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Should we worry about short term highs?

Discussion in 'Parents of Children with Type 1' started by dk10, Dec 11, 2008.

  1. dk10

    dk10 Approved members

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    Our 9 yr old daughter was diagnosed with Type1 6 months back.

    My husband and I are both very involved in managing her diabetes, but we sometimes disagree on the approach.

    While he agrees with me (theoretically) that we need to avoid the lows more actively, he gets pretty upset at the occasional high. I've added an evening snack (2-2.5 hrs before dinner) in the last month+ to her routine, which sometimes causes a high just before dinnertime. He's really uncomfortable with this due to the long term implications of organ damage and so on, and wants me to cut down on this snack. I don't want to because:

    1. The bg will remain high (170-250 range) only for a very short time - 30 min- 1 hour, because she soon gets the dinner rapid acting dose.
    2. She was earlier getting lows about an hour after dinner. We couldn't fix this even though we played around with the insulin dose timing. This way I think she has less chances of getting the lows.
    3. She's been looking a little thin and peaky of late, and the endo and dietitian are both comfortable with her eating more.
    4. Anyway, she's going to have mismatches of insulin and sugars for short periods (because of not being on the pump, and general unpredictability).
    5. her A1C improving and bg being in the 75-80% normal range most times, even after we introduced this snack

    Since I'm writing this post, I've obviously heavily weighted my side of the argument! But what I want to figure out is - isn't there almost always going to be some mismatch in the insulin/bg, and therefore should we worry about this one high so much, particularly if this is happening only 3-4 times a week or less?

    Please advise!!

    More details below for those with the patience to read through:

    We have a non-typical insulin regime for her because of long schooling hours, lack of trained staff to give her insulin at school (it's not mandatory in my part of the world, though her school's been incredibly supportive otherwise), relatively low insulin dosage, and non-availability of insulin which can be administered in fractional units. We know moving to the pump is the right answer, and we plan to do that over the next 6 months.

    These are her test numbers:
    A1C at dx 9.9
    3 mths later 7.4
    6 mths later 7.0

    We currently test her 3-4 times a day, mostly before meals. 70-180 range considered normal. In normal weeks (when she's not down with a cold/fever, and we're in town, eaing most meals at home) we typically find about 75-80%of her readings in the normal range. Of the non-normal readings, about 5 will be high, usually sub 250. 1-2 lows. She's not on the pump yet, and currently on 5 units of a 70:30 mix in the morning, 2 rapid-acting at dinnertime and 2 long acting at bedtime.

    Also, if she's high after her evening snack (for which we haven't been giving her a bolus till now) he will play/make her play for a long time to get her sugars down. She's also tended to be very tired perhaps because of the long playtime after a long day at school.
     
  2. momtojess

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    You will probably get a mixed response to this question.

    Personally, we have always been told that a high from a food spike that comes right back down is normal, and that it is sustained highs that can cause the complications.

    How long after lunch is the snack? Is there anyway you can bolus for the snack with the lunch? This would require she eat the snack at a certain time before having the chance to go low, but it would probably prevent a spike since it is basically feeding the insulin.
     
  3. BozziesMom

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    I would kill for numbers and A1C and in range percentages like that. 7 A1C is outstanding. And 250 is your highest that you visit during a spike? Wowie.

    I have no input on "who's right" but I will say I can only dream of stats like you have. And I try very very hard.

    I guess my point is, it looks like you're doing a great job. I don't know.
     
    Last edited: Dec 11, 2008
  4. buggle

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    Have you thought of switching to MDI with Lantus? We're able to get pretty good control (most of the time, anyway) and on the days she wants to eat more, this might help. Some of the parents overbolus and give a snack after a meal, when is then covered. When Wilf checks in, he'll be able to give you some good advice to tailor her insulin to her food.

    I'm in the camp with your hubby about trying to keep BGs down as much as possible. But I agree with you that she needs the snack. You can probably get it worked out where you do both. My hubby and I both really involved too and we end up in some battles when we don't see eye-to-eye on management. But... in the end, some of our compromises have created some good management ideas that were actually better when we combined both approaches.

    My son hasn't been diagnosed much longer than your daughter, but we found him getting some fatigue early on. He was honeymooning really strongly at that point and wasn't on much insulin. We found that he needed more food and more insulin to use it better, so wondering if this is the case with your daughter too. Have you considered a CGM? We started on one a while back and though it's a pain in many ways, the info is so valuable. You can see where the problems are and how trying different things works. For two parents trying to figure out the best way to manage a kid, you can sit down and look at the graphs together and see what's going on with your child and then start tweaking things to improve control. I really wish we'd gotten one months ago... but my husband wasn't on board (arghhh). :p
     
  5. buggle

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    Alyce -- toddlers are a totally different ball game than big kids. I can't imagine how hard it must be to manage a toddler. I'm sure you'll be getting much tighter control when the BozMan is a few years older. By the time he's the age of Brendan, I'm sure he'll be incredibly well-controlled. So, stop being so hard on yourself.

    <Threadjack over...> :eek:
     
  6. Sarah Maddie's Mom

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    Yes, high bg causes damage. How much and how long does it take? It depends on who you ask. But post meal spikes and the periodic unexplained high due to stress or illness and the times when insulin need outpaces insulin dose but before the dose can be adjusted all result in highs. And I think your dh needs to accept that dealing with highs is just part of living with D. 6 months in and she's most likely still honeymooning and in time you will probably see even greater swings, even with the pump.

    I guess my advice is to test more often so that you have a better picture of her patterns during the day and really importantly, to make sure that your husband doesn't share his frustration about the high bg numbers with your daughter.
     
    Last edited: Dec 11, 2008
  7. Kalebsmom

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    Kaleb was dx almost a year ago and there will forever and always be times when things just do not do what you want them to. We can weigh and measure everything and dose accordingly and he can still have high numbers in the 300's.

    He never used the same insulin regiman as your daughter, but it sounds to me like everything is going well.

    I understand that your husband may not like seeing the high numbers but it happens and will continue to happen. Kaleb's numbers change with the wind it seems.

    Just make sure that you never show the disappointment with the highs. I found out the hard way the kids taje it personal.

    Best of luck
     
  8. Hollyb

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    Brace yourself -- with the end of the honeymoon coming and then puberty on the way, you are likely to see more high numbers, often for no apparent reason. You really have to learn to roll with them. Correct, figure out the reason if there is one, move on. One of the reasons teens can start avoiding testing or faking their numbers is because they feel their parents blame them for highs and yet even when they are trying hard, highs happen.

    The other thing your husband needs to understand is that your daughter is likely already getting these short-lived highs, an hour or so after meals -- you just aren't seeing them because you are testing after the insulin has worked its magic.

    When you have a pump you will be able to easily give insulin for snacks and that will minimize those between-meal highs, but not eliminate them -- it still takes time for the insulin to work.

    Your daughter's A1c has come down nicely so it looks like things are going well. Perhaps this is something you should both talk to your endo about?
     
  9. dk10

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    Feeling better already

    The heavy snack is a good 4.5 hours after lunch so we can't bolus with lunch. (She has a lighter snack 3 hours after lunch). MDI with Lantus is something we're toying with, but it can only work for the evening - we still can't change the morning mix because of school issues. It isn't the most efficient way to manage it, but we're living with it for now.

    Typically, the highs due to the evening snack range from 190-270. They last about 30min-1 hour.

    buggle - we weren't sure about CGM because we heard it isn't that accurate and you need to do the finger tests anyway. We were thinking of moving to that with the pump. Sounds like we should re-think this and maybe get it earlier.

    Alyce - we get much greater highs when she's not well or we are on holiday and eating out. These are just the evening snack highs we know about. She gets highs at night which we don't have a handle on yet - I stopped measuring because it was so distressing. And like I said, I was weighting the argument in my favour!

    As for keeping our frustration at the high numbers away from her - I have to get my husband to read about this. He just doesn't see it. Yet, I'm hoping. He's been great in helping understand the numbers, so I shouldn't complain too much.

    Thanks for all the advise.
     
  10. buggle

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    We've had BGs on CGM within 2-3 points of finger sticks lately. If the BG is changing super fast, it will lag behind, but you can make a good guess as to what it is by looking at the trend.

    The one thing to keep in mind in all of this is that no matter what you do, your daughter will have high BGs. It's hard to accept and it's scary to worry about their futures, but we can't control every BG all the time because there are so many different factors involved in this disease that no one can perfectly control it.

    It sounds like you're doing very well and that she's under decent control. We all strive to do better and as long as we can keep trying without causing serious emotional upheaval, I think we should keep trying. But we all have to be realistic about what we can actually achieve. That's the hard part.

    If you want to talk more about CGM, I'd be happy to tell you our experience. Feel free to PM.
     
  11. Connie(BC)Type 1

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    Looks to me like you're doing a wonderful job.
     

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