Poor glycemic control

The excellent article by Dr. Kaufman and Ms. Halvorson, "New trends in managing type I diabetes" (October) prompts the following comments about poor glycemic control.

One of the more common, challenging, and frustrating reasons for unexplained poor glycemic control is noncompliance with insulin administration. This is noted primarily in older children and adolescents, and it can lead to recurrent diabetic ketoacidosis (DKA). Poor glycemic control and recurrent DKA in a patient on a relatively high dose of insulin (greater than 1.5 U/kg/d) should prompt the provider to consider noncompliance, especially if blood sugar was previously well controlled on a lower conventional daily dose of insulin.

Less common reasons for the abrupt onset of poor glycemic control include decreased potency of insulin, which may result from storage of vials at extreme temperatures (less than 36° F or more than 86° F), excessive agitation of the vials, or use of the vials after the stamped expiration date. Unused bottles of insulin should be refrigerated but not frozen. Also, some loss of potency may occur after an insulin bottle has been used for 30 days even if it is not outdated, especially if the bottle is stored at room temperature.

Furthermore, the provider needs to recognize that when regular and lente insulins are mixed, the onset of action of the regular insulin may be delayed because the zinc present in the lente binds with the regular insulin. This reaction is not noted when regular and NPH insulin are mixed.

Patients should inspect all insulin bottles for any signs of spoilage or decreased potency such as clumping, frosted coating, or a change in clarity of insulin. Appropriate-appearing short-acting insulins are clear while other insulins are uniformly cloudy. If spoilage of insulin is suspected, the vial should be discarded to avoid problems with glycemic control.

Albert DiNicola, MD
Laguna Niguel, CA

The authors reply: We thank Dr. DiNicola for his thoughtful comments on our article. These are points worth raising.

Francine R. Kaufman, MD
Mary Halvorson, RN, MSN, CDE
Los Angeles, CA

Sleeping well

We are concerned about William Carey's comments about a 9-week-old infant who needs skin contact with her mother in order to sleep (Behavior: Ask the experts, August). While we support Dr. Carey's emphasis on helping the baby sleep in the supine position, we question his insistence that the baby must immediately learn to sleep alone in a crib. This baby has slept in contact with an adult for the nine months of gestation plus the nine weeks since birth, and her behavior shows clearly that she is not yet ready for solitary sleep. The parents should be helped to find a safe sleeping arrangement based on evidence about infant physiology that allows all family members to get the maximum amount of sleep.

Since this is a breastfeeding baby, our first suggestion would be an arrangement in which the mother and child can nurse to sleep together, taking full advantage of the soporific effect of the cholecystokinin (CCK) that they both release in response to suckling (Üvnas-Moberg K: Sci Am 1989 Jul;261:78. The baby could start the night in the parents' bed, and the mother could slide the baby into a "side-car" crib after she was asleep. A second alternative is an adult mattress on the floor beside the parents' bed; the mother could safely leave the baby sleeping there and move into her own bed. There is evidence that young babies have a drop in CCK levels about 20 minutes after the end of a feeding, when they are likely to wake and look for more nursing (Üvnas-Moberg K et al: Arch Dis Child 1993;68:46). So it makes sense for the mother to stay beside the baby until that "window" has passed. The mother can be asleep through this post-feed interval.

The work of McKenna and Mosko has shown that babies sharing a bed with their mother consistently sleep on their backs, the position most protective against SIDS. McKenna theorizes that co-sleeping may further reduce babies' risk of SIDS because the co-sleeping baby receives more stimuli for arousal than a solitary sleeper (McKenna JJ et al: Sleep 1993;16:263). In addition to SIDS protection, bed-sharing is beneficial for breastfeeding, as the babies breastfeed more than twice as often as babies sleeping in a separate room (McKenna JJ et al: Pediatrics 1997;100:214). Night feedings are easy on the mother when the baby is within arm's reach, and CCK can lull her quickly back to sleep.

Dr. Carey represents one of the most prestigious pediatric training programs in the US. We believe that his response, based on the assumption that there is only one right way for young babies to sleep, has the potential to undermine American families' hard-won progress toward an increased incidence of continued breastfeeding.

Lori B. Feldman Winter, MD
Chris Mulford, RN, IBCLC
Stratford, NJ

I agree with Dr. Carey that it's important to make sure the infant is feeding well and gaining weight when making an assessment. I am also well aware of AAP's recommendation that infants sleep on their backs to prevent SIDS, and I support back sleeping as the norm.

However, it is quite normal for infants to sleep with their parents. Setting limits and enforcing separate sleeping in a 9-week-old makes no sense. Probably the majority of young infants in the world do sleep with their mothers. I would ask the mother if she and her husband slept well when the infant was in bed with them. If so, there is no need to move the baby to a crib. The baby needs contact with her mother; the infant will transfer naturally and gradually to her own sleeping space at a later date when she is ready to do so.

I would recommend that the mother try letting the baby sleep on her back beside her in bed and allow her to breastfeed at will during the night. I would also reassure the mother that this baby needs lots of physical contact and that pushing the baby to sleep on her own will only make everyone miserable. As long as mom, dad, and baby are happy sharing a bed, then it should be encouraged. Giving the baby a gentle massage prior to sleep might also help her to relax.

Dr. William Sears has written extensively on attachment parenting and the family bed. I would recommend that the mother of this infant read this literature.

Linda L. Shaw, MD
Altoona, PA

I have some comments about Dr. Carey's concern about the risk of SIDS if the infant is sleeping prone on her parents. First, sleeping prone on an adult is analogous to the so-called apnea mattresses we used to use in the step-down nursery to stimulate babies to breathe. These were little devices that preemies slept on, which were inflated and deflated rhythmically. In other words, the rise and fall of the adult human's chest would continuously stimulate the infant to breathe, so it seems unlikely that the infant would succumb to SIDS for that reason.

Second, I would like to support the view that young infants should not sleep alone. As mammals, we evolved over millennia sleeping with our mothers and breastfeeding through the night. This relatively recent trend of making our tiny babies sleep alone so that they don't get too dependent is very disturbing to me. Why not recommend to this mother that she gradually help the baby make the transition to side-lying nursing at night instead of sleeping on her? This seems more gentle and more in keeping with our biology.

Third, I would like to support lactation consultants; they are very well-trained, committed individuals who are required to have many hours of hands-on experience before they are allowed to take a board exam that few pediatricians would pass, in my opinion. If this person is IBCLC­trained, she most definitely knows about the risk of prone sleeping. These women do a wonderful job, and unfortunately get a lot of sneers and jeers from the very professionals they help the most.

Terry L. Dise, MD
New Orleans, LA

The author replies: How unfortunate it is that these critics have misunderstood both my intentions and my suggestions for management. They have spent a great deal of ammunition shooting at a friend.

The case under discussion involved a 9-week infant who had been sleeping prone on top of her mother on the advice of a lactation consultant. The newborn period had been complicated by concerns about physiological jaundice and trouble with breastfeeding, but maternal perceptions of infant vulnerability had not been explored. The mother had become overtired from this sleeping arrangement and, wanting relief, had tried without success to get the baby to sleep in a crib. My suggestions included, in brief: a weight check, a sleep diary, trying again her program of stepwise reduction of involvement after placement of the infant in the crib, and the use of a heating pad or hot water bottle to substitute temporarily for the comfort of maternal body heat.

Nothing I said should fairly be interpreted as proposing that there is "only one right way for babies to sleep." I did not insist that the baby sleep in the crib; that was the mother's idea. I have not been an opponent of prudent co-sleeping. I did not mention the use of a separate room or even placement away from the mother's bedside. I can assure these critics that their fears are completely unfounded if they are concerned that I am misleading pediatric trainees and undermining the progress of American families.

Let us not forget the main issue in this situation: The mother was described as exhausted and was urgently asking her primary care practitioner for help. My advice as a pediatrician (or in this case as a consultant) was to help the mother quickly find relief so that she could function better as a mother, spouse, and person. My top priority was to preserve her mental health. She had probably already tried those other solutions with the baby still in her bed and at this point she was desperate for sleep. If she was ready to stop having the baby in bed with her at night, it would not be appropriate for us, as professionals, to urge her to do otherwise.

Using parents' own ideas for solving behavioral problems, assuming that they are reasonable, has a greater chance for success than uncongenial techniques suggested by advisors. This mother's use of the crib was reasonable; my suggestions were aimed at promoting her success with her own method. Extensive clinical experience leads me to believe that everyone would probably have been better rested in two or three days with the implementation of my plan.

I should add that the respondents' recommended practice of putting the baby down when already asleep, whether bottle or breastfed, is likely to predispose the baby to crying problems when wakening at night both at present and in the coming months. The baby is being trained to rely on parental intervention to get back to sleep. That advice would probably be counterproductive (Blum NJ, Carey WB: Pediatr Rev 1996;17:87).

Also, there is no solid evidence that co-sleeping reduces the risk of SIDS. In fact, the AAP recently advised that it may increase the risk.

I thank these critics for their stimulating discussion. I respect their concerns but urge them to consider that their censure is misdirected.

William B. Carey, MD
Philadelphia, PA

Iris Rosendahl. Letters. Contemporary Pediatrics 2000;1:21.

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