Today is the next installment in my weeklong celebration of Type 1 Diabetes Awareness Day: Keep It Down!

High blood sugars cause miniscule amounts of damage to tissues that, over time, build up in the body and result in some pretty horrible things: blindness, amputation of the extremities (usually feet), nerve damage, kidney failure. So it's important to keep the blood sugar level low.

We spring into action if Penny's blood sugar is over 200, or if she's doing something that's likely to raise her sugar to that level (like eating).

The most common variety of diabetic -- type 2 -- can usually control their sugars by controlling their diet and physical activity. This is where type 2 and type 1 diverge the most: No matter how well Penny eats and how active she is, she will always require some amount of insulin to keep her blood sugar from getting too high. (Though a low-carbohydrate diet and regular exercise does help with control and keeps the amount of insulin she needs lower.)

And since insulin breaks down instantly on contact with stomach acid, it can't be delivered via pill. Which means that Penny requires multiple injections a day.

The tubes that look like oversized ballpoint pens are the two types of insulin she uses. The green case carries a rapid-acting insulin that we use to counteract the effects of meals and bring down highs; the grey one holds long-acting insulin that keeps a small amount of insulin burning in her system for a full twenty-four hours, which helps control the random ups and downs caused by everyday life.

(Right now, still in her honeymoon phase, Penny isn't taking any of the long-acting stuff, because her body hasn't finished destroying her insulin-producing cells yet. So she's still making enough insulin for herself to cover this basal level, and a good portion of the meal-time adjustments. But sometime in the next weeks or months, she'll need to go back on the long-acting basal dose.)

To be precise, both of the pens are, in fact, injection devices in themselves. We could get needle caps that fit over the end of the cartridge, and then use the dial at the base end of the pen to set the dosage. It's an extremely efficient and foolproof delivery system... except that Penny hates it. To use the pen system, you see, the needle has to be left under the skin for a while -- 5 seconds for the green pen, and 10 seconds for the grey one. It doesn't really hurt any more, but it kind of freaks her out. So we don't fight it. Instead, we just use the pens as carriers/protectors for the cartridges, and we draw the insulin out into a standard syringe. (We may try to reintroduce the pen concept in a few years, when Penny's ready to start injecting herself, because they're so much easier to use.)

The other advantage to using the pens as containers for the insulin is that the cartridges hold relatively little insulin -- about 300 units (a "unit" of insulin is 1/100th of a milliliter or CC, so this is about 3cc's). The normal insulin bottle that you may see holds 1000 units (10 cc's). And insulin, once you've either taken it out of refrigeration or breached its seal, is only viable for about four weeks. Right now, Penny is nowhere near using even the 300 units in the pen cartridge in 4 weeks, so going with the cartridge means there's less insulin we have to throw away at the end of the month.

This is Penny's ShotBlocker. Its purpose is to make shots less painful -- you press the spiky bits against the skin, and give the shot in the slot area. They were taken off the market just about the same time that she was in the hospital, which I didn't discover until I was trying to buy some more. The reason they were taken off the market is that the FDA wants Bionix (the company that makes them) to offer conclusive proof that the ShotBlocker actually reduces sensation. Which I think is stupid. Of course it doesn't actually reduce sensation in the area. Its benefit is mostly psychological -- with so many little pricks and pokes against the skin, the kid barely notices one more. The damn thing works, so let's hurry up, FDA, and get it back on the market, because I'll want to be able to buy new ones when we inevitably misplace ours.

So now that we have all our tools in place... how much do we give her?

The basal dose is a flat number, given just before bed each night. (Technically, it could be at any time of day, but it needs to be the SAME time, or as close to it as possible, every day. Bedtime is as close as we get to any kind of stable schedule.)

The rapid-acting dose, however, is figured by what seems to be an absurdly complicated formula.

First, we figure out the "correction" dose -- that is, if she's running high, we need to give her a little extra to bring it back down. In shorthand, it looks like this: 1:200>150. What that means is that she gets one unit of insulin for every 200 points of sugar over 150. So if she had a blood sugar of 250, we would subtract the 150, giving us 100, and then divide by 200, which results in a corrective dose of 0.5, or one half of a unit.

Now, if this is a night-time check or she's more than half an hour from her next meal, we give her the shot. But if she's about to eat, we just sit on it, because there's more figuring to do.

When she's older and we can more reliably predict what she'll eat at a meal, we'll move to dosing her before she eats, so the insulin is already in her system and working as the food hits it -- this is both more efficient (requiring less insulin to process the same amount of food) and easier on the body (because she spends less time with a high). But she is four, and at any given meal she might well eat all her food or only a few bites. So instead, we wait until she's done and then add up all the carbs she ate.

Then we figure what's called a "food bolus" -- an amount of insulin based on the number of carbs. Right now, Penny gets 1 unit of insulin for every 40g of carbs. (This is a tiny amount of insulin. Before she dropped into her honeymoon phase, it was 1 unit per 15g of carbs, almost three times as much.) So if Penny eats a meal containing 60g of carbs (a pretty heavy meal, but it's not entirely unusual for her to have a carb-heavy breakfast that meets or exceeds this) then that's 60 divided by 40, or 1.5 units of insulin.

If there was a corrective dose, then we add that to the food bolus (0.5 + 1.5 = 2.0, for our example), and there's the amount of insulin she needs. Of course, the numbers don't usually work out that neatly. Usually, we end up with a number like 1.15 -- how the heck do you figure .15 of a unit? You don't. You round it off. Of course, because Penny is small enough and reactive enough to the insulin, we're not doing the usual rounding. We're rounding to the nearest half-unit. So 1.15 would round down to 1.0, but 1.35 would round up to 1.5 units.

Because we're figuring to the half-unit, that means that Penny gets a shot for any meal containing a number of carbs greater than 1/4 of that base amount. (In this case, any meal of 10g or more. Back when her base ratio was 1:15, she'd need a shot for any meal with 4g or more.) We keep cheese cubes, sugar-free jello, and hard-boiled eggs on hand for no-shot snacking. Some veggies are okay right now but we'll have to re-evaluate that when her ratio changes again; one "serving" of baby carrots, for example, is 9g of carbs.

(One of our relatives, about a month after Penny's diagnosis, said, "I wonder how stupid people manage all this!" Truth to tell, I wonder, too.)

We're very lucky, however, that though we're supposed to encourage Penny to make lower-carb choices, we're not absolutely required to alter her diet. She can eat almost anything she wants, as long as we keep track of it and administer an appropriate bolus.

Of course, it's not as easy as that, either... For instance, if she's had an insulin dose within two and a half hours of her blood glucose measurement, then the insulin is still working in her system, and we shouldn't figure a corrective dose, to avoid over-correcting. (This is a problem at daycare, actually, because they serve meals every 3 hours, and Penny frequently takes more than an hour to eat a meal. We finally told them not to even bother with corrective doses for lunch and snack; we just take care of it at dinnertime.)

And some foods, for whatever reason, don't interact with her system directly in accordance with their carb counts. Some of these are easy -- "sugar alcohols" (found usually in diet foods) only count for half. And if her serving has 5g or more of fiber in it, then we don't count the fiber portion toward her carb total. (But we do count it if it's less than 5g.) Other foods are less quantifiable -- pastas, for example, send her blood sugar soaring all out of proportion to their carb values. But not always, and we're still trying to figure out the specifics. When we get a better handle on it, we'll be able to work in a fudge-factor to cover it; right now we just assume that she'll need a corrective shot a few hours after eating pasta or pizza.

I'm hoping when she's a bit older that she'll be able to tolerate a pump system. Pumps, like pens, deliver highly-accurate amounts of insulin, and most of them have onboard computers that will compute the dosage (and it can deliver dosages to within a tenth of a unit, so they're more accurate), and some of them can take previous doses into account, so they can still issue corrections even if they're within the 2.5-hour-mark of the previous dose. The needle is left taped into place for up to three days at a time, but it's smaller (and more flexible) than a syringe needle, so there are fewer shots to endure. (I understand that putting it into place is slightly more painful than the regular shot, but not excessively so, and that once in place, it really can't be felt at all.)

But right now, it's syringes, four or five a day.

And that's just keeping her blood sugar down. We also have to watch out for her sugar dropping too low. That's what I'll talk about tomorrow, with Keep It Up!