From St. Louis, Missouri, USA:
We have a 5 year child who has started kindergarten this past year. We have problems with control of her blood glucoses. Her regimen consists of A.M. NPH and Regular. She does well in the A.M., and before lunch, but after lunch will spike to 2-300, and that is even with well-measured amounts of food. Then if she is running around a lot, she can drop fairly dramatically: and she can even go low, but we wonder if this is because the NPH starts to peak; but if not low(and this is variable), she can remain high, with behavior problems. She does get R at dinner, and then N around 11 P.M. She tends to get high after the R wears off, but before the N has really kicked in.
Our questions revolve around any advice you might be able to give us regarding a better insulin regimen, one that would give better afternoon coverage at school, without the big postprandial spike, but with less chance of lows. Also, would it be a reasonable idea to give some NPH before dinner, and then again later, to cover what seems to be the "hole" in her coverage. Finally, would she benefit instead from a totally different regimen, e.g., using Ultralente instead of NPH, and then using the Regular and/or Lispro with meals. We have a problem with lunch, if we are not around to inject her, of course, and we are still trying to figure how to handle all these issues relating to how to give decent control at school, without the extremes in blood glucoses--since she is an extremely sweet child when controlled, but abusive and angry as much or more when high than when low!
Many parents of young children report that their children have behavior problems when their blood sugar is high. I suspect this is because they are uncomfortable rather than any direct effect on the brain. This is rarely reported by parents of older children or adults.
The problems you bring up regarding difficulty in blood sugar control are due to the difficulty of trying to match the times of insulin activity with the times of food and exercise. There is no definite answer I can give you, but I will give you some "thoughts." You should not make any changes, however, without first discussing them with your child's own physician.
- On days when your child is more active than usual in the afternoon, she will probably need extra food (unless you lower the insulin working at that time).
- It is important to try and figure out when the insulin is working in your own child (as opposed to when the books say it is supposed to be working). To do this, you want to try and change only one insulin at a time by a small amount and see when the blood sugars change (as opposed to when you think they are supposed to change.)
- It is often difficult to avoid high blood sugars 1-2 hours after eating without giving so much insulin that the blood sugar goes low 3-4 hours after eating. Adding Lispro at lunchtime might help (and lowering the A.M. NPH), but if you are not sure you can do this every day, it is best not to start.
- Your morning Regular and NPH are probably both working before and after lunch. Sometimes if you lower the morning NPH a little, you can increase the A.M. Regular without going low before lunch. The extra A.M. Regular might last long enough to help decrease the rise of blood sugar after lunch. If you are able to lower the A.M. NPH a little, she might be less prone to lows in the afternoon.
- If your child is willing, you might be able to lower the carbohydrate content of lunch a little bit and add it to the afternoon snack.
- If the blood sugars are going high in the early evening, yes, moving some or all of the NPH to before supper might help. Make sure if you do this to check the blood sugars at 3 A.M. and breakfast to make sure that she is not going low while sleeping and to make sure that the NPH is lasting long enough to carry over until the next morning.
- If none of the above work, yes, sometimes switching to Ultralente twice daily will help. This works best if you can give lispro and/or Regular before each meal. If you can't do this, you might find that a small amount of Lente before breakfast will work similarly to Regular before lunch (but again, you probably won't get a "peak" right after lunch.) On the other hand, if she takes less intermediate acting insulin (Lente or NPH) in the morning, she may tolerate a larger dose of Regular that will carry over until after lunch. (Lente and NPH are both intermediate acting insulins with similar times of action. NPH cannot be mixed in the same syringe as Ultralente, but Lente can. If you need to mix an intermediate insulin and Ultralente in the same syringe, you need to use Lente.)
Only trial and error (working with your own physician) will determine which regimen will give the fewest lows and the fewest highs.
Original posting 12 Dec 97
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