Ask The Expert
Children

I know this can be challenging and please understand that I cannot determine or diagnose what could be going on. However, I will provide some things to consider.

Start with your daughter's healthcare provider

• Your daughter may need a thorough laboratory and physical examination to rule out other contributing diseases or factors.
• Consider puberty: Due to her age, puberty can wreak havoc with diabetes control due to the hormones of puberty that can increase insulin resistance. She may need a significant adjustment/revision in her insulin dosage or regimen.
• In the resource link below, I'd recommend you review the topics under "Care Suggestions" and also "Parents" for great tips on helping to manage children with diabetes.

Re-visit the diabetes educator and dietitian

Even if you are certain your daughter is proficient in the basic skills in managing diabetes, it is always good to have a thorough assessment and review.

• Injections: For example, is she rotating her injection (or pump infusion) sites adequately? If not, she may be delivering her insulin in the same area, causing a build-up of fatty/scar tissue that could be interfering with insulin absorption.
• Food: Perhaps her meal plan needs adjusted. Although it is daunting to keep detailed records for any length of time, it is worth keeping a daily record of food, insulin, activity, stress, illness for several weeks and bringing these to the visit for detailed analysis.
  • It is not uncommon to learn that perhaps your daughter is not counting carbs consistently, or is not using the proper insulin/carb ratio or correction factor.
• Insulin regimen: Sometimes the insulin regimen may be too complex for a person to follow-for example, it could be that she is mixing up or reversing certain insulin/carb ratios or correction factors or other dosages.
• Sick Days: Do you and she know and follow the specific rules for sick days? It is worth reviewing the guidelines for when to recheck a high blood glucose, at what level to take extra insulin, when to check ketones, and when to call the healthcare team.

Analyze the data management reports for missed doses and/or wide glucose swings

• Do you download her meter results on a regular basis?
• If your daughter uses an insulin pump, it is important to download both the pump and glucose results to see if there are missed boluses. If she is not on a pump, it is still important to consider the possibility that your daughter may be accidentally or intentionally skipping some doses. Missed doses are thought to be the most common cause of erratic blood sugars and diabetes temporarily out of control in children and teens.
• I don't mean to imply that your daughter must be missing doses, but just that it is something you may need to consider.
• Consider using continuous glucose monitoring (CGM): While CGM might require more work--not less-- as you learn how to get the most out of this system, it is helpful in showing if there are wide glucose swings that may be missed with traditional testing; in addition, there are alarms and trend arrows to alert your daughter before she gets too low or too high.

Consider counseling

• As you know, being an adolescent or teen is challenging enough, and adding diabetes to the mix can be overwhelming at times.
• Your daughter may benefit from talking to someone who is not so closely associated with her medical team but who has a basic understanding of diabetes.
• Even though she may be juggling most of her diabetes care herself, she may need a temporary break where she gets increased assistance from you.

I know this is a lot to consider. Hopefully by working with your diabetes team you will be able to uncover the cause of the problem.