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So confused!!

Discussion in 'Parents of Children with Type 1' started by ashadams, Aug 11, 2011.

  1. ashadams

    ashadams Approved members

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    Hi everyone. I am so confused at this point, so I'll tell you all a little bit of what's been going on...

    My son, Javeyn, is 3 and we found out about 3 months ago that he has T1. So, I pulled him out of daycare so that me and his father could try to learn as much as possible and try to get him on a schedule. This past Monday he went back to the daycare and he will be starting school next week. Since he has been back there his sugar has been all over the place! He has been waking up with really good readings, but then before lunch he has been extremely low (between 65 and 80) and then about 3 hours after lunch when he wakes up from his nap he has been very high (200-345). His schedule has changed because he now has to wake up very early and start off his day with breakfast way earlier than before when he was home with either me or dad.

    I am just very afraid of those lows because he is only 3 and he doesn't really say that he is feeling bad or hungry to the staff at the daycare. I called his doctor on Tues. and she adjusted his insulin dose also. She said it takes about 2-3 days to start working. She reduced the amount of Humalog he will take in the am before breakfast, but I am worried that it's still not enough. And then after lunch he is really high, so I am wondering if we should increase the amount of Humalin he is getting before breakfast. (He does not have a shot before lunch or dinner. Next shot is not until 9pm.)

    Any suggestions would be greatly appreciated! :confused:
     
  2. Lisa P.

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    So he's getting Humalog and Humulin both in the morning, then Humalog again with dinner? And when does he get Lantus (or Levemir?).

    I think a lot of folks with very small kids in the care of others sometimes need to change the system them use, rather than just the dosages. When he is home with you and there aren't other children in your care, you tend to make subtle adjustments based on how the day is going that may be hard for a daycare worker to make. Also, changes in schedule and activity level and types of food eaten can contribute. Your son also may be honeymooning.

    If you post an example day with which insulins, how much, and what activity and food he has all day and night you're likely to get some more specific and helpful advice. I'm personally not good with that kind of record keeping, but it's very hard to give good advice based on generalities when you are looking at specific lows and highs.

    Best to you figuring out what works for your son.
     
  3. Helenmomofsporty13yearold

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    I don't have experience with a child that young, but I would guess that the highs are a "rebound effect" from being low. As much as some other posters on here are comfortable with lows, our clinic sets 2 or 3 a week as the goal. All insulin changes should be given a few days to look for a trend. I recommend you do not chase the highs without your doctor's consent. I may be your child needs more of a morning snack to keep from going low before lunch. The honeymoon period is brutal as the pancreas is not consistent in how much insulin it is still producing and you will have lots of dosing changes.
    To make you feel more comfortable please try to read about how young children are protected from long term diabetes consequences during the first 5 years after diagnosis and I believe this is even more the case in younger children. Also, sometimes its easier during the honeymoon to get the kid to be a little more active and drink lots of water to bring down a high.
     
  4. zoomom456

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    My son is also 3 and in daycare, so I know it is not easy to manage D and daycare. First thing to do, if you haven't already, get a written schedule of your sons day at the daycare. Look to see if he plays outside before lunch causing his low, what time does he eat lunch and is nap right after lunch. How long does he sleep on average? Is he getting tested 2-3 hours after lunch or is he a light sleeper and tested before those numbers have a chance to come down? I figured out a lot of trends once I brought my sons exact schedule home and compared that to his logbook. Then I was able to troubleshoot a little easier.

    Second thing I would do is find out if the daycare is willing to train and do any shots. This can be very tricky since some daycares are 1)privately funded or 2) associated with a religous entity. If your daycare does take federal funding, they must give insulin. If shots could be given at school you might be able to try a different insulin regime that would be more flexible to his schedule.

    When William was diagnosed we tried an NPH regime because the daycare would not do shots and we had no recourse since they are religously affiliated and do not take federal funding. Nph (Humalin) did not work for us. We were able to get the daycare to use a pump and now have a manageable program for daycare and home. I don't know if a pump would be an option for you, but something else to consider.

    Good luck! Let us know what works out!
     
  5. danismom79

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    Is he on NPH (Humulin N)? If so, my first guess is that the peak is coming too soon, and then not carrying through to cover his lunch. Did you change the time of his doses based on his new schedule? Can you post a day of times, doses, and carbs?
     
  6. Amy C.

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    Welcome to the forums.

    It is scary to have a change like this and have to make all sorts of insulin adjustments, but this happens to every child who starts school.

    Is your son is on NPH and Humalog? When does he get his shots and how much insulin does he get each time?

    How many carbs does he eat at a meal?
     
  7. selketine

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    Humulin N is NPH right? I'm really bad on knowing my insulin names. :p I am assuming she means NPH instead of Regular in the morning along with the Humalog.

    My son William was dx'd at 26 months and started out on NPH and diluted humalog. He could not use lantus (or any 24 hour basal insulin) because at first he did not need any overnight basal insulin.

    In my experience, I hated NPH - because I could never predict when the "peak" would hit for lunch. It sounds like he is getting the peak too early for whenever they serve lunch so he is going too low. My guess is then he is getting some carbs to cover the low to hold him until lunch. Then he is getting lunch. Lunch is supposed to be covered by the NPH but the NPH can't cover both the "correction" and lunch so he turns up high in the afternoon.

    I realize you are probably trying to minimize the number of shots he is getting but it seems you would need to adjust his lunch time earlier - if I was right on the correction carbs - or make some changes to the insulin.

    What is his 9PM shot - is it NPH? If he needs a basal insulin around the clock then I'd switch to a 24 hour insulin like Lantus. This will mean more shots to cover anything he eats however. NPH still has a peak in the middle of the night you know - so your child could be having lows at night. Since kids don't eat lunch in the middle of the night - this is a problem. I honestly never could see how people could deal with giving their kids NPH at night at managing that peak which will hit at 1am or so. Are you testing in the middle of the night? NPH scared the heck out of me for night time use - I switched to lantus as soon as I could after he needed an overnight insulin. We started pumping 6 months after diagnosis.

    Another parent on here has made NPH work for them - Wilf - you might try to look up his user name or old posts and send him a message. I'd rather pull out my fingernails with tweezers and rusty razor blades than use NPH on my child but some people have made it work and he is one of them.:cwds:
     
  8. Nancy in VA

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    Did he nap at home with you, or is that new at daycare? When Emma was 2 and we were going through a really weird pattern of numbers, our CDE finally realized that when Emma napped, she ran higher than if she didn't nap - we found a 2 week pattern that was almost pretty spot on with that. It seemed her insulin needs were significantly lower when she napped than when she didn't.

    Now, we were moving to pumping so we just set variable basal rates, and you can't do that, but it might help explain the numbers.

    Also, while 65 to 80 is low, that's not extremely low. Sounds like a small carb snack (5-10g carbs) would help keep that a little higher.

    Any change in routine is going to result in chaos with the BG numbers for a while - you'll start seeing a lot of threads with that theme as people start going back to school here in the next couple of weeks.
     
  9. Lisa P.

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    If Carol is on track about the timing being off on the insulin then this could be a big factor, we were taught when Selah was diagnosed as a toddler to treat a low under 70 with 15 carbs. For a little one, this can be a huge overtreatment that could result in a 300+ every time. So if the care personnel are using the standard "15 carbs at 70" rubric they may well be overtreating as well.

    Sorry about the insulin -- I thought NPH, Humulin, and Regular were the same insulin, with a 6 to 9 hour duration! That little bit of ignorance on my part should help you evaluate how helpful my advice in general is! :eek::p
     
  10. zoomom456

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    Hahahaha, I'm with you here!:D
     
  11. ashadams

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    Thanks everyone!! Ok - so some more information:

    I do have a schedule from the daycare. He arrives at 6:30 am, I test his sugar and give him 1-1/2 units of Humalog and 4-1/2 units of Humalin. He eats 60 carbs for breakfast. Between 8:30 and 9:00 am he gets 1-8oz cup of milk for snack (which was recommended by the doctor). He plays outside for about 30 min before lunch. At 11:00 am they test him again and he eats lunch - no shot at this time unless >300. He then takes a nap and they wake him at 2:00 and he gets tested again. He then has a "free snack" at this time. Around 4:00 they test him just to be sure that he isn't low since he hasn't had any carbs since 11:00 at lunch.

    I know with him being so low at lunch, and sometimes 30-40 min before lunch, that his body is reacting with a high after nap time. I just spoke with his doctor and they reduced his morning dose from 1-1/2 units of Humalog to 1 unit and keeping the Humalin the same.

    He has always taken a nap, wether home or now at daycare. He only gets a shot before breakfast and again at 9PM. He is only on Humalog and Humalin. He gets 60 carbs for each meal and 15 carbs for each snack. Snacks are two hours after each meal. So, he eats a meal then snack two hours later, then meal again two hours later. The doctor wants him on this schedule, but since he is back in daycare and school, his times are a little longer and she said that it was fine?

    From what I am reading, a lot of you don't like the NPH! I guess I'll see how this all works out over the next week or two and we might be making a change! Thanks for all of the input! It really helps figure this stuff out.
     
  12. selketine

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    I'm still guessing the Humulin is NPH so...

    I think the NPH is kicking in sometime around 10 to 10:30. When it kicks in your child will drop like a rock and needs lunch. William was on the same regime you have and would run a lovely 400 until sometime between 10:30 and noon when he would have an amazingly swift drop. He once went from 425 to 60 in less than 30 minutes. Eating lunch was an emergency with him and it never came at the same time every day.
    "
    I would not have known how high he was in the morning or how swiftly he dropped except I tested his blood glucose more than you'd probably ever want to test your child.

    NPH has a high variability rate. If you read John Walsh's book on Using Insulin he says that:
    "The activity of older basal insulins can vary as much as 25 percent from one day to the next. For instance, a 40 unit injection may have an effect equal to 35 units one day and 45 units the next."
    So not only does the insulin peak at random times - it acts stronger one day and weaker the next. Because of this - you can never know exactly what it is going to do.

    I'll again note that it is also peaking in the middle of the night. In the day you feed lunch but at night - it was not uncommon to have severe lows with NPH at night. This is why - back when more people used NPH - that there was so much talk over "bedtime snack" and using corn starch as a slow releasing carb source that helped keep numbers up overnight. We had to give William a drink yogurt with corn starch to keep that peak from taking him low.

    I hope you find some answers. I highly recommend the Using Insulin book - and of course talking to your doctor about getting off NPH and going to MDI or a pump. In the meantime - track down Wilf. I think he knows more about using NPH, regular, etc than any doctor. :cwds:
     
  13. Tigerlilly's mom

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    With the lows before lunch it sounds like the Humalin is kicking in before he is having lunch. Anyway to have a bigger snack in the am or to have an earlier lunch to prevent these lower bgs?

    Humalin (NPH) worked well for my son for the two plus years he was on it. I am sure that not having the daycare do a lunchtime shot is a huge bonus that comes with using NPH...and may well be worth spending the time "fine-tuning" how many carbs and when he has meals and snacks.
     
  14. Amy C.

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    This is what happened with my son. NPH kicked in about 4 hours after I injected it. As he grew older and lunch later, this wasn't working.

    I would say your son needs most of his lunch at his snack time and his snack at the time the other kids have lunch.
     
  15. ashadams

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  16. ashadams

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    You're right that 65 to 80 is not extremely low, but for my son's body it is. For some reason, when we first found out that he had T1D his sugar went as low as 52 and his body reacted to it. Now that he has been mostly on the high side rather the lows, when he gets down below 80 his body really reacts! He is very shaky, tired and just cries because he doesn't know what's going on.
     
  17. wilf

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    An NPH can work, but it's not for everyone. Let's see if we can sort some of this out.

    For starters here's some questions for you:

    1) How much does he weigh?

    2) What are his bedtime and waking numbers like?

    3) What shot does he get at 9 pm?

    4) Posting the numbers from a typical day would be very helpful, and is most likely to get you some good input.. :cwds:
     
  18. SarahKelly

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    I just wanted to echo some other post about nap leading to highs, we see it across the board with our son that when he lies down his digestion slows, his insulin needs rise and his BG rises, too. The insulin pump helps with that, but since that isn't what you're asking my other advice is to make sure that the lunch they're serving isn't too high in fat, higher fat meals for my son right before sleep lead to a lot more of an increase in BG than meals that are on the lower side of fat intake. I don't know exact numbers, I just know that for us foods with high glycemic index are easier to dose for as they seem to rise with the insulin, but those high fat/high protein meals cause longer slower amounts of needed insulin often leading to highs if not dosed properly.
    Does that make sense?
    For example pizza, macaroni and cheese (not Annies though!), and grilled cheese are often very difficult on his little body before naps. We tend to have a lot more snack type meals that are more even on his BG before naps - hummus and veggies, whole wheat pasta with grated parm cheese, lunch meat rolls, mini wheat bagels with cream cheese, fruits, soy yogurt...etc.
    So...just another idea, that it may also be a change in food at daycare than at home, maybe :)
     

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