How to treat rebound highs?

[hold48398]

In reference to my other post (http://forums.childrenwithdiabetes.com/showthread.php?p=73847#post73847), I was wondering what your experience has been in treating a rebound high. I am aware that a low followed by a high is more likely to create another low later as the body is trying to replenish its own glucose stores.

Do you treat a re-bound high with a full correction dose?
If not, what rule of thumb do you apply?

I gave Mia a 2/3 correction dose tonight out of fear of her dropping low again while she is sleeping but I have no idea if that is what she needs.

Thanks...

[wilf]

As I understand the term, a "rebound high" is caused by the body's own hormone response to low BG levels. I don't think she was low enough long enough for this response to be triggered.

My sense is that what has happened here is that the many grams of carbs you gave her finally got digested, and have pushed BG up as you would expect. Was your method of treatment 2/3 of what you would normally give to correct?

Things I would have been thinking when correcting were what caused BG to go so low in the first place. It could have been:
- too much insulin, or
- prior heavy exercise, with too little food to replenish muscles' glucose stores,
- too little food, or
- delay in digesting food.

My sense in light of the delayed response to extra carbs is that there was prior heavy exercise and/or food digestion was being delayed.

I would not do anything more tonight to bring her down (even if the 2/3 correction was not adequate), and check BG at least once more around time of peak action of the correction dose.

Good luck!

[hold48398]

Hi Wilf,
I really appreciate the quick reply. I normally would give Mia .60 correction to bring her from 280 to the 150 target but I decided to only give her .40 tonight. I will check her here in a bit to see where we are at.

There was nothing too unusual about today's day. She did have a *slightly* higher activity level due to a birthday party in the early afternoon but nothing to the point where I would have thought it affected her that much. I also double checked her bolus history, and the log matches with what she should have gotten at the right times. Her basals did not change.

Which leaves me with your final suggestion- delay in digesting food. What would cause this? She had a well balanced dinner tonight, which included a small ham & turkey sandwhich, some fruit, a hard boiled egg and a drinkable low-carb yogurt... What would make her body delay absorbing food?

Thanks so much!!!

[funnygrl]

If I'm high from rebounding I give a half correction.

[wilf]

Hey Marisa, sounds like the unusual thing in the day was the birthday party. Delay in digestion is typical of foods with high fat content - maybe the icing of the birthday cake, or rich ice cream?

We had a low (followed by a high) today too from a big bowl of ice cream. The bolus injection started working long before the ice cream started digesting, even though I gave a slower acting insulin (Regular)..

If your little one had very richly iced cake PLUS ice cream that might have done it.

[Heather(CA)]

I disagree, I think a 47 could have easily caused a rebound. Also, I probably wouldn't have given a correction, For us, I would rather Seth run high one night...Because if it is a rebound, her body will want that glucose back at some point. In the morning if Seth is still high, I count up everything as normal, then subtract 1 unit. This allows the body to get out of panic mode and return to normal by lunch. If a full correction is done, they tend to stay high for a long time as the body is not able to get out of panic mode.
Just a thought...Juice might be better if she's "out of it" I know the glucose tabs may work a little faster, but she's more likely to choke on glucose tabs...

Keep a close eye on her tonight...Birthday parties can be decieving(sp?), she may have run around more than you thought...I was going to ask about a lot of activity:cwds:

[wilf]

I disagree, I think a 47 could have easily caused a rebound. Also, I probably wouldn't have given a correction, For us, I would rather Seth run high one night...Because if it is a rebound, her body will want that glucose back at some point. In the morning if Seth is still high, I count up everything as normal, then subtract 1 unit. This allows the body to get out of panic mode and return to normal by lunch. If a full correction is done, they tend to stay high for a long time as the body is not able to get out of panic mode.
Just a thought...Juice might be better if she's "out of it" I know the glucose tabs may work a little faster, but she's more likely to choke on glucose tabs...

Keep a close eye on her tonight...Birthday parties can be decieving(sp?), she may have run around more than you thought...I was going to ask about a lot of activity:cwds:

You don't think the extra 50 grams of carbs could have brought up the BG? Why not? They didn't just disappear..

My reason for thinking the strong "rebound" is due to the extra carbs is because she was only low for a few minutes at most, and 47 isn't that low. YDMV, but we don't see true rebound due to bodily response reactions happening until we're much lower than that and for longer.

[Heather(CA)]

You don't think the extra 50 grams of carbs could have brought up the BG? Why not? They didn't just disappear..

My reason for thinking the strong "rebound" is due to the extra carbs is because she was only low for a few minutes at most, and 47 isn't that low. YDMV, but we don't see true rebound due to bodily response reactions happening until we're much lower than that and for longer.

Sorry if I came off too strong. It wasn't just the 47, she was dropping for a while, and Marissa was having a hard time getting her up. She wasn't low for a few minutes at most, she was low for a lot of the time for almost 2 hours. (Been there after lots of exercise)That's why I'm thinking rebound.If she's doesn't have lows like that low very often, then her body could react to a long bout of lows and a 47 by kicking out glucose...If she had given a lot at once I would think more of a over correction, it seems like she waited and retested so the body needed at least most of what it got. You could be right, I could be wrong...We just have a differance of opinion, that's ok. :D Sorry if I upset you in any way:o

She wasn't low for a few minutes at most, she was low a lot of the time for 2 hours (this is from her other thread) That's why I'm thinking rebound...Low for a long time with a 47 at the end.

[Mama2H]

I agree with Heather! We HAD this happen and it DID cause a rebound high. Hailey literally vomited when the liver kicked in, it was obvious in her. Endo agreed when she read the cgms/pump download. Sounds like you did right Jamie. Hailey was low for SEVERAL hours and WOULD NOT come up no matter how many carbs I shoved in her. ((((hugs)))) I was never more afraid than I was that night.

[jendean]

WEll, when Nolan gets a rebound high, i punish him by taking away all of his toys for a week, then i give him a spanking.
LOLOL
Sorry I am only kidding, I couldnt help it. Not funny.


They can be terrible. Poor kids, going thru so much "feeling like crap".

[wilf]

Sorry if I came off too strong. It wasn't just the 47, she was dropping for a while, and Marissa was having a hard time getting her up. She wasn't low for a few minutes at most, she was low for a lot of the time for almost 2 hours. (Been there after lots of exercise)That's why I'm thinking rebound.If she's doesn't have lows like that low very often, then her body could react to a long bout of lows and a 47 by kicking out glucose...If she had given a lot at once I would think more of a over correction, it seems like she waited and retested so the body needed at least most of what it got. You could be right, I could be wrong...We just have a differance of opinion, that's ok. :D Sorry if I upset you in any way:o

She wasn't low for a few minutes at most, she was low a lot of the time for 2 hours (this is from her other thread) That's why I'm thinking rebound...Low for a long time with a 47 at the end.

Hey no worries, I'm just trying to understand your post. :)

Marisa indicated that BG was never below 67, except for a 20 minute spell from 8:55 to 9:15 pm when she measured 67 and 47 respectively. I guess it depends on how we're defining a low, and at what threshhold the child's body responds.

Note that as I was reading up on this I noticed that another factor that was cited as possibly being responsible for an unexpected low was a site change, esp. from one part of the body to another..

[Lee]

I recently had the same problem. We were running borderline low all day, then at night, bam - big drop...she had carbs, and then carbs, and then carbs, and then carbs...and then a few more for good luck...

At midnight, she was well over 300, so I gave her a correction, but took away 1 unit.

At 3 am - 53...

The next day, I came here and asked the rebound low question, and everybody said, do not correct the high, or if you do, correct 1/2 the amount.

So, I decided to ask the endo, cause we have a great diabetes team who answers any question I ask, and our diabetes educator said no, don't correct...or just do a small correction.

The high was caused by the dramatic swing in blood sugar, and you want to try and avoid those dramatic swings...she recommended that if I had to correct, do 1/2; or wait until morning so the body could stabilize a little...

I still don't quite get it, but I am trying to understand!

[hold48398]

I really really appreciate everyone's replies. I am still unsure to what happened last night, and I am waiting on my endo's reply (I emailed her our log last night). To adress a couple of the questions that were raised: I agree that Mia had some increased activity at the birthday party. She ate 1 slice of cheese pizza (combo bolus, no problem) and a small slice of birthday cake, there was no icecream. This was a very "normal" birthday party meal for her that we have had many many times, so I don't think it coulld have cause a delayed high. Also, she rarely gets lows into the 40s or 50s these days, even the 60s is quite rare for her. So her body definitely wasn't used to running that low...if it was enough to cause the high later, I dunno....

Here is how the rest of our night went....

After the 2/3 dose correction for the 283 BG, she was BG 260 at 11:50pm- not quite 2 hours later, and I felt that she wasn't going to drop a whole lot more, so I waited another 30 minutes to retest to see which way her BG was going to go (before I was going to bed). (This is where a CGMS would come in sooooo handy!). At 12:20am, she was BG 296, so obviously her BG was going back up...strange. I gave another correction, about 80% of her normal dose. 2am BG 223. 4am BG 227. Another 80% correction. 6:30am BG 238. When Mia got up, she looked HORRIBLE, and I mean puffy faced, swollen eyes, and feeling as if a truck just hit her...

Soooo, now I am wondering: Is it possible that she is coming down with something and her body had to use up all her energy/glucose trying to fight it last night??? Hence, the lows followed by the sustained highs??:confused::confused:

This morning, I decided to put in a 10% extra basal for school. I informed our fabulous wonderful awesome school nurse of our night, and she will throw in an extra test or two to keep a close eye on Mia. Other than her looking aweful, Mia isn't actually feeling bad but she does have a sniffly/stuffy nose as of this morning...

So I pre-bolused Mia at 6:30am this morning, BG 238. She ate at 7am. With the 10% temp. basal, the nurse called and said she was BG 153 at 9am, which sounds good to me... We shall see how the rest of the day goes...

Thanks again for all the great feedback. pls keep it coming!!!

[momofphoenix]

From what Phoenix's Endo's have told me in the past years is if he has been running low (30-60) and all of a sudden he is 500 give a correction for food ONLY. DO NOT correct for the bs unless it has been 3-4 hours and then only correct 1/2 of normal dose. I still do this and it usually works itself out. When I have to treat a really low low with a lot of carbs then get a high later on they told me to give him some carbs and correct for the carbs and then do our correction factor.
500-150=350/75=4.5 units novolog divide that by 1/2 so he would only get 2 units and if he is still high later 3-4 hours to give another 1/2 dose correction to get him in range...

[wilf]

hey Marisa, sorry to hear the night was so hard on your little one. Sure sounds like it either was an inexplicable delay in digesting supper, or a true rebound phenomenon.

A true rebound high is supposed to be very resistent to correction (guess it takes the body a while to shut down the stream of hormones it's putting out to combat the low). On the other hand, she got a lot of carbs when she was low and once they were digested they would have put her up for quite awhile.

Anyhow, sounds like all's well that ends well. Keepin' my fingers crossed for you!

[Heather(CA)]

I really really appreciate everyone's replies. I am still unsure to what happened last night, and I am waiting on my endo's reply (I emailed her our log last night). To adress a couple of the questions that were raised: I agree that Mia had some increased activity at the birthday party. She ate 1 slice of cheese pizza (combo bolus, no problem) and a small slice of birthday cake, there was no icecream. This was a very "normal" birthday party meal for her that we have had many many times, so I don't think it coulld have cause a delayed high. Also, she rarely gets lows into the 40s or 50s these days, even the 60s is quite rare for her. So her body definitely wasn't used to running that low...if it was enough to cause the high later, I dunno....

Here is how the rest of our night went....

After the 2/3 dose correction for the 283 BG, she was BG 260 at 11:50pm- not quite 2 hours later, and I felt that she wasn't going to drop a whole lot more, so I waited another 30 minutes to retest to see which way her BG was going to go (before I was going to bed). (This is where a CGMS would come in sooooo handy!). At 12:20am, she was BG 296, so obviously her BG was going back up...strange. I gave another correction, about 80% of her normal dose. 2am BG 223. 4am BG 227. Another 80% correction. 6:30am BG 238. When Mia got up, she looked HORRIBLE, and I mean puffy faced, swollen eyes, and feeling as if a truck just hit her...

Soooo, now I am wondering: Is it possible that she is coming down with something and her body had to use up all her energy/glucose trying to fight it last night??? Hence, the lows followed by the sustained highs??:confused::confused:

This morning, I decided to put in a 10% extra basal for school. I informed our fabulous wonderful awesome school nurse of our night, and she will throw in an extra test or two to keep a close eye on Mia. Other than her looking aweful, Mia isn't actually feeling bad but she does have a sniffly/stuffy nose as of this morning...

So I pre-bolused Mia at 6:30am this morning, BG 238. She ate at 7am. With the 10% temp. basal, the nurse called and said she was BG 153 at 9am, which sounds good to me... We shall see how the rest of the day goes...

Thanks again for all the great feedback. pls keep it coming!!!

I am 95% sure she had a rebound...So, by all those corrections, her body is staying in panic mode. IMHO you should put the basil back to normal, then at lunch, count everything up and minus 1 unit. No correction. I know it sounds weird...But, Seth used to stay high for 24 hours or so after a rebound. Once I started using this method...He's good by lunch;)

If you try it, I hope you do because I think it will work...Give it about 3 hours to work w/o correcting

[Heather(CA)]

Hey no worries, I'm just trying to understand your post. :)

Marisa indicated that BG was never below 67, except for a 20 minute spell from 8:55 to 9:15 pm when she measured 67 and 47 respectively. I guess it depends on how we're defining a low, and at what threshhold the child's body responds.

Note that as I was reading up on this I noticed that another factor that was cited as possibly being responsible for an unexpected low was a site change, esp. from one part of the body to another..

Did you see the part where she was low from 7:15 until 9:15 with the one exception of a 117 for a short time after, I think it was juice? So she would have really dropped had she not been getting those carbs...Then the 47. :eek: That's why I'm thinking rebound.

Seth is an athlete, unfortunately, weve dealt with a few rebounds:rolleyes: He also, now that he's in puberty, goes high from adreneline, that works a lot like a rebound too...When Seth started puberty, he started going high with intense exercise, it's seems weird, but when they go high, it means they need more snack, we've been using gatorade. That way the body will use THAT instead of spitting out the glucose form the body. It's really HARD to balance:rolleyes:

[Heather(CA)]

How is she doing?:cwds:

[hold48398]

Hi guys and gals, thanks for asking. I put in a 10% basal increase for her today and her numbers have come in beautifully so far (all in target). I will probably take out the increase basal at 4pm here (in 15 minutes) because if she goes low, it tends to be after dinner. And I definitely don't want to have a repeat of last night!! So, I am cautiously optimistic...

Heather, I am not sure I understand what you are saying here?

IMHO you should put the basil back to normal, then at lunch, count everything up and minus 1 unit. No correction.

Thanks again.

[Heather(CA)]

Hi guys and gals, thanks for asking. I put in a 10% basal increase for her today and her numbers have come in beautifully so far (all in target). I will probably take out the increase basal at 4pm here (in 15 minutes) because if she goes low, it tends to be after dinner. And I definitely don't want to have a repeat of last night!! So, I am cautiously optimistic...

Heather, I am not sure I understand what you are saying here?

IMHO you should put the basil back to normal, then at lunch, count everything up and minus 1 unit. No correction.

Thanks again.

What I meant was to give less insulin so her body would have a chance to replenish it's stores and get out of panic mode. When Seth is high from a rebound, I give him less insulin than normal, that way he doesn't stay high.

For example if he's high because we counted the carbs wrong, I would give him 1/2 a unit for every 50 over 150, plus, what I would have normally given him for food.

If I know he had a rebound, then in the morning, I would add up the insulin for food, and the correction, then I would subtract 1 unit. That unit could get the body out of panic mode and he would be good by lunch. I don't correct rebounds at night...too scary for me.

I guess I said it wrong earlier:rolleyes: I would have counted the correction then subtracted a unit:rolleyes: I think that was before my nap;) By putting the basils back, it may have been enough to replenish the stores:confused: We don't use the pump, so I'm not sure