Pattern Management

Most people aim to keep blood sugar levels in the target range for 7 to 8 out of every 10 readings. Expect some variations. The insulin dose should be changed only when a pattern or trend of off-target blood sugar appears. One pattern might be when the blood sugar is high at the same time of day for 3 days in a row. Another pattern might be when it is low at the same time of day more than 2 days in a row or 3 times in a week. As long as your child is feeling well and does not have ketones, wait to adjust the insulin dose until the checks have been outside the target range:

• 3 times for highs
• 2 for lows

There might be a good reason for the highs and lows, such as exercise that wasn’t planned. In such cases, wait to adjust the dose a while longer to see if the pattern lasts.

You should also check for ketones if the blood glucose is above 13 mmol /L (230 mg/ dL) for 3 readings in a row. If there are ketones in this case, you may need more immediate adjustment. Consult the diabetes doctor or nurse immediately if this occurs.

Log Book Page Entries

Guidelines for dose adjustment

Here are some guidelines for insulin dose adjustment, for children or teens on a mixture of intermediate (NPH/Lente) and short-acting or fast-acting (Regular or Lispro) pre-breakfast insulin, short-acting or fast-acting pre-supper insulin, and intermediate-acting insulin at bedtime. Apply them only on the advice of a doctor.

If high (at any one of these times 3 days in a row)	before breakfast	increase	bedtime intermediate
	before lunch		morning short/fast
	before supper		morning intermediate
	before bedtime snack		supper short/fast
If low (at any 1 of these times more than twice a week or 2 days in a row)	before breakfast	decrease	bedtime intermediate
	before lunch		morning short/fast
	before supper		morning intermediate
	before bedtime snack		supper short/fast

Change the insulin dosage by only 10% as often as every other day until one of the checks falls within the target range.

What does a 10% dose adjustment mean?
If the child is on:	Adjust by:
Less than 20 units of insulin/day	1 unit at a time
20-30 units/day	2 units at a time
30-40 units/day	3 units at a time
Over 40 units/day	4 units at a time

Variable insulin dose schedule: "The Sliding Scale"

Most children and teens with diabetes receive a fixed amount of intermediate-acting insulin. However, they will change the amount of short- (or fast-) acting insulin depending on the blood sugar reading at the time of the injection. They will give more insulin for a higher reading, and less insulin for a lower reading. This allows gentle corrections to prevent long periods of highs or lows. In general a basic amount of short-acting insulin is prescribed for blood sugar levels that fall in the target range. A unit or 2 are removed for readings below target. One to 4 units are added as levels increase above the target.

In addition to using the scale to correct highs or lows, you can learn to make further change to balance heavy activities or a change in meal plan over the next 3 to 4 hours.

Even when a variable dose schedule is used, you still need to watch for patterns and respond to them, so that you can make appropriate adjustments.

Variable scales: Tom’s story

Consider Tom’s variable scale (see box below). His target range is 4.0 to 10.0. If Tom’s blood sugar result is 13.1 before supper and Tom is on Lispro insulin, the scale indicates that the dose Tom should take this evening is 7 + 1 = 8 units Lispro. However, if Tom is going to play tennis right after supper he may decide, based on experience and discussion with his health care team, to reduce his Lispro by 2 units. His dose will be 7 + 1 – 2 = 6 units.

Sample of variable insulin dose scale
Blood Sugar	Insulin
	Breakfast		Supper	Bed
	L	N	L	N
<3.0	-2		-2
3.1-3.9	-1		-1
4.0-10.0	5	17	7	10
10.1-14.0	+1		+1
14.1-17.0	+2		+2
>17.0	+3		+3
(L = Lispro, N = NPH)