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Cause of the roller coaster--adjust basal or bolus?

Discussion in 'Parents of Children with Type 1' started by bisous, Oct 8, 2013.

  1. bisous

    bisous Approved members

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    DS has had absolutely terrible blood sugars for at least the last two weeks. For the last week or more, he'll have periods of being very much in range. Two nights ago, for example, he stayed around 100 for most of the night! BUT at least once every single day he'll rise into the 300s and stay there!

    On school days, this is post breakfast. After eating, his blood sugar will rise precipitously by 9 a.m. and stay elevated until at least noon, sometimes 1pm. So pretty much the entire school day. Then it will start dropping like a rock and he's low every single school day afternoon.

    However, this weekend (same breakfast, very close timing) he didn't rise at all after breakfast and instead we saw a rise much, much later--closer to noon or 1pm rising precipitously until around 3 pm (when we are usually low on school days) he'll be around 300 and feel really miserable.

    Is this saying my basals or my bolus insulin is off? When he doesn't eat, he seems to be mostly good. Sometimes when he eats he is fine. Usually the spikes coincide with eating but there is no rhyme or reason. I've confirmed that the bolus insulin he is giving is administered properly. It will be a newish site (although those have been going bad at unpredictable rates as well).

    It is a complete roller coaster!

    I have a dexcom G4 and find it to be quite accurate. I feel a bit helpless as I'll see the double arrows up on the G4 but when I enter the BG it will give no insulin. I think I need to be doing more when I see that but I'm just not sure what to do? In such a circumstance do you do a manual bolus? Do you do a temp basal? Instead of helping, it is just highlighting how out of control our weeks have been!

    Ugh. It is 4 am but I just hate seeing all these 300s. If I could pinpoint one period of time that we are high I would be able to make some adjustments. Instead because we have such a mix of highs and lows at weird times, I'm lost as to what to change. I find myself using a lot of temp basals, lots of corrections, lots of lost sleep. I haven't done any dietary modifications--I'm getting a lot of pushback on that and I've always been of the mind that if DS is eating healthy food (i.e. not straight junk food like candy or soda or sweets) that I will try to match his insulin to his food to give him a sense of normalcy. I will tell you we won't be doing pasta in the near future until I figure out what is going on.

    Any help much appreciated!

    Thank you,

    Jen
     
  2. Melissata

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    How soon after a bolus is it that the pump is not suggesting a correction? What is you duration of insulin set at? We override the pump suggestions all of the time and just dial in a correction. Have you looked at the Dexcom Studio to see if there are any patterns detected? Sounds like a basal issue in the afternoon to me, and maybe just increased insulin resistance in the morning. Are you pre bolusing, and is there a lower gi breakfast that you can try? Perhaps a low or no carb breakfast would help you determine what is going on.
     
  3. bisous

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    We have our DIA set at 3 hours. I've never overridden the pump. That sounds like a good way to start correcting more quickly when you are certain that you will need to!

    I have looked at the Dexcom software and TBH it wasn't terribly helpful. It said it was detecting highs "between 8:45 am and 4:45 pm." Um, yeah. That's the whole day, lol. And he ISN'T high all day but he is usually high SUPER high at least once a day for a few hours.

    I think the morning is the key. I have dialed back my mid morning basals to counteract the drop that I see daily in the afternoon on school days. I'm thinking the highs we saw this weekend in the afternoons was because the basal rates need to be higher.

    Which gets us back to the morning. I need to tame that spike.

    I think you are right, I need to a do a low/no carb breakfast to see what happens. DS is just so set on eating his terrible Joe's O's (Trader Joe's cheerios) and I keep trying to make that work. With not great results!

    Thank you for weighing in. I'm going to try to bribe DS to do a low carb breakfast and we'll see what happens. At least I have a game plan!
     
  4. hawkeyegirl

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    I override the pump based on the Dex all the time. Seriously, all the time. Some kids have sharp spikes, but come back down. If I see double arrows up on Dex, I know I have to start blasting insulin into him, or he'll be high and stay high.
     
  5. Melissata

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    One thing that might help is that you let him eat the cereal at another time of day, my daughter eats it often for a bedtime snack. Have you tried giving him some protein with it to help slow things down? Or maybe a smaller bowl of it with something else? My daughter decided to have 2 pkgs of oatmeal the other day and it was a disaster. I suggested 1 pkg and an english muffin instead and that worked. I have no idea why, but it did. Even with her being an adult, things seem to change. I stopped buying english muffins for a long time, and now all of a sudden she doesn't spike with them anymore.
     
  6. bisous

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    I'm going to try adding something with protein in the morning to the cereal (bacon or sausage) and see if that helps. I am also going to limit him to only 2 bowls. If that doesn't work, I might try cereal for afternoon snack instead. The kids would probably love to do that and they're starving when they come home from school. But then I still have the problem that DS doesn't want to eat anything else for breakfast.

    But I've just about had it with the spikes. I cannot seem to find a rhyme or reason to why he'll spike and why he won't. I think it comes down to timing the insulin just right and with these large quantities I think 5 minutes makes a difference. I just don't have enough time or energy in the morning to be precise by 5 minutes in the midst of the chaos, IYKWIM.

    I'm going to have to get better at overriding the Dex. It is good at catching lows so I'll just have to trust it while I figure out what exactly how much insulin to give for each scenario and how he'll react.

    Thanks for weighing in. I don't remember a time in all our years (7) of diabetes that I've been so perplexed or been trying so hard with such poor results!
     
  7. ksartain

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    Maybe he needs a different carb/insulin ratio at breakfast.
     
  8. bisous

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    That's what I'm trying to figure out. I'm having a hard time teasing out this factor. If he goes uncorrected he may spike to the 300s and sit there for a couple of hours. Then he precipitously drops. I'd say that within 4.5 hours of eating breakfast he will eventually return to post breakfast BG levels. That to me says the I:C ratio is correct but the food is tricky but it is hard to tell??

    I could also try increasing the I:C ratio and see if that has any affect.
     
  9. mom2ejca

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    To me, that says not enough bolus and too much basal. I would lower the basal 1-2 hours before the drop starts and increase his meal insulin.
     
  10. bisous

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    That was my thought too. I have already dropped the basal insulin from about 10 am onward and now he's just staying high longer but the precipitous drop is still happening, just later in the afternoon.

    Then I have days like Saturday and Sunday where he DIDN'T spike in the am and instead rose really high at around 2 or 3 pm--which I'm wondering if is a result of lowering the basals several hours previously.

    I think I really need to do a basal check. I'll do it tomorrow and see. I think that will help a lot.
     
  11. mom2ejca

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    Does he eat a bigger breakfast/lunch on school days? If you log maybe go back and see if the days that he's spiking to 300 are bigger meals? If you are off just a little on a carb ratio you aren't going to see much affect on smaller meals. But if he has a bigger meal it's going to make a bigger difference in the amount of insulin he is being shorted.
     
  12. bisous

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    I think I need to actually log what is going on including timing (to the minute) when the insulin is given and when he starts to eat. Traditionally on weekends he eats MORE and bigger breakfasts. I was shocked to see that he did not spike on either day (Saturday or Sunday) this weekend. I wish I knew what I did differently.

    I'm starting to wonder if there is a stress element to school that causes a rise in BG. Because he has school 5 days a week, I'm going to try a basal check on a school day and adapt his insulin to that pattern. On the weekends I can afford to monitor more closely and adapt as needed.
     
  13. kirsteng

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    When you say 'bigger' breakfasts on the weekend, do they include other items too that might not be as high GI as cheerios? That might be a factor in why he doesn't spike in that case.

    My son can't eat either cheerios or rice krispies (brown or white) for breakfast. After a couple of months of not having them, I bought some brown rice krispies and he had a bowl (3/4 cup - I measured) on sunday. Prebolused by 30 minutes and gave him a little more rapid than normal to hopefully account for the high GI. At 1 hour and 30 mins after eating, he was at 304. Unheard of for my son.. normally he'd be in the 160-180 range at that time.

    So I'm going back to only giving those at either morning snacktime or lunchtime - both of those times work for him. I'm lucky that my son is pretty easy going though, when I explained why the cereal wan't a good choice at breakfast, but that he could still have it at snacktime, he accepted it. Are there other 'fun' breakfast foods that your son would eat if they were available.. like homemade french toast or pancakes? I often make a triple batch on the weekends, cook it all, and put the leftovers in the fridge. Makes for a super-quick and easy breakfast on school days, healthy and great numbers to boot! ;)
     
  14. shannong

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    My son has very different insulin needs on school days versus weekends. On school days he has a dramatic drop in bg in the afternoon (in fact I give him up to 30 uncovered carbs) to compensate for the drop that happens right after school, it is so fast and furious that I just go with carbs although I could play with basal rates if I wanted, but he happens to want a snack afterschool anyway, so I just don't cover it.

    So the exact opposite happens on weekends - he has a dramatic rise in the afternoon at the very same time that he normally drops during the week. I just recently figured this out after going through my log books and being frustrated with his weekend numbers.

    Also, I have found that if my son does not get good numbers in the morning, then it can mean spending the day fighting highs that I probably won't get down until the afternoon. Starting the morning off with good numbers after breakfast has been really important for us. Cereal had to go for us - we tried adding in protein and fat, but nothing worked. Actually we tried cereal at other times of day too and it just doesn't work or I can't bolus well for it - either way it's out.
     
  15. nebby3

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    We homeschool but my dd still had different insulin needs on weekdays. I
    I think it is adrenalin related on school days and there is not much you can do beyond give him way more basal on those days.
     
  16. bisous

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    Thanks for all the comments and suggestions. I was so beside this morning when I posted this. Just so confused and frustrated. The endo (whom I never consult) was not terribly helpful in this regard. Its like he doesn't listen long enough to know what the real problems are!

    I will do a basal test tomorrow so it happens during school. To get us ready, we'll have a nice low carb, low fat dinner so we don't have wacky numbers messing up our basal check in the morning.

    Thanks again!
     
  17. Mish

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    I'm going to say, "welcome to the start of puberty".... Around age 10 is where we saw all sorts of garbage happen - roller-coastering being the biggest issue we're facing. It's just been non stop for us since age 10. So, I feel for you. I really do.

    Something I've been trying lately, and I"m having better luck with it, is to have our DIA at 5 hours. BUT, I also have previously tweaked the boluses and the basal. There are times when I DO need to override it, but less so now that I have the other two set better. Even on Apidra, we definitely still see a TINY bit of action at 5-6 hours, but, if I have the ratios set lower, I can better account for that, when meals overlap 3 or 4 hours later.

    It's just something (after much agonizing) I've found is working for us.
     
  18. missmakaliasmomma

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    I don't know if cereal works for anyone here. It doesn't work with my daughter so she doesn't eat it. I'm sure there's other things he'll like to eat. I'd definitely be much more concerned with the "stuck highs" then him getting to eat the cereal.
     
  19. Melissata

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    A couple of years ago I read here that someone used Soy Milk on cereal to prevent the spike. We were having problems and I decided to try it. Have been using it ever since. I think that she would have a problem with 2 bowls of any cereal though, and she is an adult. She uses the serving size on the box and weighs it. Since there is a touch of fiber in most cereals, she doesn't add for the carbs in the soy milk. Her ratio for breakfast gives her a lot more insulin than any other meal. Is breakfast later on weekends? I would try a ratio that would give him a bit more insulin for breakfast. Monitor it and increase if it helps. If he dips slightly low, you could lower the basal a bit before that time.
     

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