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What is your child's target range?

Discussion in 'Parents of Children with Type 1' started by Shopgirl2091, Aug 27, 2014.

  1. sszyszkiewicz

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    mertdawg there are lots of things you obviously do not understand.

    First of all you should not be poking your child to satisfy your curiosities. Why would you ever, ever, do another fingerstick 20 minutes after a prebolus? Second, for as smart and learned as you are, i mean you have read thousands of pages by your own admission about t1d, you would think by now that you would know that if your child has a reading of 100, the actual number is somewhere between 80 and 120, and that assumes perfectly clean fingers and no screwups on your part doing the test. Strips are +/- 20% in that range. they tighten up the tolerance at 70 and below, but your question belies a fundamental ignorance on how accurate the tools we have actually are.

    so really, and this will sound harsh, stop experimenting on your child and perhaps bring yourself to read practical books on the management of t1d in children.
     
  2. Theo's dad Joe

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    The reason I checked my son after 20 minutes is because the doctor told me to move the bolus back farther to 25 or 30 minutes (knowing full well that he is in a honeymoon, with A1C under 6 within 10 weeks). She even suggested upping his bolus because he was sometimes over 170 90 minutes after breakfast (which it now looks like is pretty good). I had seen him actually with better numbers with less insulin at dinner and didn't trust that moving the bolus back was going to improve his peak. I tried to explain to the doctor that with a low GI meal he may be going low and rebounding.

    For all of her fear of him going low-she told me that if I ever found him under 130 at night I was to feed him!-she didn't have a clue that humalog may be faster than a low GI meal.

    The doc wants 7 tests a day and I have averaged 4.6.


    Anyway, I had since found recommendations that T1D kids under 12 should not peak above 225. http://www.diabetesselfmanagement.c...blood-glucose-management/strike-the-spike-ii/
    Some sources recommend 200.

    When I asked my former colleague why they would recommend 200 or 225 (I thought it was overly safe, or just accepting the difficulty of management) he said that its probably because he find non-D kids between 170-200 after breakfast all the time and over 170 regularly after meals. He said that there is just very few non-D kids getting their PP blood sugar tested, nobody really knows where they go.

    Nobody and no resource ever suggested to me that having a bolus early can cause rebound hypergylcemia. Bernstein even claims that it is a myth, which it may be in late stage T1D http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021855/. I was also concerned about having his shot 20 minutes ahead of time at school, especially when he came to lunch in the 70s. The doc assured me that humalog does not start for at least 20 minutes, and that a honeymooning kid at 75 could not go low in 20 minutes before eating.
     
    Last edited: Jun 14, 2015
  3. Theo's dad Joe

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    What I have read is that non-T1Ds will have a glucagon response to hypoglycemia which can cause a rebound from liver glycogenolysis while people with full T1D GRADUALLY lose the rebound response over 20-30 years. Patients under 10 years in still have a profound rebound. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021855/

    I just see no reason why your child at 80 is not going to drop points or have some rebound with a 20 minute prebolus.

    In my sons case his own active basal should even turn down some to compensate.
     
  4. Theo's dad Joe

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    For the record, if I do fewer than 7 tests on average per day the glucometer report give a red flag. I told the doctor I refused to do 7 at this point, and agreed to test post prandial randomly after each meal once a week, one breakfast, one lunch, one dinner.
     
  5. wilf

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    If Bernstein says rebound hyperglycaemia is a myth then Bernstein doesn't have a clue either..
     
  6. wilf

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    I think we've established that your doc/endo doesn't have a clue about how to manage the diabetes in a honeymooning child.
     
  7. sszyszkiewicz

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    I can tell you that once the honeymoon is over you will see spikes that will knock your socks off. All of us wish our kids would stay 200 or less after breakfast, but once the beta cell mass gets down to a certain size, and you lose that automatic dose that works immediately, trying to time Humalog/Novalog to the meal as precisely as you seem to be aiming for, well you are going to drive yourself (and your child) nuts.

    The tools we have are not as precise as we all would like. Insulin begins to work in 20 minutes, peaks at 90, and is done 4 or so hours later.

    That is reality.
    You are MDI.
    deal with it.

    You have a ruler that only measures in feet and are trying to get it to measure inches.

    on mdi without cgm you need to fingerstick *once* before eating. Given how often meals and snacks are you will likely find that sufficient. Before cgm we did checks at breakfast, morning snack, lunch, afternoon snack, dinner and bedtime. You will have to work out how your family deals with nighttime checks. There are different philosophies on that issue and it is sensitive, which is fine because D is different by person.
    the
    But honestly, worrying about 20 points here or there, that is a fools errand with T1D. We can barely measure that accurately.
     
  8. njswede

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    If your doctor wants you to track his BG at a super granular level, he/she needs to write a prescription for a CGM stat! It's the only way to get that kind of control. And then you can use share and/or nightscout to view the numbers on all your devices and obsess over it 24/7. :) My insurance gave me a CGM without any out-of-pocket cost. I think most decent plans will give you one at a low or no cost.

    My son was also diagnosed January 2015, so I know exactly how you feel. We're currently freaking out a bit, since his D isn't as forgiving to our mistakes, presumably due to fading honeymoon. Yesterday, he was running perfect numbers until I stupidly corrected a slight low with twice the carbs I intended. BOOM, and he was having wild swings up to 260 all evening. Crap happens. :( But we're running decent A1C numbers and our endo says we're doing great, so I'm just going to learn from my mistakes. Obsessing over numbers does me no good. Or my son.

    There's a book called Sugar Surfing that people on the Dexcom group on Facebook are raving over. I don't have it yet, but supposedly it deals with how you can use a CGM to recognize patterns and proactively deal with them. It sounds like that would be a book for you!
     
  9. Michelle'sMom

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    First, I hope you're paying close attention to the details in all the studies you're reading. I think you'll find that very few studies involve children with T1. As has already been mentioned, there's a big difference.



    Inappropriate glucagon response
    http://ajpendo.physiology.org/content/298/4/E832.long

    http://www.ncbi.nlm.nih.gov/pubmed/18594062

    I can't find the link right now, but Gary Scheiner wrote an excellent article on the optimal premeal BG. He stated that a premeal BG lower than 80-85 actually stimulates more of a glucagon release, & can lead to higher postprandial spikes. We've found than we do much better with a starting BG of 85. Any lower & we see a much higher spike, regardless of carb content.

    This speaks specifically to adolescents with T1, but might be educational.
    http://care.diabetesjournals.org/content/35/8/1757.full

    http://bjdvd.co.uk/index.php/bjdvd/article/view/12/37

    I agree with Wilf that it's likely your son went low enough to rebound, which led to the post prandial highs.

    It's also possible the drop you were seeing had nothing to do with the recently injected insulin. Insulin secretion during the honeymoon is totally unpredictable. It's possible something earlier triggered an insulin release that just coincided with the drop. It's one reason for the extremely conservative treatment guidelines during the honeymoon. I would suggest you read up on long-term T1s, especially those who still rebound.

    You're assuming your son's insulin secretion is normal. It's not. The few remaining beta cells are dysfunctional. His body can no longer effectively & reliably control insulin secretion, for meals or otherwise.


    And to respond to a few more of your comments.

    Unlike many here, I've actually read Dr Bernstein's book several times. I also attend his webinars occasionally. He makes some very good points & I've found some of his information very useful. Some of his statements/theories just don't hold up, including his belief about rebound hyperglycemia.

    Re: your question about the timing of post prandial BG peak
    http://www.ncbi.nlm.nih.gov/pubmed/20226708

    Re: your question about my dd's A1c. At her request, I no longer disclose her A1c to anyone. She considers it private information & I respect her wishes. I will tell you that her A1c has steadily remained far below the new recommendations for her age group. She's had 3 exceptions, 2 prior to her PCOS dx (which her endo team totally missed), & 1 during a 4 month period without CGM & following testing & treating suggestions of her endo & NP. That little trial resulted in her highest A1c since dx, & also proved to me that medical texts & studies don't always translate well to real world treatment.

    Re: feeding at night. This is very common, particularly with MDI. Insulin needs are at their lowest usually between 2-4am. While most studies & endos will say long acting insulin analogs have no peak, there is evidence (& plenty of personal testimony) that says otherwise. You can't control the release of Lantus or Levemir after injecting, but you can raise BG to ward off nighttime lows. Uncovered bedtime & nighttime snacks are pretty standard for this reason.



    You can read millions of pages of scientific studies, every book on T1D available, tons of articles & opinions available online. While they may help understand the processes, none of them will prove true for every T1 everytime.
     
  10. Michelle'sMom

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    I second the Sugar Surfing recommendation. We've used the techniques outlined in the book since starting CGM.
     
  11. Michelle'sMom

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  12. rgcainmd

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    I'm off to order Sugar Surfing just as quickly as my fat fingers will allow! Sounds like it will complete our "T1D Trilogy" (along with Think Like a Pancreas and Pumping Insulin.)
     
  13. rgcainmd

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    Having a heck of a time ordering Sugar Surfing by Stephen Ponder, MD. Any advice will be greatly appreciated!
     
  14. Michelle'sMom

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  15. Michelle'sMom

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    Slide 6 should interest you.

    http://www.google.com/url?sa=t&rct=...m4tt2VNprRH2ZUfMA&sig2=7E1nPim3Q23Z9f_4NRpFXg
     
  16. rgcainmd

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  17. rgcainmd

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  18. Theo's dad Joe

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    Thank you. I understand that he is still hormonally controlling gastric emptying rate, although it doesn't explain to me why a kid in honeymoon would drop 20 pts in 20 minutes with 1 unit of HL and someone out of the honeymoon would not.

    The concept of gastric emptying is something I had studied extensively for years already. It is complex though because there are agents, like full fat dairy and acetic acid that slow gastric emptying but we don't know if they do so by stimulating amylin, or by another gastric reflex that is independent of amylin. Butter can slow gastric emptying by 30 minutes and move the entire curve 30 minutes down for a non T1D individual so its great for T2D (and by the way butter consumption strongly negative correlates to heart disease and diabetic complications), we don't know though if butter is just signalling amylin by putting a dose of triglycerides into the liver, or if it is shutting down cortisol or glucagon at the liver level. We know that dairy slows gastric emptying in addition to its butterfat content. We also know that some food lower glycemic index in non-diabetics, like some proteins, leucine for example, but in Non T1Ds, leucine lowers GI by stimulating extra insulin. A non T1D who takes 5 grams of leucine by itself will often drop 10 points in blood sugar because the insulin elicited greatly excedes the net glucose.

    We also know that adding 5% fructose to a glucose polymer lowers the total excursion for non-D people, but we don't know if it does so by reducing liver glucose secretion or by stimulating insulin. (Most fructose, maybe 10 grams per meal goes to the liver without entering circulation at all, and is turned to glycogen, and then glucose and released around the 2 hour mark, but fructose over that level gets turned into liver triglycerides which don't turn to blood sugar on any set time frame, but unfortunately cause liver insulin resistance over time. The fructose that does spill into the blood can back up the pylol pathway and cause sorbitol toxicity and also causes glycation of hemoglobon and fatty acids (which may be the real culprit, that is glycated triglycerides can carry more glycation and oxidative damage to cells than high blood sugar can), but this is only a problem if fructose intake is higher than optimal and if blood sugar is high when the fructose hits.

    GI can be very misleading even if you account for glycemic load. El-Dente pasta for example has a GI of about 35 because it forms dense pieces, but El-Dente pasta tends to promote a high release of glucose, its just that it happens 2-6 hours down the line and often unpredictably. Sucrose and fruit had low/moderate GI of about 60, but in reality they have "mixed" GI, with 40-50% of the carbs entering the blood with a GI of about 100 and half with a GI of of about 20 (the fructose) So we get a spike in 30-40 minutes and then the fructose acts over 2-10 hours.

    Fiber is also largely misunderstood. Even though fiber is a carbohydrate and some soluble fiber is turned into calories, it is not turned into glucose. When fiber yields calories it is because intestinal bacteria turn it into butyrate, a short chain saturated fatty acid. So fiber should never be counted as "carbs" but food labeling allows food produces to list it in the total carbs or NOT. There is not rule. (when fiber is turned into butyrate it yields about 1 gram of fat per 10 grams of fiber).

    I have also read that humalog action times were based on 10 units of injected humalog into the same site and that smaller doses are in and done significantly faster, that 1 unit may have an action curve that is only 30% as long as 10 units.

    My sons meals are very slow digesting for now. I prevented lows and highs with pasta by combining it with fruit to provide a "mixed" GI meal. I've had a friend nutritionist who estimates that the GI of his meals are about 40 which means that he's still getting significant glucose after 2 hours, though it allows the basal and his own insulin more time to work on it too.

    Anyway this has all pretty much convinced me that I need CGM, and to pump. Once he is above 1 unit of Lantus which I anticipate will occur early as the honeymoon ends, I want to know what is happening at night, but I also think that I will go to pumping and ditch the Lantus. I am glad I had the honeymoon to work this out. I think that bolusing for entire meals at one time may not work the way he eats though. Little kids can digest a full meal for 4 hours, but if the carbs aren't too high it seems impossible to match one bolus or eventual prebolus to the action of a complex mixed meal. I have read some people going to regular insulin for isocaloric or zone macro ratios. I think though that splitting HL may work too. Anyway I'm getting in touch with dexcom today before I HAVE to. Do I need a prescription or can I just buy one? Can I just buy a pump if I want to?
     
  19. sszyszkiewicz

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    Because the strips have an accuracy of +/- 20%. So a 100 and a 120 are in fact equivalent.
     
  20. njswede

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    Just to put things into perspective: I can easily get a 20 point difference between two readings taken 30 seconds apart. When you calibrate the Dexcom, you sometimes need two samples, and I'm always chocked how inaccurate the meters are. I've tried both the Freestyle Lite and the OneTouch and they seem about the same in terms on (in)accuracy.

    Our kid is in honeymoon too, and judging from the Dexcom graphs, there's no significant drop in BG that shortly after a pre-bolus. It takes 45 minutes before we see any appreciable effect from a 1-2U bolus.
     

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