From Prince Edward Island, Canada:
My 11-year-old daughter was diagnosed in with type 1 in June 2012. Her first A1c was 7.2, her second 8.2. We go at the end of the October for her next endocrine appointment and also to start her insulin pump. For the last two months, her blood sugar has been in a very tight range, 4 to 7 mmol/L [72 to 125 mg/dl], 90% of the time. I cannot find any support groups or anyone who encourages this tight of a range. We are very active with adjusting her insulin on a per needed basis when we notice a pattern. She is on Levemir, 15 units in the morning and 18 units at bedtime. Her carbohydrate to insulin ratios are 1:12 for breakfast, 1:14 for lunch, and 1:15 for supper. I am expecting a 5 to 6% A1c at the appointment. My daughter does not want her range to change. She says she feels so good in such a tight range and feels when she is high and low even if she is in the 9s mmol/l [162 to 178 mg/dl] and, on the other end, 3s mmol/dl [55 to 70 mg/dl]. Why is there no support for a tight range for blood sugar levels? Why are the expected ranges so high? I understand the fear of hypoglycemia, but we do not have the issue with this. Yes, she drops into the 3s mmol/L [55 to 70 mg/dl] sometimes, but if we see a pattern, we fix that issue. She is also very active so we are trying to figure out how to prevent the after exercise lows. My daughter is alway high during exercise. What advice, suggestions, support can you provide to this mom that is looking for clarity and support on keeping blood sugars in a nice tight range?
A normal serum glucose value, before a meal, is typically about 60 to 100 mg/dl [3.3 to 5.6 mmol/L]. For the non-diabetic, the normal HbA1c value is typically less than 6%. The American Diabetes Association has offered "target" HbA1c values for different aged children and for an 11 year old, that target is <8%. The American Association of Clinical Endocrinologists may suggest a tighter target of <7.5% for that range. I do not know if similar organizations in Canada have different targets but I think you might discuss with your child's pediatric endocrine team their concerns with "tighter" glycemic control.
In general, tighter control using today's typical insulin regimens, have the following potential disadvantages:
- increased hypoglycemia
- increased hypoglycemia unawareness
- weight gain
But, in my mind, these are disadvantages and certainly issues to be mindful of, but not necessarily absolute, deterrents to tighter glycemic control. Common sense still prevails: I would not target a glucose of 75 mg/dl [4.2 mmol/L] during the child's athletic event. Indeed, studies suggest that in highly trained athletes with type 1 diabetes mellitus, peak performances occur with glucoses about 150 mg/dl [8.3 mmol/L].
Finally, while you and your family may be "on top of things now," life has a way of changing: children tend to get rebellious and oppositional and resistant to parental/ adult oversight. Meal planning changes. Lifestyles change. For example, I would not want her driving an automobile with a glucose near 60 mg/dl [3.3 mmol/L]. Also, not all families are necessarily as careful as you might be.
So YOUR diabetes team may be supportive of YOU and YOUR daughter being in tight control; but they may not want such a blanket statement for all 11 year olds who may not have such good supporting families.
Talk to your team and see if and why they might be resisting or cautious of your daughter's tight control.
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