to 19 years (no lower limit). Although "no lower limit" has been indicated, it is implied that one would not want the HbA1c to be too low, as that would indicate unacceptable incidences of hypoglycemia. A common non-diabetic range for HbA1c is 4 to 6%. It is important that these are guidelines derived from expert medical consensus. But, accommodations must be made for individual patients and their overall health, lifestyle, educational background, medical and social support, etc. The risks of "tight" glycemic control (as then reflected by a lower HbA1c value) include significant increased risk of hypoglycemia and weight gain. Both are issues that can be avoided with careful and good attention to overall diabetes management. On a practical, clinical basis, patients with diabetes have two main ways to have "good" HbA1c values: (1) overall very good glucose control and (2) lots of hypoglycemic values that balance out lots of hyperglycemic values. Therefore, you can see that the HbA1c value is not the whole story. I do not know why your general pediatrician does not want your son's HbA1c value to be less than 8%. Perhaps she has misinterpreted the ADA guidelines; perhaps she has some non-confidence in her ability to really be aggressive in diabetes management; perhaps she knows something about your son in terms of individualizing care (as noted above) that weighs heavily into the decision. But I think that it is unlikely, at least at this point with HbA1c at 8%, that your son is being set up for "horrific consequences." As for free classes on pump management in your state of Wisconsin, I would suggest any of the following: Contact your nearest children's hospital or medical school and speak with members of their Certified Diabetes Education office and/or Divisions of Pediatric Endocrinology Look in your local directory if there is a Certified Diabetes Education program near you (CDE programs might not be free but shouldn't be expensive) In the past, insulin pump manufacturers have commonly put on seminars and classes for people wishing to learn more about insulin pumps and pumping. Your son uses an insulin pump so contact the maker and speak with a local representative. I would imagine that you met a company representative when the child first began pumping. In fact, I can't imagine that you didn't have some sort of a certified pump trainer and class before you began pumping! Finally, recognizing my bias, and with complete respect and deference to your general pediatrician, you might wish to have a consultation with a pediatric endocrinology team. DS [Editor's comment: If there is no pediatric endocrinologist in your immediate area, you might be able to find one in Minneapolis or a nearby larger town in Wisconsin. While a pediatrician can provide good medical care, it would be beneficial to have your child seen by a pediatric endocrinologist at least once a year, if not more often. BH]