For those with CGM...How high does your child tend to go post meal?

I am curious as to what type of curve you see following a meal while the insulin is doing its thing. I have no idea what is realistic to expect/hope for.

 

Well... no two days are every exactly the same, but I will say that the graph can be rather shocking. Yes, it's great data, but it's not easy, at first, to actually look at. It rather proves that to some degree ignorance is bliss ;-)

That said, the number one thing that CGM'ing has affirmed, is the importance of pre-bolusing.

At home, for dinner, if we pre-bolus and carb count correctly we can see just a negligible spike into the 150s which doesn't last long. At school, where she really doesn't have time to pre-bolus and when her carb counts may be off we can see spikes into the 250 range or higher, which need a correction to come down. At the same time, we can have days when management is sloppy and her graph remains close to flat. Above all, the CGM (G4) has affirmed that D is a really hard disease to outwit and sometimes the graph fails to "reward" good behavior while it ignores the "bad". '-)

 

I agree - you can prebolus the exact same amount for the exact same breakfast (weighed to the gram), for the exact same amount of time on two different days, and one curve will go to 13 (mmol) while the other one might only hit 8. It's very strange and confounding.

So I'll say on a good day (like today!).. our entire day's graph has been between 5 and 8.5. These days are very few and far between, and I can't say for sure that I've done anything to deserve this success.

Other days we'll see spikes to 15 even with a great prebolus, even though it's say a high fiber, healthy item. But those are not exactly the norm either, at least not for my son. If I had to pick an 'average' day of 'average' spikes, I'd say he goes to 11 or so after each meal for a brief amount of time before starting to come down.

 

It seems random but we can see anywhere between a no spike to a 350 spike. Our breakfast is an average of a 250 spike no matter what we do it seems.

 

It does vary, but we use our basals to offset meals. I run higher basals prior to breakfast and lunch times so that an extra 2-4 units is on board and acting when my son eats and an extra 1-2 for my daughter. This really helps minimize spikes and we rarely get post-meal alarms on the CGMs, which means my son rarely reaches 170 and my daughter rarely reaches 160. We off-set the high basals with really low basals after so we don't have follow up lows. Dinner tends to be slower carbs and we have basketball almost every night so we don't do this for dinner. We've always had fairly consistent meal times, even pre-D, so this works for us.

Without this, breakfast was easily spiking to 300 and lunch to 250. When we saw that, we started pre-bolusing by longer times. When that wasn't working as well as I'd like, we started playing with basals.

 

Generally, I try to monitor things so that our post-meal spike is less than 160 or so. If it goes much above that, he becomes insulin-resistant, and it generally takes a boatload of insulin to bring him down.

 

Hard to say really, but mostly under 200. We have the high alarm set at 200 and I rarely see yellow dots associated strictly with meal issues.

 

Great responses. Thank you!

We had the CGM with the Medtronic pump, but it was horrible. Well, at least for us it was. However, we recently ordered the new Medtronic pump with CGM, so we'll see how it goes.

I posted this in another thread, but I recently took over his pump settings. We have a great and kind doctor, but I wasn't feeling that his suggestions were working. So, we started from square one with a single basal rate all day, as well as a single carb ratio and correction setting. His highs seem less high and his lows seem less low -- which is good -- but I am noticing that he is still spiking after meals. I don't want to do anything, though, until I have a few more weeks of data. I might even wait until we start using the CGM again.

For those that up the basal prior to meals, when do you start raising it and when do you lower? So, if your child always eats breakfast at 7 AM, how would you handle that?

It's not that I am against raising and lowering the basal in this manner, but I am kid of hoping that I don't have to since Matt's eating schedule tends to vary a lot, especially on the weekends. If I can get the A1C result that I am hoping for without doing that, then I might hold off a bit and see if better prebolusing could help.

 

If I can keep him below 200 I'm pumped. Doesn't happen often.

 

We pretty much did the same thing a few months back at the suggestion of our doctor. We went down to 2 basal periods and 2 ratios. We're back to 3 basal periods, but I honestly feel like everything is so much flatter lately. And the less I mess with the basals, the better things go.

So maybe look at ratios and ISF and see if you can tweak there to fix the spikes before you start doing big basal changes.

 

This is exactly the approach that I'd like to evolve to and I feel is the only way to generate anything remotely close to a stable day...I'm happy to hear someone else is doing this successfully. I don't believe we will get much support from our endo for this approach, and I think as a result, I a going to be fighting uphill with my wife. DD is only 4 and we have only been on the pump for 4 months so I think it is too early for us, but do you mind if I ask what the reaction from your endo was to this approach?

 

We do something similar, but with temp basals, especially if he's highish going into a meal, or we don't get a great prebolus in. I doubt our endo has a clue that we do it. But we've been diagnosed 6+ years at this point, and our endo has pretty much handed the reins over to us at this point.

 

I think the CGM is such a game changer in diabetes management and something that is both art and science. Even if they trial a CGM, their graphs are rather uninteresting, so they can't learn the data analysis IRT that we use constantly. They can learn the science, but not the art, and it takes both.

 

That is an excellent way of putting it.

 

Our endo is generally supportive of what we do. She has commented before that we are among the 'most hands-on' parents in the practice when it comes to managing independently. She reviews data, makes suggestions if she notices a pattern but typcially lets us do what works without fuss. She sees us a few times a year and realizes that her input is limited. Sometimes we take her suggestions, sometimes we don't, and either option is fine. Our only issue in all these years is that she won't prescribe EMLA as she doesn't feel there is enough long-term impact studies done on frequent users. Drives me nuts and I buy stuff on Amazon instead. Works fine but it would be nice to only have a copay And, with everything else being a great partnership, it's not a deal-breaker for us. I think the endo issue isn't nearly as important as the spouse issue, though - I hope that you can find a solution you are both comfortable with. I'm lucky that my DH, while being completely hands-on with management is happy to be completely hands-off on the math. I set up basals, corrections, etc. If we had to talk about it, I think it would be so much harder.

I actually have a new plan in place that just started. My son is a tween that does not want to bolus at lunch with his friends. It's been a stressful, frustrating experience for all of us and the resentment has been growing. So, I decided to make it a non-issue for awhile. We pack his lunch and he is getting the exact same amount of carbs in his lunch every day. I have his lunch dose completely built in. He still has to do corrections (bolus for highs, temp basal or eat for lows) but those don't bother him, for whatever reason. Is it ideal? Absolutely not. Is it taking out a stress that really upsets him and frustrates us? Yes. So...we're trialing it. Fingers crossed that we can make it work. If it doesn't, we're returning to the 'visit the office before lunch every day to have your bolus monitored' step so he's been motivated to make it work, too. Very rarely do changes make me nervous, but this one did! We see the endo next week so this will be an interesting discussion and I wanted to have results ready. So far, it's worked really, really well for three lunches (assuming that today continues to go smoothly.) NOTE: I am NOT recommending this to anyone. Just commenting on how far we have decided to go with this. We will revisit this again but I'm willing to test something that makes him feel like he has a say in how private he wants to be in his care. I'm not doing it with my daughter, either - this is specific to him and his situation and his outlook.

 

Your creativity with the basal is interesting and has me thinking of situations where we could implement. Said another way, you have me thinking outside the bolus. So thanks. Why not get your son a phone so you guys can text for lunch? Then he'd go from uncool to cool and save a trip to the nurses office?

 

Stacy, when you say you have his bolus "built in", do you mean that he gets that amount in basal at some predetermined point before lunchtime? I'm just curious as to how exactly you accomplish this?

 

He doesn't need help with calculations -it's the actual bolusing that he hates. If he doesn't have a witness, it doesn't happen so we either need a witness or an absence of a bolus. Plus, he has a phone - but he never has it on him. Tweens... I like to remind myself that these years are temporary

 

Exactly. He gets 100 carbs (plus or minus a few) every lunch. I calculated the bolus for the carbs and added that to his basals. He eats at approximately 11:45 so I have a portion added to the hour between 11:00 and noon, a larger spike at noon, then a drop to regular (non school day levels) for a bit, before a really low basal from 1:30-3:30-ish. That's the part we've been adjusting the most and we are at .5 an hour right now, which is low for him. His daytime, weekend basals are about 2 units for the same time of day, for comparison. We've had some afternoon lows (thus the reductions) but pre-lunch to 2:30 has been really stable so far.

I originally looked into using NPH for lunch but endo talked me out of that a few months ago but it put the idea in my head of not dosing for lunch so that's where my mind was.

Edited to add: times and levels are off the top of my head as DS is at school. If anyone wants specifics for an example, I'll look at his PDM and share.

 

Coming in late to this, How do you deal with IOB?