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Thread: Puberty Experts: A Question

  1. #1
    Join Date
    Apr 2013
    Location
    Glen Ellyn, IL
    Posts
    578

    Default Puberty Experts: A Question

    OK experts, I need some advice.

    My daughter BG skyrockets at night. But the rise starts at different times, sometimes it's evident at the 9:00pm check, other times that number is fine, but the number will double and then some by midnight.

    In order to combat the rise, the rate increase must be really big and I'm stumped as to when to start the rate increase. I know it should be an hour or two before we see the rise, so I'd like to start it at around 7:00pm to try to prevent the insulin resistance that I see when she gets into the 300's+, but I'm concerned about her falling dangerously low should the rise not begin until 10:00 on a given night.

    Complicating things further is until around 9:00, I don't really know whether a higher number is a result of dinner or hormones. By 9:00, her meal insulin should be virtually gone, so I know if she's high then, the rise has begun, but I don't think testing at 7:00 or 8:00 is going to gather any valuable information.

    What would you do?

    My daughter is somewhat interested in a cgm and I've got the process rolling, but I can tell by her attitude that while she would welcome the information at this point, she is not thrilled with wearing a second device and while I can hope, I must be realistic that 24/7 cgm'ing may not be in her future.
    DD diagnosed March, 2013 at age 10, now 11 years old
    T:slim (Humalog) as of August, 2013
    Dexcom G4 as of November, 2013

  2. #2

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    Quote Originally Posted by mamattorney View Post
    OK experts, I need some advice.

    My daughter BG skyrockets at night. But the rise starts at different times, sometimes it's evident at the 9:00pm check, other times that number is fine, but the number will double and then some by midnight.

    In order to combat the rise, the rate increase must be really big and I'm stumped as to when to start the rate increase. I know it should be an hour or two before we see the rise, so I'd like to start it at around 7:00pm to try to prevent the insulin resistance that I see when she gets into the 300's+, but I'm concerned about her falling dangerously low should the rise not begin until 10:00 on a given night.

    Complicating things further is until around 9:00, I don't really know whether a higher number is a result of dinner or hormones. By 9:00, her meal insulin should be virtually gone, so I know if she's high then, the rise has begun, but I don't think testing at 7:00 or 8:00 is going to gather any valuable information.

    What would you do?

    My daughter is somewhat interested in a cgm and I've got the process rolling, but I can tell by her attitude that while she would welcome the information at this point, she is not thrilled with wearing a second device and while I can hope, I must be realistic that 24/7 cgm'ing may not be in her future.
    CGM was actually going to be my suggestion, it'll give you the information you are lacking. My son wore his sporadically, there's nothing to say you MUST wear it 24/7, it's still a great tool. He'd wear it to figure out problems, and he'd wear it before appointments, that's it. Now, in college, when things are more important to him, he does wear it 24/7, but he didn't for years.

    What time does she go to bed? Do you notice any difference in that 9p number based on what she ate? Clearly insulin is done by 9 but that doesn't mean the food is! I think for that time of day I would do a correction, and not a rate increase, if it's inconsistent it may just be food and not basal needs. For my son the puberty stuff and cortisol rises showed up in the middle of the night, not during waking hours. YDMV of course.

    ~Nancy~
    Homeschooling our way through high school, learning with them!
    19 year old son diagnosed T1 2/5/10, pumping Tslim beginning 7/13 ; Dexcom on occasion. Animas Ping 10/10-7/13. College student August 2013.
    16 year old daughter teaching her mom all about patience and grace
    .

  3. #3
    Join Date
    Apr 2013
    Location
    Glen Ellyn, IL
    Posts
    578

    Default

    All good questions, with no good answers. I'm not a gourmet chef, so our dinners are relatively predictable. And she was not seeing these 280-325 numbers at 9:00om ever before, even if we ate at 7:00pm, which happens a couple of times a week and just adds more confusion to the picture. I thought maybe it was Halloween candy, but I don't think so. She takes candy in her lunch at school and the three hours post lunch numbers (which is when PE is every day) are universally fine. She "goes to bed" at 9:00pm for what that's worth. She often wanders out at 10:00 or 10:30 and hasn't slept yet.

    She's got some killer foods (most notably cake in any form - muffin, regular cake, brownies, etc), but she hasn't eaten any BG killers since I've noticed this craziness.

    I can't guarantee is isn't food, maybe it is. I don't know anymore.

    So far, I've been doing my best to manage the numbers using corrections and the past couple of days I've added temporary basal boosts to the mix. What I am seeing are things like:


    11/1 (late dinner, snacking before so numbers muddled with IOB and the like)
    6:53 (pre dinner) 236 (correction as allowed with IOB and food)
    8:51 308 (correction as allowed)
    10:46 380 (correction)
    12:06am: 309 (correction)
    3:02 173 (correction)
    8:27 139

    11/2
    5:46pm 125
    8:20 123
    10:00 108
    10:10 81 (15 g carbs)
    12:11am 283 correction
    1:43 296 correction
    4:03 229 correction
    8:33am 153

    11/3
    5:22pm 132
    8:02 253 pump said no correction - turn on 120% temp basal until midnight
    8:46 325 correct as allowed
    10:03 257 correct as allowed
    12:02am 197 continued 120% basal but no correction
    3:03 173 turned off temp basal
    8:14am 169

    11/4
    7:02pm another later dinner 254 (these are high because she snacks beforehand)
    9:02 244 - could have been dinner so I did nothing but run 120% basal
    11:57 299 - correction plus 140% basal 3 hours
    3:07 93 - turned off temp basal plus 10 carbs because she woke up and was afraid of going low
    8:09am 153

    11/5
    6:32pm 80
    8:21pm 158 --- added a 10% increase to basal insulin until 3:00a.m.
    9:44pm 202 correction plus 120% basal (of new rate)
    12:02am 285 correction plus 120% basal (of new rate)
    3:03 193 correction turn off temp basal
    7:51 129

    As I write it out, maybe there isn't as much of a pattern as I think. It definitely doesn't help that we eat dinner later quite a bit. Uggh.

    Well, any help or "this is what I would do", would be most welcome. I'm at a loss.
    DD diagnosed March, 2013 at age 10, now 11 years old
    T:slim (Humalog) as of August, 2013
    Dexcom G4 as of November, 2013

  4. #4

    Default

    Well, the one pattern I see is that she is always high at midnight. It would have been interesting to see what would have happened on 11/2 if you would have let that 81 ride, but I understand why you can't do that without a CGM.

    I might start by increasing the 9:00 or 10:00 basal for a couple of hours and see what that does. I also wouldn't base much of anything on those nights where she goes into supper in the mid 200s. We have never figured out how to effectively deal with Jack going into a meal high. We either delay the meal or if that's not feasible, he skyrockets.
    Mom to J., age 10
    Dx 2007 @ age 3
    Medtronic pump and CGM (4/2008-6/2013)
    Tandem t:slim and Dexcom G4 CGM (current)

  5. #5

    Default

    Quote Originally Posted by mamattorney View Post

    11/1 (late dinner, snacking before so numbers muddled with IOB and the like)
    6:53 (pre dinner) 236 (correction as allowed with IOB and food)
    8:51 308 (correction as allowed)
    10:46 380 (correction)
    12:06am: 309 (correction)
    3:02 173 (correction)
    8:27 139

    She may need a more aggressive correction factor for numbers over 250. You are going to be seeing some insulin resistance at high numbers. It is looking to me that your corrections are basically keeping her flat. Also, if she is still going up because your basal is too low your corrections aren't going to work well either. I would be adding a temp basal in addition to the corrections and talking to the endo about changing the correction factor.

    11/2
    5:46pm 125
    8:20 123
    10:00 108
    10:10 81 (15 g carbs)
    12:11am 283 correction
    1:43 296 correction
    4:03 229 correction
    8:33am 153

    Again the corrections are not doing much. I would be adding temp basals in there as well.

    11/3
    5:22pm 132
    8:02 253 pump said no correction - turn on 120% temp basal until midnight
    8:46 325 correct as allowed
    10:03 257 correct as allowed
    12:02am 197 continued 120% basal but no correction
    3:03 173 turned off temp basal
    8:14am 169

    I would consider overriding the pump at certain times. Also, you can/should be more aggressive with temp basals if you are checking as frequently as a you are. Again, I can't tell if the corrections are not working because the factor is wrong or because basal is off. I would guess it is both.

    11/4
    7:02pm another later dinner 254 (these are high because she snacks beforehand)
    9:02 244 - could have been dinner so I did nothing but run 120% basal
    11:57 299 - correction plus 140% basal 3 hours
    3:07 93 - turned off temp basal plus 10 carbs because she woke up and was afraid of going low
    8:09am 153

    It looks like your carb ratios are actually good since she ended up the same 2 hours after dinner. I would have done a small correction for the 244. Temp basal and correction looked like they worked great. I would have done less than 10 carbs but overall the 93 was handled well.

    11/5
    6:32pm 80
    8:21pm 158 --- added a 10% increase to basal insulin until 3:00a.m.
    9:44pm 202 correction plus 120% basal (of new rate)
    12:02am 285 correction plus 120% basal (of new rate)
    3:03 193 correction turn off temp basal
    7:51 129

    The rise from 202 to 285 is indicating both a basal and correction problem to me.

    As I write it out, maybe there isn't as much of a pattern as I think. It definitely doesn't help that we eat dinner later quite a bit. Uggh.

    Well, any help or "this is what I would do", would be most welcome. I'm at a loss.
    Overall thoughts:

    1. You are handling this great.
    2. I would consider changing the correction factor.
    3. You can/should be more aggressive with temp basals. I would be trying 150-170% but not hesitating to double basal if you are testing very frequently.
    4. I am not seeing any night where she is even lowish after midnight so I would not hesitate to increase basal from 10 pm on.

    I wouldn't consider a CGM optional right now. You need to be able to sleep in more than 3 hour increments and I don't see any way around the frequent testing without a CGM. Also, how is your daughter feeling? I find consistent highs at night can give me a yucky hungover feeling the next day. Lots of fluids will help with that though both before bed and when she wakes up.

    Good luck!

    ETA: Looking over it again I am going to change my opinion on the aggressive temp basals. The 140% and correction actually worked really well. You may try to switch her basal to 130% of current basal from 10 PM on and test frequently and see what happens.
    Last edited by Megnyc; 11-06-2013 at 11:41 AM.
    Meg
    College Junior, Age 20
    Pancreatectomy 2/17/2003
    Pumping 2/19/2003, Currently w/ Minimed Revel and Omnipod
    CGM: MM 2006-2013, Dexcom G4 2013-Present
    Symlin since 4/2013

  6. #6

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    To add onto what Meg has said, sometimes when I see a correction is simply holding my daughter's BG steady on G4, I know that it is replacing needed basal rather than working as the correction it was meant to be. I will look at the amount of the correction and then use that to adjust the additional amount she needs in basal to know a good approximate temp basal guess (My daughter tells me, "I've always hated guess and check in math, and diabetes has WAY too much.") and then I recorrect her again. It works well most of the time to get her BGs moving toward target.

    If you're seeing the climb start at a couple of differing times, I would choose the later one to change the basal rate at; I'm assuming it's caused by how quickly she falls asleep. I have many times seen a 100 point climb (that would go higher without temp basals and corrections) start as soon as my daughter falls asleep. You can check how much her BG has climbed when you go to bed and give her a correction to get her toward target. It would be safer than having it set too early and then creating a low. But, from your posted numbers, you definitely need a different nighttime basal profile.
    Last edited by MomofSweetOne; 11-06-2013 at 11:56 AM.
    8/2010 - 9/2011 MDI, Lantus & Humalog
    9/2011- Medtronic Revel 723 & CGM
    11/2012 - Dexcom G4

    "Life is not waiting for the storms to pass, but learning to DANCE in the rain."

  7. #7

    Default

    Quote Originally Posted by mamattorney View Post
    All good questions, with no good answers. I'm not a gourmet chef, so our dinners are relatively predictable. And she was not seeing these 280-325 numbers at 9:00om ever before, even if we ate at 7:00pm, which happens a couple of times a week and just adds more confusion to the picture. I thought maybe it was Halloween candy, but I don't think so. She takes candy in her lunch at school and the three hours post lunch numbers (which is when PE is every day) are universally fine. She "goes to bed" at 9:00pm for what that's worth. She often wanders out at 10:00 or 10:30 and hasn't slept yet.

    She's got some killer foods (most notably cake in any form - muffin, regular cake, brownies, etc), but she hasn't eaten any BG killers since I've noticed this craziness.

    I can't guarantee is isn't food, maybe it is. I don't know anymore.

    So far, I've been doing my best to manage the numbers using corrections and the past couple of days I've added temporary basal boosts to the mix. What I am seeing are things like:


    11/1 (late dinner, snacking before so numbers muddled with IOB and the like)
    6:53 (pre dinner) 236 (correction as allowed with IOB and food)
    8:51 308 (correction as allowed)
    10:46 380 (correction)
    12:06am: 309 (correction)
    3:02 173 (correction)
    8:27 139

    11/2
    5:46pm 125
    8:20 123
    10:00 108
    10:10 81 (15 g carbs)
    12:11am 283 correction
    1:43 296 correction
    4:03 229 correction
    8:33am 153

    11/3
    5:22pm 132
    8:02 253 pump said no correction - turn on 120% temp basal until midnight
    8:46 325 correct as allowed
    10:03 257 correct as allowed
    12:02am 197 continued 120% basal but no correction
    3:03 173 turned off temp basal
    8:14am 169

    11/4
    7:02pm another later dinner 254 (these are high because she snacks beforehand)
    9:02 244 - could have been dinner so I did nothing but run 120% basal
    11:57 299 - correction plus 140% basal 3 hours
    3:07 93 - turned off temp basal plus 10 carbs because she woke up and was afraid of going low
    8:09am 153

    11/5
    6:32pm 80
    8:21pm 158 --- added a 10% increase to basal insulin until 3:00a.m.
    9:44pm 202 correction plus 120% basal (of new rate)
    12:02am 285 correction plus 120% basal (of new rate)
    3:03 193 correction turn off temp basal
    7:51 129

    As I write it out, maybe there isn't as much of a pattern as I think. It definitely doesn't help that we eat dinner later quite a bit. Uggh.

    Well, any help or "this is what I would do", would be most welcome. I'm at a loss.
    Midnight definitely jumps out at me, I'd do a basal increase at 10p.

    ~Nancy~
    Homeschooling our way through high school, learning with them!
    19 year old son diagnosed T1 2/5/10, pumping Tslim beginning 7/13 ; Dexcom on occasion. Animas Ping 10/10-7/13. College student August 2013.
    16 year old daughter teaching her mom all about patience and grace
    .

  8. #8

    Default

    There's a quote in Pumping Insulin that has become our motto for survival.

    "Hormonal changes at puberty can make this month's insulin program obsolete next month. During growth spurts and puberty, growth hormone and cortisol levels rise. This requires insulin doses to also rise. Covering teen hormones and growth spurts brings humility to the best diabetes clinicians. The most effective advise is to be prepared to adjust basal and bolus doses frequently to keep up with growth."

    If you're like me, you'll soon find yourself thinking, "You don't even have a clue" when other (non-D) parents are complaining about the challenges of puberty.
    8/2010 - 9/2011 MDI, Lantus & Humalog
    9/2011- Medtronic Revel 723 & CGM
    11/2012 - Dexcom G4

    "Life is not waiting for the storms to pass, but learning to DANCE in the rain."

  9. #9
    Join Date
    Sep 2012
    Location
    Toronto, Canada
    Posts
    462

    Default

    Well, my son is only 7, and not going through puberty, however, the most difficult times for me is the early part of the night because he has huge spikes when he goes to sleep. These numbers are tied to sleep. My son could go to sleep and be in the 70's and literally an hour later be in the 400's. However, I find that if I set the increased basal rate too early, he will go low before bedtime. Generally, I set a very aggressive basal rate for the first two hours of sleeping, then it gets backed off. If the spike gets higher than 200, I also need to use very aggressive corrections. I definitely see the best numbers if I can set a higher basal rate for the hour before bedtime to help combat the spike, however I have found that I have to be a little more conservative during that time to avoid lows before bedtime. Also, I have found that if he has a bolus working from a later evening snack, the combination of a higher basal rate and the bolus can send him low (not sure why - because I am only covering the food).

    It is kind of like the dawn phenomenon - but at night, rather than early morning.
    Mom to T, 8yrs dx: Aug/2012
    and son 11 yrs, non-d.
    Animas pump June/13
    Dexcom G4 Dec/13

  10. #10
    Join Date
    May 2009
    Location
    Southern CA
    Posts
    593

    Default

    Quote Originally Posted by MomofSweetOne View Post
    There's a quote in Pumping Insulin that has become our motto for survival.

    "Hormonal changes at puberty can make this month's insulin program obsolete next month. During growth spurts and puberty, growth hormone and cortisol levels rise. This requires insulin doses to also rise. Covering teen hormones and growth spurts brings humility to the best diabetes clinicians. The most effective advise is to be prepared to adjust basal and bolus doses frequently to keep up with growth."

    If you're like me, you'll soon find yourself thinking, "You don't even have a clue" when other (non-D) parents are complaining about the challenges of puberty.
    I agree with the person that said basal increase at 10pm. and this. Even long before she starts to have her menstrual cycle...a cycle is happening. Things are going to change from week to week, based on hormones. Every time I think I have a handle on it, I don't. Test often & do the best you can. If you can do a cgm, do it. We didn't have the best experience with ours, but I think if we tried again now, it would go better. These years are not easy, it sounds like you are doing a good job. Hang in there.
    Kim
    Mom to Danielle, age 15, dx'd type 1 age 3. MM 722...pump break 9/13, lantus/novolog, back on pump 10/13
    dx'd celiac 6/09

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