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Before bed snacks - how to bolus

Discussion in 'Parents of Children with Type 1' started by Sprocket, Oct 22, 2014.

  1. Sprocket

    Sprocket Approved members

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    I would appreciate anyone's experience with how they bolus for bedtime snacks. My daughter (12) loves her bedtime snack - usually a piece of toast and an ovaltine (about 20 or 25 carbs). She is on NPH through the day, Levemir at night and rapid for breakfast, after school snack and supper. I am not fond of bolusing her at 9pm for her snack, but I also find if I don't, she will absolutely wake up high in the morning. Last night, prime example why I dislike bolusing before bed, she was 11mmol at 9pm, I bolused her (her normal 1:10 ratio) for her snack, and by midnight she was 6.5, and by early am 4.6 - which are great, numbers, however, the drop was far too great for not having given her any correction dose.
    Does anyone else have another strategy for bed time snacks. Not having a snack is not an option. I wondered if anyone over-bolused for dinner to compensate for the before bed snack.
    Thanks in advance for any info. She has recently exited her honeymoon (for the most part) and so we're still fairly green. Her A1C is 6.6%, so she's well controlled, but some things are still mystifying.
     
  2. sszyszkiewicz

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    Hey Sprocket this is how we go about things. First of all knowing about how much a carb will raise the numbers is important. It places an upper bound on your problem. I use the information in this article and it works very well.

    http://diatribe.org/issues/55/thinking-like-a-pancreas

    20-25 carbs before bed would have a big affect for a typical 12 year old. That would raise my kids numbers by like 100 points (usa units). What I would do is see what the glucose number is at snacktime and decide if you need to bolus for the entire amount, some portion of it, or none of it. Having the ability to accurately dose rapid within 1/2 of a unit is important because it gives you that bit of precision you need just before bed (avoiding lows).

    So basically for 20-25 carbs

    - if he is near the low end of his range, we bolus 1/2 of the carbs to bring him up a little.
    - If he is middle to high we bolus the entire amount.

    Since we do a lantus shot at night, we check about 2 hours later after a bolus because between the lantus and the fast acting (humalog in our case) it can stack and drop him.

    I do not have any experience with NPH so i dont know how that plays out in your situation.
     
  3. Sprocket

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    That's good info. Thank you. I have seen that article, and I have calculated that one carb increases her .20 (Canadian). She's a tall, large framed girl (3" taller than me). That's a good idea about bolusing for half - I had a kind of "all or nothing" thinking going on. Perhaps last night having three boluses (4pm, 6pm, 9pm with some IOB calculations in there) maybe was a bit like stacking last night. Her NPH is long out of her system by night time, we just use that for the day time to cover her lunch at school, so that's not a factor.
    Maybe it was just a wonky night, but thank you for the info, I will use those tricks.
     
  4. MomofSweetOne

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    We use the same carb ratio as supper, but any extended bolus (because my daughter is on a pump) for nighttime requires 1/2 of what the same food requires during the day. I was really uncomfortable with IOB at night before we got the CGM. Now, while there's some stress involved, it's far less than it was before. Before we had the CGM, we were instructed by our CDE to set an alarm at the 3-4 hour mark to see if she had gone low with the insulin action.
     
  5. RomeoEcho

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    As an additional thought: Do you see the same drop if she goes to bed high without a snack? Does she have "true" lows overnight or on waking? (below 60)

    Overnights are the last place that you can see the honeymoon hanging on and this can be happening even if there are no indications of honeymoon on daytime numbers. While fasting, the body will use the little bit of insulin it has the ability to make to pull down to a normal fasting bg. So the drops you see may not be from you bolusing for food, but rather her own production. If it is resulting in actual lows, then I would be concerned, but the drop isn't necessarily an indication of a problem if it's only bringing her to a healthy range.
     
  6. Sprocket

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    Yes, I suspected that it might be a honeymoon thing. It doesn't happen much. Quite often she is bang on steady on levemir all night - if she goes to bed higher (uncorrected), she'll wake up high in the same range. I figured in this instance it was too much insulin over a period of 5 hours that seemed to intensify the affect, or that her own insulin kicked in and brought her down.
    No, she doesn't have lows overnight and is never low when waking - mostly because she goes to bed at a safe number and stays within that range, or drops a little, but not much.
     
  7. nebby3

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    Are you happy with Rapid and NPH? I guess I should ask to be clear: is this the old style Rapid that works over 4-6 hrs or so? I know thee are different names in different countries. Because it sounds like you don't really have a fast acting insulin like humalog or novolog and I would think that would make corrections hard.

    Do you prebolus at all? I agree with giving less than a full dose if you think she is coming down later too much but giving the insulin well before she eats can also help eliminate the initial upward spike.
     
  8. Sprocket

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    It is Novolog called Novorapid - it's rapid acting insulin, not regular. Yes, I do like NPH/rapid combination. It works very nicely for us - we work with the peak of NPH and avoid a lunchtime bolus at school. We do prebolus, but not by much.
     
  9. tammy82

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    We always give bedtime snack too and wouldn't not do that. If my child is near target range I always do half. If on the higher end closer to 3/4 to whole correction. Also depends on how active your child is before bedtime. If she is running around like crazy we also take that into account and lower the correction alot because always in the middle of the night is when the drop will occur. Also a snack with some protein along with the carbs helps. My daughter likes her cookies and/or chips but now I always make sure she drinks some milk along with it so she doesn't drop
     
  10. Sprocket

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    Great, thank you to everyone for the info so far. I will certainly try splitting the dose depending on her b.s. I tried an experiment last night of giving her another 2 units at supper, and by bed time (about 2.5 hours later), it was really dropping her, she then had a small granola bar and an Ovaltine and it brought her back up to a nice 7.9 where she stayed all night and into the morning. So much trial and error this diabetes thing! I am glad I am getting more adventuresome with insulin as time goes on. It sure pays off to find ways that best work for our kids.
     

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