Is the basal/bolus model the only way to think about insulin dosing?

[Dragan1]

You’ve already received some good broader replies, so I’ll try to be brief and to the point. Regarding the question in the title of your post: the basal/bolus model is just a crude attempt to mimic insulin production in non-D individuals. More importantly, the model yields relatively simple “rules” explainable to average medical professionals and average patients (apparently with limited success, but that’s a different topic). In engineering, we try to decouple complex problems into simpler sub-problems. In that sense, the basal/bolus model splits bg control problem into two sub-problems: longer-term, somewhat repeatable patters are dealt with using pre-programmed basal, while shorter-term and less predictable disturbances - meals and a myriad of other factors - are dealt with boluses (which could be done as normal or extended boluses, or temp basals) or carb corrections.

@Tia_G

this dosing was recommended by his ENDO

It won’t take long before you learn how to dose insulin for your kid much better than your endo or anyone else in the world for that matter.

@Tia_G

and all the books say it should typically be 40 to 55 percent of TDD

I have yet to find a viable reasoning behind this % basal/bolus split recommendation. I’ve never paid any attention to this number.

@Tia_G

On top of that, his dose is so low that I can only drop it by 25%, or perhaps have periods where it’s on/off to mimic the total he needs over a longer period. That would make for a very confusing basal profile prone to error.

If needed, I would try the on/off approach. I do not see why this would be any more confusing or prone to error than anything else.

@Tia_G

he was arguing that an admittedly “wrong” basal could still reduce overall variability.

In my opinion, your husband is completely correct and completely wrong at the same time A basal higher than what is needed in the absence of disturbances can be a very powerful tool in dealing with after-meal spikes. However, such higher basal rates should not be pre-programmed. You may use temp basals instead, but only when you have good reasons to do so. The pre-programmed basal should not drive your kid low (or high) when he is sleeping, or when he is in day care, or any other time. As a side note, you may take a look at my recent post on the subject of bolusing for high protein/fat meals.

@Tia_G

I’m struggling to convince my husband that lowering the basal is the right way to go.

I am with you - I’d try to adjust the basal rates the best I can, and then not rush to make daily basal changes - wait for longer-term patterns to emerge (as basal needs do change over time, especially for kids). Use boluses, extended boluses (or temp basals), and carb corrections to deal with meals and other shorter-term daily disturbances.

Best luck to your family!