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Puberty Experts: A Question

Discussion in 'Parents of Children with Type 1' started by mamattorney, Nov 6, 2013.

  1. mamattorney

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    OK experts, I need some advice.

    My daughter BG skyrockets at night. But the rise starts at different times, sometimes it's evident at the 9:00pm check, other times that number is fine, but the number will double and then some by midnight.

    In order to combat the rise, the rate increase must be really big and I'm stumped as to when to start the rate increase. I know it should be an hour or two before we see the rise, so I'd like to start it at around 7:00pm to try to prevent the insulin resistance that I see when she gets into the 300's+, but I'm concerned about her falling dangerously low should the rise not begin until 10:00 on a given night.

    Complicating things further is until around 9:00, I don't really know whether a higher number is a result of dinner or hormones. By 9:00, her meal insulin should be virtually gone, so I know if she's high then, the rise has begun, but I don't think testing at 7:00 or 8:00 is going to gather any valuable information.

    What would you do?

    My daughter is somewhat interested in a cgm and I've got the process rolling, but I can tell by her attitude that while she would welcome the information at this point, she is not thrilled with wearing a second device and while I can hope, I must be realistic that 24/7 cgm'ing may not be in her future.
     
  2. nanhsot

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    CGM was actually going to be my suggestion, it'll give you the information you are lacking. My son wore his sporadically, there's nothing to say you MUST wear it 24/7, it's still a great tool. He'd wear it to figure out problems, and he'd wear it before appointments, that's it. Now, in college, when things are more important to him, he does wear it 24/7, but he didn't for years.

    What time does she go to bed? Do you notice any difference in that 9p number based on what she ate? Clearly insulin is done by 9 but that doesn't mean the food is! I think for that time of day I would do a correction, and not a rate increase, if it's inconsistent it may just be food and not basal needs. For my son the puberty stuff and cortisol rises showed up in the middle of the night, not during waking hours. YDMV of course.
     
  3. mamattorney

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    All good questions, with no good answers. I'm not a gourmet chef, so our dinners are relatively predictable. And she was not seeing these 280-325 numbers at 9:00om ever before, even if we ate at 7:00pm, which happens a couple of times a week and just adds more confusion to the picture. I thought maybe it was Halloween candy, but I don't think so. She takes candy in her lunch at school and the three hours post lunch numbers (which is when PE is every day) are universally fine. She "goes to bed" at 9:00pm for what that's worth. She often wanders out at 10:00 or 10:30 and hasn't slept yet.

    She's got some killer foods (most notably cake in any form - muffin, regular cake, brownies, etc), but she hasn't eaten any BG killers since I've noticed this craziness.

    I can't guarantee is isn't food, maybe it is. I don't know anymore.

    So far, I've been doing my best to manage the numbers using corrections and the past couple of days I've added temporary basal boosts to the mix. What I am seeing are things like:


    11/1 (late dinner, snacking before so numbers muddled with IOB and the like)
    6:53 (pre dinner) 236 (correction as allowed with IOB and food)
    8:51 308 (correction as allowed)
    10:46 380 (correction)
    12:06am: 309 (correction)
    3:02 173 (correction)
    8:27 139

    11/2
    5:46pm 125
    8:20 123
    10:00 108
    10:10 81 (15 g carbs)
    12:11am 283 correction
    1:43 296 correction
    4:03 229 correction
    8:33am 153

    11/3
    5:22pm 132
    8:02 253 pump said no correction - turn on 120% temp basal until midnight
    8:46 325 correct as allowed
    10:03 257 correct as allowed
    12:02am 197 continued 120% basal but no correction
    3:03 173 turned off temp basal
    8:14am 169

    11/4
    7:02pm another later dinner 254 (these are high because she snacks beforehand)
    9:02 244 - could have been dinner so I did nothing but run 120% basal
    11:57 299 - correction plus 140% basal 3 hours
    3:07 93 - turned off temp basal plus 10 carbs because she woke up and was afraid of going low
    8:09am 153

    11/5
    6:32pm 80
    8:21pm 158 --- added a 10% increase to basal insulin until 3:00a.m.
    9:44pm 202 correction plus 120% basal (of new rate)
    12:02am 285 correction plus 120% basal (of new rate)
    3:03 193 correction turn off temp basal
    7:51 129

    As I write it out, maybe there isn't as much of a pattern as I think. It definitely doesn't help that we eat dinner later quite a bit. Uggh.

    Well, any help or "this is what I would do", would be most welcome. I'm at a loss.
     
  4. hawkeyegirl

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    Well, the one pattern I see is that she is always high at midnight. It would have been interesting to see what would have happened on 11/2 if you would have let that 81 ride, but I understand why you can't do that without a CGM.

    I might start by increasing the 9:00 or 10:00 basal for a couple of hours and see what that does. I also wouldn't base much of anything on those nights where she goes into supper in the mid 200s. We have never figured out how to effectively deal with Jack going into a meal high. We either delay the meal or if that's not feasible, he skyrockets.
     
  5. Megnyc

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    Overall thoughts:

    1. You are handling this great.
    2. I would consider changing the correction factor.
    3. You can/should be more aggressive with temp basals. I would be trying 150-170% but not hesitating to double basal if you are testing very frequently.
    4. I am not seeing any night where she is even lowish after midnight so I would not hesitate to increase basal from 10 pm on.

    I wouldn't consider a CGM optional right now. You need to be able to sleep in more than 3 hour increments and I don't see any way around the frequent testing without a CGM. Also, how is your daughter feeling? I find consistent highs at night can give me a yucky hungover feeling the next day. Lots of fluids will help with that though both before bed and when she wakes up.

    Good luck!

    ETA: Looking over it again I am going to change my opinion on the aggressive temp basals. The 140% and correction actually worked really well. You may try to switch her basal to 130% of current basal from 10 PM on and test frequently and see what happens.
     
    Last edited: Nov 6, 2013
  6. MomofSweetOne

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    To add onto what Meg has said, sometimes when I see a correction is simply holding my daughter's BG steady on G4, I know that it is replacing needed basal rather than working as the correction it was meant to be. I will look at the amount of the correction and then use that to adjust the additional amount she needs in basal to know a good approximate temp basal guess (My daughter tells me, "I've always hated guess and check in math, and diabetes has WAY too much.") and then I recorrect her again. It works well most of the time to get her BGs moving toward target.

    If you're seeing the climb start at a couple of differing times, I would choose the later one to change the basal rate at; I'm assuming it's caused by how quickly she falls asleep. I have many times seen a 100 point climb (that would go higher without temp basals and corrections) start as soon as my daughter falls asleep. You can check how much her BG has climbed when you go to bed and give her a correction to get her toward target. It would be safer than having it set too early and then creating a low. But, from your posted numbers, you definitely need a different nighttime basal profile.
     
    Last edited: Nov 6, 2013
  7. nanhsot

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    Midnight definitely jumps out at me, I'd do a basal increase at 10p.
     
  8. MomofSweetOne

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    There's a quote in Pumping Insulin that has become our motto for survival.

    "Hormonal changes at puberty can make this month's insulin program obsolete next month. During growth spurts and puberty, growth hormone and cortisol levels rise. This requires insulin doses to also rise. Covering teen hormones and growth spurts brings humility to the best diabetes clinicians. The most effective advise is to be prepared to adjust basal and bolus doses frequently to keep up with growth."

    If you're like me, you'll soon find yourself thinking, "You don't even have a clue" when other (non-D) parents are complaining about the challenges of puberty.
     
  9. shannong

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    Well, my son is only 7, and not going through puberty, however, the most difficult times for me is the early part of the night because he has huge spikes when he goes to sleep. These numbers are tied to sleep. My son could go to sleep and be in the 70's and literally an hour later be in the 400's. However, I find that if I set the increased basal rate too early, he will go low before bedtime. Generally, I set a very aggressive basal rate for the first two hours of sleeping, then it gets backed off. If the spike gets higher than 200, I also need to use very aggressive corrections. I definitely see the best numbers if I can set a higher basal rate for the hour before bedtime to help combat the spike, however I have found that I have to be a little more conservative during that time to avoid lows before bedtime. Also, I have found that if he has a bolus working from a later evening snack, the combination of a higher basal rate and the bolus can send him low (not sure why - because I am only covering the food).

    It is kind of like the dawn phenomenon - but at night, rather than early morning.
     
  10. kim5798

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    I agree with the person that said basal increase at 10pm. and this. Even long before she starts to have her menstrual cycle...a cycle is happening. Things are going to change from week to week, based on hormones. Every time I think I have a handle on it, I don't. Test often & do the best you can. If you can do a cgm, do it. We didn't have the best experience with ours, but I think if we tried again now, it would go better. These years are not easy, it sounds like you are doing a good job. Hang in there.
     
  11. mamattorney

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    Thanks everyone.

    In my emails to the nurse practitioner about getting a Dex, I recounted my tale of woe. She reviewed the uploaded pump data on t:connect and came up with a new profile to try. I didn't even ask her to do it, but it seemed to follow the basic pattern of what's going on. A daytime rate (higher than it is now), an increase at 8:00pm, a larger increase at midnight and starting the daytime rate at 4:00 a.m.

    It's so easy to create new profiles on the t:slim that I just did it and activated it last night a little after 8:00pm and figured we'd just see what happened. I thought the larger increase should take place at 10:00 like you all said, but I decided to just start with the new one and go from there.

    I think it was a 15% basal increase overall to bring her into a less extreme basal bolus profile. With all the corrections, she had fallen into almost a 30/70 basal bolus percentage. We had parent teacher conferences last night and didn't get out until after 7:00pm, so we stopped and got Chipotle for dinner - so fast food AND eating after 7pm, not a good combo when you are struggling with patterns, but that's life for you.

    We didn't even check at 9:00pm because she didn't finish eating until almost 8:00pm - she was up at 10:30pm and we checked then. She was 198, but was hungry so we added food to the mix (an apple, so pure carbs, again terrible for analysis, but the kid was hungry), I checked at midnight and she was 234 and did a correction as allowed by the pump, checked at 3:00 and she was 164. I was thrilled to see that "1" at 3:00am with little to no effort.

    I'm hopeful that we can use this new profile as a base and manipulate it when needed.

    The letter of medical necessity for the Dex should be faxed in today. I'll follow up tomorrow and hopefully they can run the insurance and get things moving forward with that. I'm good at "gently reminding" people to get things done, so hopefully it will be a short process.
     
  12. missmakaliasmomma

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    Mine is not going through puberty, but we usually see a rise at night between 9pm and midnight. It differs on different days. With her, I see a difference due to what she eats. When she was pumping, nighttime would be her highest amount of basal. In addition to doing what you have to with adjusting the insulin, I'd keep a log of what she's eating and how that might be affecting her BG. My daughter's been on a pretty good food regimen (eating healthier, whole foods, things like that) and her numbers have definitely been better as a whole. However, we don't eat alot of bread, muffins, stuff like that so I think that helps alot, at least with my daughter. She's 5 though, it's easier for her not to eat those things than an older child
     
  13. mamattorney

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    That's way to much effort - LOL. I know which foods greatly affect her BG from repeated experiences and all I do with that information is shrug my shoulders at the numbers that result from it and correct, correct, correct. We joke that cake loves her so much it wants to stick around for 2 days.

    Everyone has different life experiences and I have WAY too much experience with eating disorders and the lifelong struggles that result from them to ever think of restricting a food or food type (or even hinting that eating a certain type of food is bad idea) solely because of what it does to her blood sugar, and if I'm not going to restrict it, then why keep detailed notes? I'll just acknowledge the "big 3" or "big 4" that always affect her numbers and try to laugh about it. It might not be best for her A1C or her potential for long term consequences, but ED's also have long term mental and physical consequences and I'm just trying to balance. You have to remember that my daughter is headed into junior high next year - probably three of the most physically superficial years of her life. My goal is not to add to that. Maybe I'm more extreme on this end than others or even more than I have to be, but as I said, we are all shaped by our experiences.

    We count carbs because we have to in order to accurately dose insulin, but I don't want to go beyond that. No judgment here if any given meal is 80-120+g of carbs. Spaghetti, salad, garlic bread, followed by dessert is OK by me.
     
  14. MomofSweetOne

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    Isn't it hard juggling diabetes with puberty in ways other than just BG issues? It's the WHOLE picture; trying to grant independence appropriately at the same time teen forgetfulness enters and can be dangerous in two different directions of BG, them sleeping so hard that nothing wakes them, trying to turn more and more control over at a time that any concept of trying to manage D takes every speck of what we've learned over the years to try to assimilate into decisions of what is causing what, trying not to focus on food or weight gain because of the risk of diabulemia while also knowing that a focus on food is necessary, trying to guess what on earth is happening in their body and trying to predict messes things up more....
     
  15. missmakaliasmomma

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    Maybe if you keep the detailed notes- even if you're not going to restrict it- you might see that certain foods need more insulin than you would think based on the carb counts. I know that with my daughter, some foods need more insulin even if it only has x amount of carbs. On the subject of eating disorders, I only have experience with my sister who was hospitalized from it. However, we grew up together eating the same things- nothing was restricted from us. Yet, she struggled with an eating disorder and I didn't. I was always heavier than her too. I think so much of it has to do with personality than whether or not you couldn't have a specific food. I do think that in our specific situation, having my daughter eat healthy now will help her make better food choices when she's older and doing her own thing. I'd rather her want to make her own food than go to mcdonalds everyday. I still let her have candy once in awhile & she gets a normal snack for school that any other kid would have. I'd even let her at 5 years old eat an 80g meal once in awhile.

    You might be on one extreme end and me on the other extreme end lol. When it comes down to it, all that matters is we do what we feel is best for our kids.
     
  16. Mish

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    Is't puberty lovely?

    It's pretty much the same for boys, as far as the night time resistance, so I'll chime in and just add that what's worked for us was also raising basals during the day, much more than I would have thought we needed, and only raising the basals at night a tiny bit. It seemed totally counter-intuitive to me, because the day time hours were our best hours and the nights were the problems, but it's really worked well on our end. Overall bg is much, much better, and resistance isn't so horrible at night.

    We're right around a 55-60% basal now, where before, 30-40% has always worked. And, we reduced down to just 3 basal rates for the whole day. And...we've extended insulin duration (on apidra) to 5 hours. We've seemed to have broken a cycle of high to low to high to low to high to low. I think a too low basal was making the insulin duration appear shorter than it really was. And, our day time numbers really aren't that much lower than they were before, but everything seems to be working ...better.

    Hope any of that helps.
     
  17. mamattorney

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    I am going to file this away for the future - especially for summers. I can actually see how having a higher basal than you think you need can "take the edge off" the work of the bolus insulin and prevent resistance - especially if you've got a kid who is eating frequently and you've got bolus insulin working more often than not, which sounds like the definition of a teenager to me.
     
  18. mmgirls

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    Well you will only know what true duration is if you test it.

    But I have to say that I have never seem anyone have duration for Apidra be more than 3.5 hrs.
     
  19. Mish

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    Well, now you have.

    I've seen plenty of people 'complaining' about apidra's weird tail. The literature seems to indicate that while apidra works faster (which is why it's so good for spike issues) it lasts as long as novolog / humalog. AND, most of the testing compares apidra to 'regular' insulin, not novolog/humalog. This is apidra's OWN prescribing info where they show the duration - look how long it lasts, even though the lowering ability is negligible after 4 hours, it's still hanging around with a weird tail: http://products.sanofi.us/apidra/apidra.html#section-13 and since most current pumps use a curvilinear method for calculating IOB which takes that into account, it seems silly to set the DIA to a too short amount.

    But, for us, in real life action, I can see clear indication that it's at least 5 hours, maybe even 6. But, the thing with testing fast acting is that you don't know if you're also testing a bad basal issue or testing the bolus. The only real way to test it is in a hospital setting.

    John Walsh has a lot to say about cutting duration of insulin time on pumps :
    http://www.diabetesnet.com/about-diabetes/insulin/insulin-action-time/duration-insulin-action
     
    Last edited: Nov 8, 2013
  20. hawkeyegirl

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    You just HAD to post that article and get me questioning our DIA, didn't you, LOL? :p

    We use Novolog, and I confess that our DIA is set at 3 hours. I really never have seen much indication that boluses affect his BG for longer than that time (a really large bolus might, however), but who am I to argue with John Walsh and his research? :) I can't imagine the massive retooling we'd have to do if we set the DIA to 5 or 6 hours, however. But I will keep it in mind if everything goes all to crap and we have to start from scratch at some point. It is interesting, because virtually no one does set their DIA for that long.
     

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