Attempts to develop an inhaled insulin have so far yielded less than idea results, she says. The dosing is hard and so much depends on technique. As millions of asthma sufferers have found, inhalers are difficult to master. Many have "terrible or variable" technique, Murray says.

Joshua gets five shots a day and eats on a schedule. He came home from the hospital on a strict diet, his mom remembers.

While Murray says doctors don't require as tight control with kids as with adults, standards are still high because there are so many long-term complications, from eye damage to heart disease or kidney failure associated with diabetes.

Even with good control, there are no guarantees, she says. "You may still have some of the side effects. Or you can do everything horribly and avoid the side effects, if you have the right genetic background." Statistically, though, improved control decreases the rate of complications significantly.

Carrie Black says many things can throw off the delicate balance they've achieved with Joshua. Stress, virus, bacteria — "it can all toss things out of whack." So can medicines for other things.

Carrie Black was worried when Joshua went to kindergarten, but his teacher was experienced with the disease. Her own daughter has it and that raised Carrie's comfort level. Now he's starting first grade in a few days and she's a little nervous. "My hands are tied in some ways. He's so young, if his sugar drops, he might not realize it soon enough. I plan to go at lunchtime, monitor his blood levels and give him insulin if he needs it," she says. All of the carbohydrates he consumes have to be accounted for, something his parents have become adept at, by this time. She's not sure she's ready to count on others to keep close tabs.

Joshua has an insulin pump, which provides a continuous small dose of short-acting insulin through the day. Last year, just in the Salt Lake area, Murray said, Primary Children's doctors started more than 100 children on pumps, which are programmed to provide a "background dosing of insulin to control glucose when they're not eating." Settings vary because the body's insulin need is not the same when a child is sitting at a desk studying as when he's out playing soccer. While a physician oversees that dosing, the goal is to educate the family so well that they can anticipate things that will change the insulin needs and make adjustments.

Joshua hates the pump, although it's small and unobtrusive. The problem is, other kids don't have it. And every three days, it has to be moved. He hates the poke of the needle into his skin yet again. Sometimes, he cries from a mix of pain and frustration.

He can't graze like other kids. When they trick or treat, for instance, Joshua can't come back and stash his cache to nibble on whenever he wants.

"It's moderation in all things," Carrie Black says.