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Does this look like Somogyi?

Discussion in 'Parents of Children with Type 1' started by Theo's dad Joe, Jan 21, 2016.

  1. Theo's dad Joe

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    I would appreciate it if we can put the past behind us. I'd say that the balance for me tipped to the intuition side at about 6 months, and its probably 70/30 now. It doesn't sound like you would have ever gotten good control following any "by the book" strategy, and I don't think I can either.

    What I need is the mental health to be a dad and do family things without being obsessed about the dexcom reading at a given instant, what its doing etc, and to get good enough control. I apologize for the past. The science based knowledge did give me a good framework to start but it stopped fixing problems at least 6 months ago.
     
  2. Michelle'sMom

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    The pump is not a magic fix for all the management problems. Because of your persistence & dedication to precision, I think you'll do very well. You've probably read comments that allude to the the fact that starting pumping is very much like being dx'd all over again. That can be true for many. Just be patient until his body & your thinking adjust to the change. And one small warning: making multiple changes in basals & ratios the way you've done on MDI can be a big mistake with the pump, so be very patient & stay vigilant.

    Switching to the pump doesn't have to be permanent. You can always try untethered or go back to MDI. Having choices is always a good thing.:wink:
     
  3. Michelle'sMom

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    No harm, no foul. I knew you would eventually learn what I meant.

    CGM can be a wonderful tool. It can also drive you nuts when you see what's really going on between those fingersticks. I went through that same single-minded obsession. I think most parents do to some degree. It comes with the job of parenting a child with T1.
     
  4. Theo's dad Joe

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    Thank you! See above. Also the real problem now is that his night time basal needs vary so much from day to day depending on what his honeymoon decides to do. I want an option other than waking him up to eat at 1:00 am once or twice a week.

    He would probably not rise much without any basal right now. He had 2 in the am and 1 in the pm a month ago and was 67 in the morning. My son was great with shots. He was not bothered by them at all, not even Lantus.

    I haven't really changed his bolus ratios in 4 months. He may be 10:1 at breakfast instead of 11:1, and 14:1 at lunch instead of 15:1, but typically as I added some basal I would reduce the bolus slightly for 2-3 days to see what happened, just to be safe. I typically assumed that for an extra unit of daily basal I needed to cut about 1/4 unit off of each meal bolus, again just to be on the safe side.

    Anyway I will ask for help.
     
  5. Michelle'sMom

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    One day maybe I'll ask my daughter's permission to post one of her old graphs. For about 18 months we made weekly basal changes using 4 different profiles. Each week of the monthly cycle had its own settings, both ratios & basals. I do understand the frustration of constant change & trying to stay on top of things but flailing in the water instead. The upside for me was in starting pumping during the honeymoon with all its challenges. By the time puberty hit & PCOS reared it's ugly head, I had a pretty good feel for how & when to make changes, so I only beat my head against the wall occasionally now.:redface:

    You'll do fine. Keep asking questions. For those that bother to read, your posts are thought-provoking & often educational.
     
  6. mmgirls

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    I did not say he was "rebounding" 70 is not a sever hypo nor is he going Hyper, I am saying he is he controlling his own BG very well. I am sure you can find a study that shows an insulin "clamp" study and how well the human body is able to control BG.

    Why is it a problem that his Honeymooning body is bring him down to 80? Many times there is absolutely nothing you can do about a honeymooning kid dropping to Non-D levels at night when there is no carb consumption to deal with. my youngest was dropping down into the 60's before she ever started insulin, I would give her half a juice and it would bring her up for an hour and then right back there to 60s. 60's was her fasting level and there was nothing I was going to do to tell her body that Mommy doesn't like you that low or that the Dr. said you need treat anything under 75 and I should give you a bedtime snack if below 130.
     
  7. Theo's dad Joe

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    The problem is that his honeymoon will bring him down to 80 at 10:00 pm and sitting at 80 when he is very sensitive to insulin, that makes the 5 units of Lantus to much for him to counterregulate.

    Also a 60 fasting blood sugar may not be that unusual for a kid, it is unusual on a 30% carb diet which tends to drive up fasting blood sugar.

    Also I think my son had had reactive hypoglycemia off and on prior to dx based on his behaviors after consumming larger carb meals. My wife also had surprising bouts of hypoglycemia when she was carrying him-herself waking up in the low 60s after having somewhat elevated blood sugar with our daughter.

    But I didn't mean "rebounding" what I meant was that you are saying that he is counterregulating when he gets down into the 70s for a while and using up the counterregulatory hormones, then they are not there at night. That makes sense, but last night he actually didn't run low after dinner. He ate at 130, peaked at 180 and was back to 130 at 4 hours. Some days his pancreas works hard right after a meal and he is down for an hour, and the next day there is no downward bend at all on the prebolus. That's the problem I think right now. He can go loweron a 20 minute prebolus one day and the next day just start taking off.
     
  8. Theo's dad Joe

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    Thank you. I am curious about one thing for now. You mention having most peaks within 2 hours because of prebolusing. That is something that I can't understand at this point. If I prebolus my son more right now, he tends to peak LATER and later with more prebolus, but milder and milder. For example, if I want him to peak in the first 2 hours because we are swimming after dinner, I will bolus after eating so that he peaks in the first 90 minutes. He may peak at 190 while if I prebolus him he peaks later and less high, around say 140. So at least what I have seen so far, prebolusing pushes his peaks LATER by steamrolling the first 2 hours, and makes the eventual peaks less. It also greatly lowers the average because he's rising so late. He can go to 140 at the 3 hour mark but only average 120 over the entire 3 hour period, where if he peaks early everything is higher at each point in time.

    So I am thinking that we are stuck between getting help with the first response to glucose, and not getting help with the first response. Dinner last night he just goes up. Lunch today he just goes up. He will get 4-5 meals without early "help" and then 4-5 meals where he goes lower for an hour right now.
     
  9. Theo's dad Joe

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    When I go on our appt on the 11th, I suspect the doc will give me a Rx for pump and other items? If that is something that takes a long time to approve I might want to get that started now by E-mailing her, or the NP. I also don't know if the clinic pushes a certain pump. Our clinic definitely prefers humalog (Plus Lantus for MDI) while it seems that others go with others. What do I need to know by 2-11 to get started learning the fastest? They have a monthly class at the clinic. I really don't know anything. i don't know how it even delivers insulin. My son has no problem with shots, but he hated the CGM on his arm or shots or CGM in the area around the stomach above the waist. He has virtually no bodyfat. Its hard to even get the cgm on his bottom, there's maybe half an inch either way for putting it. I don't know if the CGM would work at all on his lower abdomen because of the lack of fat, and I would have to bribe him big time to put it there, and he may even pull it off when he's asleep.

    He also barely has room in his pocket for anything at his size and has CGM receiver on his belt.
     
  10. mmgirls

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    The thing is that if insulin is matching carb absorption you may not see a "curve" or a "peak", all the time. there is nothing for breakfast, but you see one for lunch and a late snack before going out shopping with dad.
     

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    Last edited: Jan 24, 2016
  11. StacyMM

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    Long-acting insulins have a spike and a tail and the timing can be adjusted and doses split to mirror a PWD's natural basal needs. Neither of my kids have a flat basal need but it's okay because neither use a flat basal. DD uses a basal insulin that lasts 30+ hours and we have worked it out to have 95% given at 5:30 in the evening and 5% to be given at breakfast. It's not flat, but it's arranged to match the times of day that she needs more or less insulin so it gives her a flat line when we basal test. And, for me, there is less of a need for fine-tuning on MDI. Using a long-acting and using a multiple-times-an-hour push of fast acting are two different approaches. For my DD (who, as you can see from my signature has alternated between pumping and MDI'ing for 9 years), the long-acting insulin acts so smoothly that when she decides to go back to pumping, it's rough. Fast-acting every 6 minutes just isn't the same. On pumps, I spend hours every week on weeding through reports and figuring out what to do. On MDI, we adjust the basal a few units here and there a few times a month (puberty) and that's about it. I can easily go several weeks without making any adjustments to her settings. Her numbers are beautiful, diabetes is very predictable and she feels really good. MDI can be an excellent choice and it can have fantastic results.

    My son MDI'ed for such a short time (we started the pump process at diagnosis) and was honeymooning, anyway. In fact, three years in and I think he still in a honeymoon-like stage (more than .5u/kg but still able to bring numbers down without insulin sometimes). His CGM lines are ugly...but that's because he's 13 and still can't remember that food=bolus :cwds: In his situation, pumping is easy because his diabetes is, quite simply, 'easier' than hers. For him, he *wants* to pump, so it's what he does and we make it work.

    Pumping is not some super amazing, best tool ever, must-have approach. It's just a different way of administering insulin. If it works for you, great. Keep pumping. For other people, MDI works. That's also great. And they should keep MDI'ing. If he doesn't feel a pump is the way to go, shouldn't that end the discussion?
     
    Last edited: Jan 24, 2016
  12. rgcainmd

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    Can't do temp basals with MDI.

    Yes, it should end the discussion. If not this, then something. Anything...
     
  13. Michelle'sMom

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    Pumping Insulin by John Walsh is the pumper's bible. I didn't understand half the technical stuff he covers when I first read it, but I have a feeling you'll get more out of it.

    Medtronic, Animas, Accu-chek, Insulet & Tandem all have websites where you can request demos of each pump. You can actually request a dummy pod (Omnipod) from Insulet. Your endo clinic may be able to let you do a trial. It's best to get your hands on each pump to see how they work & decide which one you're more comfortable with. My daughter was adamant that she wanted a tubeless pump until she wore the dummy pod. It can save some disappointment in the long run.

    You won't be given the Rx for the pump. Usually, the endo sends it to the pump company, along with any other documentation your insurance requires. The Rx will be for the pump & all supplies.


    Spibelt. They make an excellent pouch for pumps, & even one with a double pouch for pump & Dex. Pumps with tubing also come with detachable clips.
     
  14. Michelle'sMom

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    Would you prefer it if Joe started a new thread? Fortunately we all have the right to pass on reading any post. If there was a problem with discussion length, some of the most valuable threads here wouldn't exist.
     
  15. rgcainmd

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    Hmmmm, wasn't it you that posted the following, or was it another "Michelle'sMom"? :p

    "60+ comments on this thread, all discussing 1)a graph I wouldn't consider to remotely resemble a rebound & 2) trying to improve on what, by even the highest standards, seems to be a remarkably well-managed, honeymooning CWD.

    No matter how much you think you know about how insulin & carbs are metabolized, or how much insight you gain from researchers/experts/books, the simple fact is that it's impossible to achieve perfection in controlling T1, at least with the tools we currently have. You may or may not have better results with a pump, but it would most certainly give you more control over the insulin than you have now.

    If & when you make the choice to switch to a pump, I encourage you to give the T:slim a long look. With the dosing precision you're trying for with MDI, you'll love the minute dosing capability.

    Personally, I print out graphs that look like the ones you've posted here. They're so few & far between, I save them as reminders that every now & then we really can defeat the beast."
     
  16. Michelle'sMom

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    I'm old but my mind & recall ability are doing fine.

    If you bothered reading the more recent posts, you would see the topic has changed.

    Regardless, I certainly hope my comments above don't appear to be remotely as rude or overbearing as yours on this thread. People come here for help. If you don't feel capable of offering it or choose not to, you're free to move along to the next thread, or use the ignore feature.
     
  17. wilf

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    Dudette, it is not about you. It is about something else. Why not just step away from the laptop, and leave this discussion to those who are interested?! :cwds:
     
  18. wilf

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    I have actually gone through and read every post in this thread. Fascinating discussion. Helpful in spots, maddening in others.

    I have a few thoughts for you:

    1) Consider the possibility that your son's digestive system is significantly slower than that of most people, and see if that helps explain what you're seeing.

    2) You might consider putting the Dexcom in a drawer for a week, or month. I'm not sure it is helping you at this point, as the wealth of information it provides seems to be feeding a bit of an obsession with wringing the last possible smidgin of BG control out of any given pattern you're seeing. 10 years ago no one had Dexcoms and it was not the end of the world. We're doing fine without a Dexcom even now, living our lives.

    3) If you decide that you need to continue to manage things down to the last detail (which I advise against), then you must get a pump. My concern with a pump is that between it and the Dexcom you'd be tempted to get even more obsessive about the D management.

    4) For us the period you are in (waning honeymoon) was the trickiest to manage outside of puberty. The pancreas tended to turn on and off at random, and still had enough beta cells in place to have that make a significant difference in BG levels.

    5) The diabetes will over the next few months get easier to manage, but you will also have worse numbers. This will be hard for you, and you need to accept that it will happen. Remember that D management for our children is a marathon, not a sprint.

    Good luck! :cwds:
     
  19. njswede

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    Wow! While I've been busy treating a sinus infection and unable to keep BG below 200, you guys have filled 9 pages of discussion about an almost perfect graph. Let's switch! :)
     
  20. Theo's dad Joe

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    Thanks. Wilf, my main issue now with Lantus is that as I have raised it, it has tended to prevent late hanging higher blood sugar after meals, 2-4 hours out. They instead start turning back around and come down, BUT every 3-4 nights he drops into the 60s and falling well after mealtime bolus and with morning Lantus. I hung in with them under 65 for an hour and fingersticks matched, but then they slipped under 60.

    Two nights ago he went to bed at 130 and was 120 4.5 hours after dinner but was 58 an hour later. Then last night he kept rising after dinner and was 200 and didn't come down from mild peaks (150) after breakfast and lunch, just slowly rose to 150. He corrected the 200 on his own by midnight and ran flat at 100 but didn't go low.

    SO he corrected 100 points on his own in 4 hours. He was 95 2 hours after dinner and 200 4 hours after. He got 3 units for 33 grams of carbs, and he was 100 points higher in 4 hours, but he's self correcting 100 points in 4 hours later.

    here is the problem now the last 2 nights. This is 5 Lantus in the morning. Night 1, he's over 120 4 hours after dinner bolus, but low at 11:00 (58), and again at 3:00 am (58).
    The next night he is 200 4 hours after eating dinner even though he was below post prandial for a long time. I did NOT correct and by midnight he was at 105 and started rising to 130 at breakfast.

    So Basically without dexcom i would have no way to know what is going to happen more than 4 hours after dinner bolus at bed. He is still obviously correcting a lot after 4 hours post dinner, but he's not helping out in hours 2-4. These were bolused at about 12:1. They both had about 40 grams of carbs and significant fat, and some protein (15 grams).

    The doctor thinks he got too much dinner bolus on the first night and that 5 units of morning Lantus won't make you go low at night. He got the same dinner bolus the second night and was 200 at 4 hours. Look I can handle 200s, but some days he just drops a lot starting about 10:00 pm.

    Is is possible that his insulin is working early, or maybe his own insulin is working early and or some insulin is getting bound up by autoantibodies and released later? He ONLY had bottom borderline insulin autoantibodies and no other antibodies at dx. Zero not even trace. He did have low borderline celiac autoantibodies but 1% of what was considered a true positive and not other symptoms except that he is still small and growing slowly.
     

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    Last edited: Jan 25, 2016

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