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Question:

From Glencoe, Minnesota, USA:

We took my daughter to the doctor because she had been cold for a couple months. When the temperature was 85 degrees and humid, she was huddled under a blanket. She is 3 years old and weighs 35 pounds.

They tested her metabolites because my wife and mother-in-law both have problems with the thyroid and take Synthroid. My daughter's blood glucose was 377 mg/dl [20.9 mmol/L]. They called us to say she had type 1 diabetes and that we needed to check a fasting blood sugar the following morning and start insulin right after.

Her fasting blood sugar the following morning was 109 mg/dl [6.1 mmol/L] and was 97 mg/dl [5.4 mmol/L] two hours later when we were in the diabetic educator's office. The A1c was 220 mg/dl [12.2 mmol/L] (the average from the last two to three months, I was told). Two hours after eating a small bag of Cheetos, my daughter's blood sugar was 340 mg/dl [18.9 mmol/L]. We started her on two units of Lantus that night, with a sliding scale of.5 units per serving of carbohydrates (about 15 to 20 grams) with each meal the following day.

That weekend, we had problems keeping her readings above 100 mg/dl [5.6 mmol/L], which is the lowest end of the range they prescribed (100 to 200 mg/dl [5.6 to 11.1 mmol/L]). We decided to give less insulin than was prescribed because she was running so low. We called and made an appointment with a pediatric endocrinologist for Tuesday. With the low numbers, she took her off the NovoLog with meals and left her on Lantus. We gradually decreased the amount of Lantus over the next three days due to lows, eventually eliminating it for two weeks, although my daughter's blood sugar would rise to 250 to 300 mg/dl [13.9 to 16.7 mmol/L] after meals. During this time, her blood sugars were 60 to 70 mg/dl [3.3 to 3.9 mmol/L] before meals and at 3 a.m.

One morning, she woke up at 127 mg/dl [7.1 mmol/L] and, over the next seven hours, rose to 426 mg/dl [23.7 mmol/L] with only 20 grams of Cheetos for carbohydrates that day. She had eaten hot dogs, lunch meats, cheese, etc, with no breads and no other carbohydrates, no milk, pop, etc. Four hours later, her blood sugar was 88 mg/dl [4.9 mmol/L].

Last Friday, she had a small amount of carbohydrates and had blood sugar readings between 110 to 180 mg/dl [6.1 to 10.0 mmol/L] all day long, then read 321 mg/dl [17.8 mmol/L] at bedtime. The carbohydrates that she had that day were eaten with lunch, around 1 p.m. This is a day with no insulin.

After speaking with the doctor, who had been on vacation most of the time when my daughter was without insulin, my daughter was put on NPH starting Saturday morning. Since then, my daughter has been between 120 to 250 mg/dl [6.1 to 13.9 mmol/L] during the day and then up to 350 mg/dl [19.4 mmol/L] at bedtime, which is at 10 p.m. We give the one unit of NPH in the morning, around 9 a.m. Her 3 a.m. readings have been both high and low. Some nights she is around 300 to 350 mg/dl [16.7 to 19.4 mmol/L] at bedtime, then 300 mg/dl [16.7 mmol/L] or 80 mg/dl [4.4 mmol/L] at 3 a.m. It seems that, regardless of the insulin, she bounces all over the place, both high and low.

This may be unrelated, but my son, who is now five, sat down at school and took a nap from which he couldn't be awakened for an hour. He also grew nine inches in nine months during the school year.

I mentioned my wife's family history of thyroid problems. Her oldest brother was/is hypoglycemic (mostly outgrown from childhood). My father and sister have type 2 diabetes (my sister's started as gestational) and my maternal grandmother had type 1 diabetes and was insulin dependent. I, myself, was a concern for diabetes because when I was in the hospital for a severe allergic reaction, and for several months after, my blood sugars were in the 240 mg/dl [13.3 mmol/L] range, but would drop within 15 to 30 minutes into the 60 mg/dl [3.3 mmol/L] range. I haven't monitored this since that time. As a child, I grew quickly. When I was 10, I was 5 feet 10 inches tall and weighed 180 pounds, had a full chest of hair and shaved every day. What role does the pituitary gland play in issues like this? I thought the pituitary secreted hormones for the pancreas to start and stop production of insulin as well as telling the body to release extra sugar stores if the blood sugars were low. It almost seems to me that the pituitary is slow in secreting those hormones to start and stop production of insulin. Or, the pancreas is slow in responding to those hormones, which would explain why my daughter goes high when she eats, but then when the pancreas does kick in with insulin, it doesn't know when to stop and then she goes low. Then, you throw in the added issue of the hormone (that glucagon replaces) that tells the body to release sugar stores which might explain some of the highs, I guess.

I don't know and my doctor is slow in responding to these questions. The nurses and diabetic educators that we speak with don't know and have flat out told us they don't know what to tell us. I don't want to continue treating my daughter for diabetes if this diagnosis is rushed and it may not even be the problem. I know the highs and lows need treated to prevent damage, but I want to know what's causing all of the highs and lows and ups and downs and unexplained spikes in blood sugars when she's had no sugars or carbohydrates.

Answer:

This is a long a complicated story. I am sorry that you feel you are not getting timely or clear responses, but I am glad you are following with a pediatric endocrinologist.

First of all, the A1c value that you gave of "220" is NOT the A1c value; the A1c is measured in terms of a percentage, i.e. the percentage of hemoglobin that has glucose attached. Non-diabetics range from about 4-6%; diabetics in extremely poor control could be up to 16-20%. I think that the diabetes team tried to correlate that whatever her A1c value was, it would have been associated with an average blood glucose of 220 mg/dl [12.2 mmol/L] over the preceding weeks. This is very high.

Secondly, your interpretation of pancreatic control is not really correct. The pancreas is NOT under direct control from the pituitary gland in the brain. The largest influence on pancreatic insulin production is the amount of glucose in the blood perfusing the pancreas. The pituitary gland does control many other aspects of the hormonal system; some of those hormones, such as pituitary growth hormone and adrenal gland cortisol, do act to increase the blood glucose.

Sadly, I think that your daughter does have impaired glucose regulation and she probably has diabetes. Just as "not all that glitters is gold" - not all that is hyperglycemia is diabetes. But, it most often is. As your diabetes team as outlined, I'm sure, the regulation of glucose requires an on-going, perpetual balance of insulin with meals and activities. In a three year old, this could be especially problematic. Indeed, activities and meal planning can be problematic for any toddler, regardless if they have diabetes!

I would also treat the child as if she had type 1 diabetes (did she have ketones?); I would suggest that your team obtain blood samples for those immune proteins that "attack" the pancreas during type 1 diabetes, including GAD-65, ICA-512, and insulin autoantibodies. I would also try to utilize an insulin plan that provides a subtle background of insulin and then base extra insulin dosing depending on her intake of carbohydrates. Lantus has not been approved for use in the U.S. for children less than age 6 years, so I more often use Ultralente, which I find typically works better as a twice a day, background, baseline insulin, but which can be mixed with other insulins, unlike Lantus.

The use of NPH only is also reasonable. RARELY, will I use a premixed insulin called 70/30 in this situation. 70/30 means that the ratio of intermediate NPH-to-short acting insulin is 70-to-30. So, one unit of this mix contains only 1/3 unit of short-acting insulin.

Please maintain an on-going dialogue with your diabetes team.

DS

DTQ-20040803182355
Original posting 16 Aug 2004
Posted to Diagnosis and Symptoms and Hyperglycemia and DKA

  
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Last Updated: Tuesday April 06, 2010 15:09:58
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