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Question:

From Charlottesville, Virginia, USA:

My 11 year old son was diagnosed with type 1 14 months ago. He is on a combination of Humalog at meals and Lantus at night. He does not like to eat breakfast and we were reassured by the nutritionist that, with his flexible treatment plan, this is fine. Before he leaves for school, he does a finger stick first thing in the morning. After doing this for several days, a pattern has become apparent in that without eating breakfast or a morning snack, he will have at least a 70 to 80 mg/dl [3.9 to 4.4 mmol/L] rise in his glucose readings by the time he does his pre-lunch finger stick at school four hours later. I am certain he is not eating anything that he is not telling me about it because when he is at home on the weekend mornings, he routinely refuses food until noon. We did not notice this pattern over the summer as he did not check his sugar until just before he ate and he was not awake at 7 a.m. like he is on school days. What is responsible for the increase? Would his liver be releasing glucose? Is he still digesting dinner?

His morning readings are usually over 150 mg/dl [8.3 mmol/L], so I don't think he is dropping too low and experiencing rebound. I now insist he eat breakfast so I can give him insulin coverage, and I have even started covering him not just for carbohydrates eaten in the morning, plus the correction factor if necessary, but also for the spike that I know is inevitable! It is a little scary covering him for this spike as I know it can change, but by lunchtime his number is within normal range, not low, leaving me to believe that without the extra, he would be too high.

Answer:

This is not uncommon and one of the "trade-offs" for the flexibility of the basal-bolus insulin regimen. And, I generally agree with your nutritionist: if he doesn't eat, then he need not (necessarily) take insulin.

I think a couple of things may be going on. First of all, it is very possible that your son is beginning to emerge from his "diabetes honeymoon." Up until now, any "mismatches" of excess calories to insulin have been addressed, to some degree, by some residual insulin secreting capacity of the patient's pancreas. You may wish to read previous questions about the diabetes Honeymoon. But, all honeymoons end and when this one ends, it often is manifested by some higher readings by lunchtime. The diabetes honeymoon commonly lasts a year or so. His body indeed produces glucose if there is not glucose coming in. The liver is the primary source. Of course he needs glucose, and needs to utilize it properly, to help his activities, academic and physical, during the day. Unless dinnertime is remarkably late and/or the bedtime snack has a load of cornstarch (typically a slow digesting carbohydrate), I doubt his dinner intake plays a role here.

I think that awakening in the morning with glucose levels over 150 mg/dl [8.3 mmol/L], tells me that he could tolerate a bit more nighttime Lantus. This may also help sustain the glucose levels in the mid-morning.

I see no harm in giving him a correction bolus at the surge and/or around lunchtime. Alternatively, he could get a morning shot of NPH (or maybe Regular, if done carefully), even if he does not eat breakfast, to help blunt that surge you know is coming. What is the schedule like for activities in the morning and before lunch at school? They probably differ now from the summer time. Do they need/can they be addressed?

Talk with your own Diabetes Team about trying to get things back in balance for you. Maybe you/he are ready for an insulin pump.

DS

DTQ-20040923081803
Original posting 29 Sep 2004
Posted to Daily Care and Insulin Analogs

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