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Question about lows

Discussion in 'Parents of Children with Type 1' started by mikegl31, Jan 4, 2017.

  1. mikegl31

    mikegl31 Approved members

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    I had our quarterly endo appointment yesterday, and while I love my son's endo, I left the appointment very frustrated. They feel that he is having too many lows (he gets down into the 60s a number of times a week). They also feel that my wife and I are doing too much work in that we utilize temp basals a lot on the pump and shouldn't be doing that. I'm willing to listen to everything they say and give anything a shot. He did have an A1C of 7.0, so I feel like we are doing something right.

    Anyway...as fate would have it, and to prove their point I suppose, my son drops to 55 at the appointment...great. So I give him a 15 carb juice box. They were very concerned about the low and wanted me to check him about 8 minutes later...he's now 62. They tell me I should give more carbs, so they produce glucose tabs. I would have waited a little longer, but I didn't want to seem difficult, so I give him 2. They also tell me I should suspend insulin delivery on the pump. I told them that I wouldn't suspend insulin delivery at this point, especially being that he has now had over 20 uncovered carbs. They also wanted me to give him a protein bar that I carry around to help stabilize the blood sugar. I got a little frustrated at this point, and told them that if I gave him 20 uncovered carbs, suspended insulin delivery, and gave him an uncovered protein bar, that he would be in the 300s by the time I got home. Their response was - well, that is our recommendation for covering lows, and giving some protein is a good idea. I told them that I understand all of the theory and really appreciate their input, but that real life does not always mirror what theory says. My son was 135 10 minutes later - however, they said that they would be concerned that he would drop again because the juice and the tabs were just a temporary fix. The nurse, or diabetes educator, told me that I should really watch my son in the car on the way home just to be sure he doesn't drop again....I told her I would make sure he is okay.

    I got home and was really frustrated. I told my wife maybe we are approaching things the wrong way, I don't know, and maybe we aren't as afraid of lows as we should be. We always treat the lows and move on. They made such a big deal out of it at the office, and that is really unlike what we do.

    Am I wrong in how we treat the low?
     
  2. Manuel

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    Hi Mike, from my experience Doctors have the tendency to care more for short term (lows) than long term and parents usually are more concerned for long term.
    My son has 2.8 years old. Last month we started with omnipod, before that, with MDI he use to have 1 hypo lower than 60 per month and a A1C of 7.1.
    When we started with omnipod it rised to 2 lows (in the 50s) per week, until we set the correct basal (it took us around 1 month to catch it right), now we have occasional lows (1 per month or less).

    At the end is kind of personal opinion. For example, I hate lows. So if he is trending down (120 with a diagonal arrow down) I give him half tea spoon of caramel syrup to stop the drop. And usually it stops around 100 and stays there. From the other hand, my wife waits until he is in the 80s to do the same, and usually he has more lows (under 70) with my wife than with me.

    There are studies* indicating that lows (under 60) in small children can impact they learning and memory in the near future (5 to 10 years later). So, that's why I have fear to lows. I don't know if in this studies, they were referring to prolonged lows or just short time lows but several of them or both.

    In my opinion, having Dexcom and Omnipod, lows under 60 should be something occasional. The technology allow that. If he is having lows (under 60) every week maybe you should test his basal and boluses. Using Dexcom and Omnipod he can have the same A1C without the lows.


    *Here is the link to the study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518367/

    -----------------------------------------------
    Son dx at 2 years old, June/2016
    Omnipod + Dexcom G5
     
  3. mikegl31

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    Thanks Manuel. I am going to do a basal test to see what that looks like.
     
  4. Snowflake

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    I agree with Manuel's answer. The effects of frequent lows on brain development worry me, and worried me even more when my dd was a little younger.

    I see where the nurse was coming from big picture, but it sounds like you were in the right about treating this low. The classic approach is 15 carbs and wait 15 minutes, and it sounds like they were too antsy to follow their profession's own guidelines! That is very frustrating that the nurse seemed to have no idea what diabetes management is like in the real world.
     
  5. mom24grlz

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    We recently switched to an endocrinologist closer to home. They made us redo diabetes training to prove that we know how to treat lows, give insulin, test BS. She's been diagnosed for 7 years this march! Anyway they were pretty insistant on the 15 carb 15 minute rule. And got upset when we said we don't follow that. But like i tried to tell them every person with diabetes is different. 15 carbs-15 minutes does not work with Ashleigh, most times. A lot of times she needs closer to 30 carbs, and I've found if i wait 20 minutes it's better (she'll continue to rise after 15). So no i would not have tested after 8 minutes. Because at 8 minutes we probably would have seen very little rise in BG levels. Ashleigh is MDI, but when she pumped the only time we suspended was if she had a stubborn low that was taking 40+ minutes (2 treatments) to come up.
     
  6. Theo's dad Joe

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    Just thoughts.

    1) We were told not to suspend for mild lows. (if the child could talk and drink juice or eat a tab)

    2) We also typically use 6 grams of carbs for a mild, slowly dropping low, or to avoid one that is coming, but we see the curve on the dexcom.

    3) We have been told that for kids under 50 pounds, 7.5 grams of fast carbs is now the standard. (maybe its 40 pounds). Out of honeymoon we see 7-10 points per gram and my son is 57 pounds.

    4) I have had times where I have given 6-12 grams and he continued to drop and needed more, though based on Dexcom we are only in the 60s about 2-3% of the time. We were told that 8% low or less on the Dexcom was considered to be good. With 2.4% low the software rates his hypoglycemic risk as "low" (Without a Dexcom I would probably give extra carbs, 10-15 grams at least at 55 not knowing what's going on.

    5) Get a Dexcom

    6) It may be true that fast acting carbs give a little falsely high spike which settles down. For example, if my son is at 68 and flat, and I give him 6 grams of fast carbs, I expect to see about a 40-50 point rise to 110-120 range, but he will often register by fingerstick and dexcom with a spike in the 130-150 range, but then have it back down to 110-120. I have been told that this is because the fast acting carbs tend to get to the periphery of the body first-skin, fingers, and then spread out more evenly throughout the extracellular fluid of the body, so I think that the idea that fast carbs are temporary may be due to this phenomenon.

    7) We almost never do a temp low basal after the fact or on the way down to catch a low. I tried it and it is too slow. It takes 30 minutes for us to see any slowdown of a drop and then we get a spike 90-120 minutes later. A 4 carb gram slice of banana is going to have the same effect as an hour of zero basal for us (30+ points) and is going to happen much faster. I think I would only use a temp low basal ahead of time if there is going to be increased activity. Even at school if he drifts under 80 with an hour until lunch, I am not going to run a temp 0% basal for a half hour because it won't even work until after lunch and then we have basal off board at lunch when we calculate. I have suspended insulin at a higher level at night when he had been vary active, like if he hit 90 and was drifting down.

    8) Overtreatment just raises the need for more corrections which raises the chance for more lows. Overtreatments therefore IMO don't reduce the risk of lows, they raise it.

    9) I sometimes treat mild lows, or downtrends with extra carbs, and follow with a bolus at 15 minutes or when the dexcom is clearly showing an uptrend.

    regarding the specifics, If my son was at 55 without a dexcom and I gave 15 grams and 8 minutes later he was 62 I would not give more carbs. I would check again in 10 minutes. It would also depend on if we were still in a mealtime bolus window or drifting low from basal. I believe that the dexcom probably results in at least a 1.0 lower A1C, and maybe 1.5 because of how I would manage him without one. I would have him running at least 25 points higher. With the dexcom I have seen drops that don't turn around with carbs. I have seen a 200 point drop in an hour with only .5 IOB that laughed at 15 grams of juice. In the case you described, it would depend largely on when he had his last bolus and how large it was and even the time of day. When was the last meal bolus? Dexcom shows me that our basal is within +/- 20% or so during the day.

    The truth is though, the meaning of lows depends so much on the time of day, the meal, the bolus pattern, the activity level. I don't know how people ever came to learn this stuff without a dexcom. My son just ran flat 95 for 4 hours after breakfast this morning at school, but I can tell from his pattern that he is not going to go low before he gets to lunch. Sometimes he goes up much higher, but comes down faster. If I didn't have a dexcom and I just did a 2 hour check and got 95 with 1.5 IOB I would probably give him nearly enough carbs to cover that IOB, at least 10 grams.
     
    Last edited: Jan 5, 2017
  7. MomofSweetOne

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    I read your post to my daughter who was laughing and saying "YES!!!" as she was brought 15g of juice at an endo appointment when her BG was 90. She didn't use it. :)

    Our goal is 5% or less lows on Dexcom without severe lows. We like to avoid the 60s if possible because those put the body under stress that it doesn't need to be under with the help of the Dexcom. We'll bump lines trending that way up with small amounts of carbs.
     
  8. kim5798

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    The medical professionals do not have as much "real life" experience with diabetes as you do. In the early years, I would get so upset with situations like the one you described. YOU and your family are the ones living it day to day. They have no clue. They lecture and make you feel like you are the worst parent in the world, when HELLO! you are keeping this child alive & well, being their pancreas in addition to all the other parts of raising a child! That you are here looking at info on how to care for your child's diabetes is evidence of that. You have to remember, you are most likely the exception when it comes to parents caring for children with diabetes. Many kids do not have parents who do research, read, test like crazy, look for the latest technology, etc. Some just do the basics & move on.

    You have a pump & dexcom. You KNOW how to read the numbers & how your kid usually reacts. Smile, nod & do what they say at the visit & then do it your way. You will be saner for it!
     
  9. WestOfPecos

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    Hi Mike-

    My son is 12, with a Dexcom and MDI. We would have approached it EXACTLY like you did. As I was reading your post I was thinking - we would have done just the same (different numbers, same spirit). We are teaching our son to microcarb. Imho, the 15-15 one-size-fits-all rule is for new parents. Once you have learned a bit more about how your child responds, a more custom strategy can also minimize carbs.

    Of course, with a fast-moving low, things are different.

    I did some quick research a few days ago. So far, research shows that lows do not have a long term effect on the brain. What I seem to have found out is that nurses and endocrinologists who are not T1Ds themselves are missing a lot of the knowledge that we have. Someone wrote to me recently: in diabetes, the patient is the PCP. Pretty true.

    Maybe the wrong endo practice for you? Or possibly you can ask for a specific nurse who understands your practices better?
     
  10. barbiduleny

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    Couldn't agree more with this: We are lucky to have some T1 NPs and Endos in our practice and we have been naturally gravitating towards them as primaries, they just 'get' the fact that the reality of diabetes is that treatment needs to be completely individualized, they don't judge and the adjustments are more suggestions than orders. Might be worth considering another practice or another NP / Endo...

    As a side note, i find it baffling that they would recommend suspending basal on the pump as a regular thing to treat a low: by the time that suspend actually has a meaningful effect, it's been an hour and half. Seems like a recipe for bouncing back to a high and getting stuck in a pattern of highs and lows.
     
  11. Snowflake

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    I totally agree with this. We do sometimes suspend in extraordinary circumstances -- for example, if dd is sick, low, and having a hard time eating, and we've been trying to get her bg up for a while with no success.

    Suspends take a LONG time to affect the bg and then, when we do start to see the effect, as often as not it's a rocket high that is hard to bring back down. Suspends are not a day-to-day management tool, IMO.
     
  12. Snowflake

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    That study was of teens and adults.

    I do recall that there are a fair number of studies show subtle cognitive differences in very young kids who experience frequent lows. Some of these studies aren't that helpful for assessing the impact of frequent mild lows, since they only look at severe lows and seizures. And I'm not sure how applicable studies from the pre-CGM era (that assume a lot of undetected hypos in the little kid population) are to families that manage small children with CGMs nowadays. However, the evidence is worrying enough that this brain development issue is pretty much the first thing our endo brought up at our then-2-year-old daughter's first clinic visit after her diagnosis.
     
  13. samson

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    Wow, your endo team seems way too aggressive about lows. We came home with the protocol of treating with 4 g, waiting 15-20 minutes, retesting, and repeating. Our son is a toddler. 15 g would send him to the stratosphere.

    Also, in general I think endo teams are too focused on avoiding lows. My guess is that's because they got their training before CGMs were widely used or understood. Without a CGM, a person can be low for hours without treatment, and the risk of seizures is much higher. With a CGM you can head off most lows almost completely.

    Very few studies have looked at the impact of brief, mild-to-moderate lows as documented on CGM. One small study found moderate, frequent lows may be associated with disordered nerve conduction to the heart, but I think it used finger pricks to confirm lows. Other studies show mild cognitive impairment in very young kids experiencing frequent lows. But again, those weren't with CGM if I remember correctly. It's hard to map between, say, 3 lows a week that are shown on CGM and total less than an hour, and two finger-prick lows that mean a person could have been even lower for many hours and just not known it. Also, the CGM in our experience frequently overstates the lowest of the low. Maybe the lowest our son hits on finger-prick is 55, but CGM says 40 for 20 minutes.

    And keep in mind that kids running elevated A1Cs -- even those below the 7.0 guideline -- show brain abnormalities and subtle deficits in learning and memory in tests as well. So it's just a crummy tradeoff we all have to make. If only there was a way to protect our kids from all these complications -- we need faster insulins, better treatments and a CURE!
     
  14. wilf

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    You are doing fine and the medical professionals you were dealing with come off as a bunch of nervous nellies.

    In Germany where we got our training parents are told that if your child doesn't get into the 50s at least once/week that you are running them too high.. :cwds:

    There is no known issue regarding lows affecting brain development. I should note that as a distance runner I went low on a regular basis in my high school and university days with no effects on my brain.

    By comparison, there are well known complications that arise from too-high blood sugars.
     
  15. rgcainmd

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    I'm a firm believer in the above.
     

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