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Rising and Falling at Night

Discussion in 'Parents of Children with Type 1' started by dshull, Nov 5, 2012.

  1. dshull

    dshull Approved members

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    Hello,

    My son is 7 and on MDI. He was just diagnosed in August so we are still very new at this. He is definitely honeymooning and does not require very much insulin. For about the last week, we have had a big problem with his BG skyrocketing once he goes to sleep, then coming down overnight on its own. It is driving me crazy and I can't figure out why. Here are last night's numbers as an example:

    6 PM Dinner (1:55 ratio, 1.5 units Novolog), BG 117
    8 PM Bedtime (1 unit Levemir), BG 110
    10:30 PM BG 306 - usually we correct over 300 but he was so close we elected not to
    11:30 PM BG 274
    4 AM BG 147
    7 AM BG 161

    Excuse me, but WTF??? This has happened for about the last 5 nights. Sometimes he is so high (over 350) at night we do correct him. We always check his BG more than once before correcting, so I know it is accurate.

    My hunch tells me that we need to adjust his dinner ratio, and that is what is responsible for the super high numbers around 10:30/11 PM. But, if you see above, his number was 110 when he went to sleep, a perfect number for sleeping. I worry if I gave him more insulin at dinner, he would be way too low at bedtime and I would end up giving him a snack to bring him back up.

    I should also mention that the 161 at breakfast this morning was unusually high for him - he is usually close to 100 at breakfast no matter what he looked like the night before.

    What am I missing?? Any ideas would be appreciated!
     
  2. MomofSweetOne

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    I would talk to your endo.

    At first read, I agreed with you that he needs more insulin at supper, but when I reread it, I changed my mind. A 110 with IOB is not a good number for bedtime necessarily. There will still be insulin acting for another two hours, which means he may actually be going low and rebounding (the liver pumps out glucose in response to the stress of the lows, more common in the early days after diagnosis) to the 300s because he had too much insulin at supper. Since you don't have a CGM, I would test him every hour tonight to get a better picture of what is happening. He could be having a low around 9 followed by a spike.

    Does he get Levimir once or twice a day? It could also be that his prior Levemir dose is wearing off early, allowing him to go high and then he drops as the new dose kicks in.

    A CGM would be invaluable for seeing what is happening every 5 minutes.
     
    Last edited: Nov 5, 2012
  3. TheFormerLantusFiend

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    Check at 9 PM.
    If he rises like that every night, then how about a half unit shot of Novolog at 8 PM for the rise you know is coming?
     
  4. MomofSweetOne

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    Another thought: is he in the midst of a growth spurt? The kids typically need much more insulin shortly after falling asleep during growth spurts, due to the release of growth hormone. If he's like my daughter was, his growth had been affected pre-diagnosis and she started growing like crazy after going on insulin.
     
  5. danismom79

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    I agree with all of the above posters. A 110 two hours after a bolus, plus the Levemir makes me think rebound first. Get a check in between bedtime and 10:30. If you don't find any lows, then my second thought is growth spurt.
     
  6. wilf

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    I likewise think the combination of insulin on board at bedtime plus the evening Levemir injection coming on is most likely causing him to go low and then rebound.

    For the next few nights try checking blood sugars at 8:30 pm, 9 pm and 9:30 pm and see what you find..
     
  7. shannong

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    This is exactly what happens to my 6 yr old (almost 7yr old). From what I have read (loved Dr. Roger Hanas' book), young children tend to rise early in the night, which totally fits. I have tried many things to deal with this early rise - tried more dinner rapid, but this only made him go low before bedtime. I tried giving his second dose of Levemir at dinner, rather than bedtime to try and have it kick in earlier - but this only made him go low before bedtime too. I am pretty sure that it must be growth hormones kicking in when they go to sleep, making them more insulin resistant. My son tends to go high, even during naps. I have also tried giving him rapid right before he goes to sleep, which I have had some success with, but really hate giving him rapid right before bed, especially when his numbers can be great right before bed. So far, an increase in Levemir at bedtime has helped the most - in fact I don't see the highs at all. The major drawback however has been a low that happens about 2 or 3am (it's so predictable thought that I always catch it when it's going down before he gets too low. I have to wake him and feed him about 8grams, then he's perfect again until morning. I hate having to wake him, so I'm search for advice on what to do too! My latest thought is trying cornstarch, so I'll let you know how that goes. Please tell me if you figure anything out!
     
  8. dshull

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    Thank you for all of your replies. Had a long talk with the nurse at the endo's yesterday. Before meals, we are supposed to figure out how many carbs he will eat, inject him, and then wait 15 minutes before eating. She thought that the rise at night was due to a post-meal spike, and so we needed to be more vigilant about waiting the 15 minutes before eating to allow the insulin to do it's job. She agreed that giving him more insulin at dinner would likely result in him being low at bedtime. So last night we set a timer and made him wait the full 15 minutes. (when he is hungry, I am more likely to let the time slide a little). It did not change anything!! Here are his numbers:

    6 PM: BG 146 (1.5 units of novolog for dinner coverage)
    8 PM: BG 140 (1 unit of levemir)
    11 PM: BG 299!!!
    11:30 PM: BG 284
    2 AM: BG 200
    7 AM: BG 111

    People here suggested that he might be dropping very low early in the evening and then his liver was dumping glucose. Seemed reasonable so that night I checked him every 30-45 minutes until 12 PM and found he was rising on a steady stream, not suddenly. I had planned to do the same last night but honestly was caught up watching election returns.

    Clearly his pancreas is still working and bringing him down overnight. He is never even remotely high in the AM. If we give more levemir, he will be 80 by 7 AM. I am pretty confident if we give him more insulin at dinner, he will be low at bedtime.

    So, if this is a growth spurt, what to do? Ride it out and wait? His numbers are beautiful all day long (nurse called me and she has checked him twice today - 125 at snack and 117 at lunch).

    Thanks in advance for your help!
     
  9. MomofSweetOne

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    So it's a growth spurt; good detective work! What did your nurse say about the idea of giving a smidge of novolog at bedtime to counteract the growth spurt? Since his pancreas is still working enough to adjust down, perhaps it wouldn't have to work quite so hard if it had just a bit of a boost to do so? Again, talk to them.:)
     
  10. DavidN

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    I'm new at this as well but my two cents ...
    My first thought was also post-meal spike. Is this every dinner? What is the typical meal? This is exactly our scenario if our son eats burgers, pizza, mac n cheese or hotdogs.
     
  11. Lakeman

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    You could try eating dinner an hour earlier so that more than two hours has passed before bedtime.

    The basal may be too high.
     
  12. wilf

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    Excellent work in getting those measurements in. Here is another possible explanation for what you are seeing.

    Levemir typically doesn't last 24 hours in children. My guess is that the previous day's Levemir is pretty much worn off at 8 pm when you give the next injection. Then he starts rising because the supper bolus is having to cover both the meal and the missing basal. At some point he stops going up because the new Levemir has kicked in, and then he drops overnight as his pancreas pulls him back down..

    To address this I'd start giving a bit more Novolog at supper. Try a half unit extra for starters, and see if it helps curb the rise. If you need more you can go up by 1/2 unit increments each night.

    Good luck! :)
     
  13. shannong

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    My 6 year old son has the same profile of bg numbers. If you don't want to increase Levemir, I would try rapid right before he sleeps which is when it seems to rise for us (any earlier and my son will go low). My son doesn't want injections while he is sleeping, but that is an option. I always make sure and do several blood checks if I give him rapid before he sleeps, but it's pretty much done it's work by 3hours and whatever bg he has at that point, he tends to stay at, until he starts to go back down again in early a.m. hours. Rapid doesn't usually work for long enough to fully cover his rise, but it does get his numbers better.
     

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