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Can someone help please :)

Discussion in 'Parents of Children with Type 1' started by ck8506, Mar 21, 2010.

  1. ck8506

    ck8506 Approved members

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    It was recommended by another user here that I post to get some assistance with our insulin pump doses.

    We have not heard from our local hospital since before Christmas, and they continually ignore our calls and emails requesting help - so im on my own with changing doses etc and training other people.

    History - DD was dx at 2y 8m in October 2008. Turned 4 in Feb 2010. Pumping since August 2009. She is in daycare/preschool 5 days per week from 6.30am until 6pm (most of the time) They deal with her meals there and have a specific carb counting menu on hand.

    We are on the Medtronic Paradigm pump with the following settings:

    BASAL
    12am (midnight) 0.15
    9am 0.25
    12pm (midday) 0.45
    4pm 0.4
    9pm 0.2
    TOTAL in 24hours is 6.65u

    BOLUS WIZARD
    30g = 1u
    Sensitivity = 12
    BG Target = 6.5-7
    Active Insulin Time = 3 hours

    We had pump failure last weekend, so we were back to injections for 4 days, but here are the last 3 days of readings. I have no idea what changes need to be made

    Sunday 21st March
    1am - BSL 13.6
    10am - BSL 11.1, 0.3u given
    12md - BSL 8.7, 28g, 0.9u given
    4pm - BSL 10.9, 0.3u given
    7pm - BSL 5, 25g, 0.6u given
    9pm - BSL 11.3, 16g, 0.6u given
    AVG BSL - 10.1
    Carbs - 69
    Meal Bolus - 2.2
    Correction Bolus - 0.5
    Basal - 6.65
    Total Insulin - 9.4u

    Saturday 20th March
    12am - BSL 7.8
    8am - BSL 2.9
    9am - BSL 16.2, 25g, 1.5u given
    12md - BSL 21.5, 1u given
    3pm - BSL 7.2, 57g, 1.9u given
    7pm - BSL 8.8, 20g, 0.7u given
    11pm - BSL 20.9, 1.1u given
    AVG BSL - 12.2
    Carbs - 102
    Meal Bolus - 3.3
    Correction Bolus - 2.9
    Basal - 6.65
    Total Insulin - 12.9u

    Friday 19th March
    6am - BSL 11.5
    7am - BSL 10.1, 21g, 0.9u given
    9am - BSL 21.4, 14g, 1.5u given
    12md - BSL 6.2, 22g, 0.6u given
    3pm - BSL 25, 35g, 2.5u given
    5pm - BSL HI (so 33.3 entered in pump), 2.1u given
    7pm - 35g, 1.1u given (unsure of BSL she was with her father)
    10pm - BSL 15.2. 5g, 0.6u given
    AVG BSL - 17.5
    Carbs - 132
    Meal Bolus - 4.1
    Correction Bolus - 5.2
    Basal - 6.5
    Total Inslulin - 15.8

    Can anyone please help. I want to get the CGMS but simply cannot afford it, and of course our hospital wont help. We have not seen an Endo for 12 months, as ours is on maternity leave and we weren't offered any other solution (even going to the nearest childrens hospital)

    I have found that she has to go to bed a bit high to ensure she doesnt wake up low, but when we had her basal at 0.1 until 6am she was waking up high, so no idea on what to do

    ETA - She weighs between 14 and 15kg, and is 4 years.
     
    Last edited: Mar 21, 2010
  2. GaPeach

    GaPeach Approved members

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    I am so sorry that you do not have an endo that will communicate with you. Hopefully, someone from Australia will be able to help you more in HOW to get SOMEONE there to help you.

    I am headed out the door right now to church. I need to convert to US and chart those numbers first. Then, I may have a few suggestions of what I might do if I woke up in your shoes. I'll check in later today.

    But, in general, I would figure out what her usual total daily dose has been. I would set up 40 - 60% of that amount as basal. Chart the numbers and see when she tends to be higher and add basal to those time periods. You may need to add in other basal times. Usually, the basal change will effect the BGL about 2 hours post rate change.

    MOST IMPORTANT test frequently whenever you make changes.

    I'll check in later. (Post today's BGL later as an update)
     
  3. StillMamamia

    StillMamamia Approved members

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    The BG converter is this

    http://childrenwithdiabetes.com/converter.htm

    Maybe add it to your siggy?

    So, to understand you are on shots now, while waiting for a new pump??
     
  4. ck8506

    ck8506 Approved members

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    We are back on the pump - started again on Wednesday. Pump has Novorapid (and she was with her father when she was 2.9 - he said he gave her juice)

    And I will add the converter, thanks :)
     
  5. StillMamamia

    StillMamamia Approved members

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    Ok, I'll add my thoughts then. :eek:

    I think the basals are too low for overnight. You probably need to do some overnight testing. Maybe you can cut it up into 2 parts for a couple of days for each part - test 2hrs after dinner, midnight, 2am, 4am ; then the other 2 days, test at 3am, 5am and 7am. You can get a good picture of what is happening. Try to give the same foods each night and keep the activity level the same, and exclude illness. But I think your basals are too low (growth spurt maybe, given the age), so you have to up those late evening to very early morning basals (we have a setting from midnight to 3am, but it differs for each person). Maybe getting this part down, the rest of the day will be better.

    Another thing which maybe is happening is not enough bolus for breakfast or maybe it's a question of using prebolus (if possible at all) or trying a different type of bolus (combo/dual wave or extended/square wave). Prebolusing will work only if your child eats for sure what you put in front. If not, you can split the bolus, by giving half about 10-15mins before eating, the rest later on.

    Also, I would try to test 2hrs after a meal to see if the meal bolus is accurate.

    Also, be careful about overtreating a low. Advice given here is to give a fast acting carb, test in 15mins. If still low, give another fast acting carb, wait 15mins, etc etc, until BG is up to within range, then follow up with some slower carbs. I think for the 2nd day, maybe the combo of correcting the low and breakfast was probably too muc??

    Sorry I can't be more helpful, but I really think you should try to get those overnight numbers fixed first, and work your way down the day.
     
  6. ck8506

    ck8506 Approved members

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    Thanks for the advice - its a start on the right path.

    Im taking the day off from work tomorrow (I usually work remotely 2 days a week and in the office 3 days) but im going to concentrate on this.

    I will test her again in 50 mins (which is midnight) and then again at 2am, 4am, 6am and 8am (no sleep for me tonight LOL)
    At daycare there is 2 hours between meals (most of the time) so we bolus after she has eaten (as she never always eats what is in front of her)
    Brekky - bolused 7-7.30am
    Morning tea - bolused 9.30-10am
    Lunch - bolused 12.30-1pm
    Afternoon tea - bolused 3-3.30pm
    Late snack - bolused 5.30-6pm
    Dinner - bolused 7-7.30pm
    After dinner - check at about 9pm

    Sometimes (depending on how we go through the night) i check at about midnight and 3am. Im a single mother, so its hard when I have a full days work ahead of me (and a child who doesnt actually go to sleep until I do!!!)

    Thanks again - will post up tomorrows readings :)
     
  7. StillMamamia

    StillMamamia Approved members

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    Ok, sorry, my pc blocked:rolleyes:, but wanted to add that you'll get more advice with formulas and stuff, so probably easier to follow. Someone should chime in with that.

    For the prebolus - try to give 1/2 of the bolus 10-15mins before a meal, the rest after. It helps curb any meal spikes.
    I know how hard it is with younger ones who decide at the last moment not to eat.:rolleyes:
    For all the ISF, DIA stuff, someone probably will chime in on that. Not my best stuff, I have to admit.:eek: But you can test that too.

    Try to keep the midnight test always. We also do a 3am test sometimes, but not always. Some test everyday at 3am, but you have to do what you can do.:cwds:

    For now, I would concentrate on getting those overnight basals better and to test diligently those 2hrs post-meal BGs. That will give some insight as to your meal bolus.

    Good luck and hoping someone from your area can help you find a helpful diabetes team.
     
  8. SarahsMum

    SarahsMum Approved members

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    Hi Cate

    Im glad you found this site, Ive found it extremely helpful in the past when we have had issues.

    Hope the overnight testing has gone ok. I too think the overnight basals are part of the issue.
     
  9. ck8506

    ck8506 Approved members

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    Okay so here are our overnight readings (converted too)

    11.33pm - 8.6 (155)
    3.02am - 9.8 (176)
    6.02am - 6.1 (110)
    8.02am - 2.8 (50) - juice was given at this point
    9.41am - 2.6 (47)

    So im guessing the basal which works between 6am and 10am is too high - but the thing is, and as bad as this sounds (and it may be half our problem) on days I dont physically have to get up for work, I dont get out of bed at 6am, and neither does she.

    We have sleep issues, which are being dealt with separately, but like today she did not wake up until 9.30, and I can tell you I was thrilled as it took me until 3am this morning to fall asleep (and thats with trying my hardest to fall asleep)

    Hopefully, fingers crossed, I start working in the office 5 days per week, which will mean a routine through the week. But weekends can something be done about her basal?

    Any thoughts?
     
  10. skimom

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    lower the basal rate starting at 5 am (try 10-20% lower)- this will help the 8 am number
     
  11. ck8506

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    So I change it to everyday, including those when she is up at 6am and had breakfast by 7am, or just to those when she isnt up a bit later (usually between 8 and 9am)
     
  12. GaPeach

    GaPeach Approved members

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    OK - I usually recommend only changing one thing (Basal, ISF or I:C Ratio) at a time. Following a change - frequent checking; wait a couple of meals to see if Carb Ratio change works; wait 2 days to see if basal rate change works; observe 2 or 3 corrections to see if ISF change works.

    In looking over a chart of your BG #'s, I wou;d consider a change to the basal to prevent the morning lows and a small change to the I:C. Then, if still having the afternoon highs, I would think about the afternoon basal rate. After those are dealt with, I would see if corrections are effective and possibly change the ISF.

    Here are my thoughts:
    12am (midnight) 0.10 - To combat the nighttime drop
    9am 0.30 - to bring her down midday to early afternoon
    12pm (midday) 0.45
    4pm 0.40
    9pm 0.15 (Or keep at .20)

    (If the 12am -0.10 causes wakeup highs, you change add in a bit of basal at 11PM -0.20 or 0.25 for just one hour.)

    I know as a single mom checking every 2 hrs is tough. But those 2 hr checks for a few days will provide you with a wealth of info to base changes on.

    Although, I usually wait to see how the new basal works, I would go ahead and change the I:C to 1:25. I think the main problem is the I:C.

    If those changes help but a few small corrections are needed consistantly, then consider a slight change to the ISF.

    An excellent book is "Pumping Insulin" by John Walsh. Also, "Think Like A Pancreas" by Gary Scheiner.

    It's evening (8PM) here in Georgia (USA). I'll check in to this thread in the morning.

    Have a great day.
     
  13. ck8506

    ck8506 Approved members

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    Thanks for the help

    I will check through the night again tonight - and try to get approval to work from home tomorrow so I can get up that little bit later

    I have changed her carb ratio to 1u per 25g as well as the basal rate.

    Will see how it goes :)
     
  14. GaPeach

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    Just checking in and wondering how things are going. Post recent numbers when you can.
     
  15. ck8506

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    Okay so here are our latest readings (converted too)

    Monday 22nd March

    12 (midnight) - 8.6 (155)
    3am - 9.8 (176)
    6am - 6.1 (110)
    8am - 2.8 (50)
    10am - 2.6, 38g, 0.8u (47)
    1pm - 14.2, 36g, 1.8u (256)
    4pm - 10.4, 23g, 0.9u (187)
    6pm - 5.5, 38g, 1.3u (99)
    9pm - 3.2 (58)
    AVG BSL - 7.0 (126)
    TOTAL INSULIN - 11.1u

    Tuesday 23rd March
    12 (midnight) - 9.6 (173)
    3am - 10 (180)
    6am - 6.2 (112)
    7am - 5, 21g, 0.6u (90)
    9am - 20.2, 0.8u (364)
    10am - 18.5, 30g, 1.4u (333)
    11am - 2.5 (45)
    12 (midday) - 4.9, 21g, 0.6 (88)
    2pm - 7.6 (137)
    4pm - 12, 25g, 1.4u (216)
    7pm - 2.2, 13g, 0.1u (40)
    10pm - 9.7, 0.2u (175)
    AVG BSL - 9 (162)
    TOTAL INSULIN - 11.3u

    Wednesday 24th March
    12 (midnight) - 6.7 (120)
    3am - 13 (234)
    6am - 7.5 (135)
    10am - 2.6, 32g, 0.6u (47)
    12 (midday) - 6, 30g, 0.9u (108)
    2pm - 11.9, 0.4u (214)
    5pm - 4.9 (88)
    AVG BSL - 7.5 (135)


    BASAL RATES WERE:

    Monday
    12am - 0.15u
    9am - 0.25u
    12pm - 0.45u
    4pm - 0.4u
    9pm - 0.2u

    Tuesday
    12am - 0.1u
    9am - 0.3u
    12pm - 0.45u
    4pm - 0.4u
    9pm - 0.2u

    I made some changes last night which affected the basal, but also changed the carb ratio back from 25 to 30.

    Here is the basal from today

    12am - 0.1u
    6am - 0.2u
    9am - 0.3u
    12pm - 0.4u
    9pm - 0.2u

    What do you all think? I found out a few reasons as to the sugars all over the place on Tuesday (daycare didnt bolus breakfast till 8am, but then did finger at 9am and corrected, and then again at 10am with morning tea, with another correction - which I think very much contributed to the hypo at before lunch time) I also think the carb ratio might of been too high, hence the drop last night (before dinner)

    She was at home with me today, hence the semi staggered readings, but she is back at daycare tomorrow. I have asked them to do her pump in 2 sections

    Enter the BSL in so she at least gets some insulin before eating, and then entering just the carbs when she has finished. I am also going to be reviewing their menu and working out a better way to dish up meals so we can accurately count carbs.

    I guess our averages BSL for the day is good, but we are having some big waves of sugars going from very high to very low.
     
    Last edited: Mar 24, 2010
  16. PatriciaMidwest

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    Hello and welcome to CWD. So glad you are getting some help here. I wanted to mention that the MM pump has a "Patterns" setting where you can add 2 different basal profiles. I would try that for the weekends. Check your user guide - I believe you have to enable patterns in the menu before you can go in and set one up.
     
  17. GaPeach

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    It looks like you are changing the basal based on the lows. I think you have made logical changes. You were responding well to those lows.

    The highs are not as frequent (except the one late bolus/correction for breakfast at the daycare). Looks like the change in I:C is helping with the highs.

    I would recommend sticking with your latest changes to the basal and I:C for 24-48 hours and see what trends develop by FREQUENT BG checks.

    My thoughts are that the reduction in basal will combat the lows and the increased bolus from the I:C change will combat the highs after meals. If the I:C appears to be off, try changing it slightly to 1:28. (You can have different I:C's for breakfast, lunch and dinner if needed.) For a young one, a small change can mean a lot.

    Hopefully, things will settle down by the weekend and you can get some well deserved rest!
     
  18. GaPeach

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    Notes below...


     

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