From America On-Line:
My son is 3 1/2 years old and was diagnosed with diabetes about 8 months ago. His initial A1C was 8.4. We currently have him on 3 shots a day, NPH and currently lispro in the AM, lispro before dinner, and N at night. His preprandial sugars generally run between 80 and 140, recent A1C was 6.2. I am a cardiologist and have discussed my son with several pediatric endocrinologists who have different opinions regarding the level of control aimed for in this age group. One of them is very concerned about this degree of control in our child despite the fact that he has never had significant symptomatic hypoglycemia. We check him 6-8 times a day. The other physician thinks we are doing fine. What do you think?
In addition, I switched my son to Lispro from Regular to drop his post prandial sugars which were mid 300 on Regular. His A1C was 6.2 on the Regular. Do you think postprandial sugars should even be measured if the A1C is favorable?
This question goes right to the heart of the current debate raging over control in childhood. It raises several issues and I will tackle them in turn.
- Control in infants
There is a sum total of no evidence for the importance of tight blood sugar control in young children on long term outcome in diabetes. Extrapolation of the DCCT is tempting but scientifically unsound. All paediatricians agree that we should strive for as good control as possible in school age children while avoiding recurrent severe hypoglycaemia. In children under 5 years old, however, the risks of hypoglycaemia may be greater - there is some evidence of impaired IQ in young children who have had severe hypos and we know that the brain is still growing at this age.
- The Honeymoon Period
Your son's initial HbA1c tells us nothing about his diabetes other than offering confirmation of the diagnosis. Latterly, his good control may be as much a reflection of his ability to go on producing some insulin as it is an indication of good treatment. I can't make any judgement on this without knowing the doses you are using. Many children have near normal HbA1c results at this duration of diabetes and this doesn't necessarily reflect an increased risk of hypoglycaemia. I must also say that I can't make any sensible statement about the HbA1c levels you quote without knowing what the age specific normal ranges are for your hospital's lab.
- A Medical Parent
As a medical parent myself, I hope you will forgive me for suggesting that we are not good at being objective about our own children. I understand why you are striving for excellent blood sugar control but you are doing so from the position of an adult physician. I don't mean to be critical but please take the advice of your paediatric endocrinologist and diabetes team regarding blood sugar targets and which insulin to use. Lispro is brand new, unlicenced in this age group and I would certainly be nervous about its use except in specific circumstances.
- Blood tests
Your desire to know what's going on is understandable--I would be the same with one of my children--but 6-8 tests per day is excessive and will lead to sore fingers and possibly increase the likelihood of later rebellion. In any case, your son will soon be attending school and the logistics of this rate of testing will become overwhelming.
Good control is important. We should not be aiming for DCCT style control in pre-school children. Medical parents have to be very strict with themselves and trust their Diabetes Teams.
Original posting 19 Oct 96
Last Updated: Tuesday April 06, 2010 15:08:51
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