Hi, my son (3 years old) started with Omnipod one month ago, and we are still stuggling with basals, boluses and corrections. This is what I have figured out:
If I follow the ±30 points theory of basal rates, the corrections an meal bolus don’t work as they should. If I increse 0.05 (the minimum on Omnipod) the basal, he will be trending down (very slowly).
For example:
BREAKFAST
CASE 1:
BASAL: 0,1 U/hr (with this basal he will be flat all morning)
BOLUS: 1 U
CARBS: 25g (2 slice of bread)
SPIKE: +150 points (from 100 to 250)
Need 0,4U more to correct
CASE 2:
BASAL: 0,15 U/hr (with this basal he will trending low but slowly)
BOLUS: 1 U
CARBS: 25g (2 slice of bread)
SPIKE: +50 points (from 100 to 150)
Slow drop, needed 4g carbs to stop the trend down.
CORRECTION
CASE 1:
BASAL: 0,25 U/hr (with this basal he will be flat all afternoon)
BG: 250
BOLUS: 0,4 U
EXPECTED DROP: 100 points
REAL DROP: 30 points
CASE 2:
BASAL: 0,3 U/hr (with this basal he will trending low but slowly)
BG: 250
BOLUS: 0,4 U
EXPECTED DROP: 100 points
REAL DROP: 100 points
Hi libustrina,
Don’t say you are doing anything wrong! Everyone on this forum is always trying to learn and get better. The rules that are given to you by doctors or pump trainers are always just starting points to learn from. Adjustments are always necessary.
A few things to keep in mind. Corrections do not generally work the same for every blood sugar. They are not linear. For many people, the higher the blood sugar, the higher the correction RATE.
If I am understanding the question - in the examples you gave, if your son has more insulin from a higher basal rate, then it seems natural that he would have a bigger drop from a correction. The basal and correction insulin are doing the same thing. I want to emphasize that, because sometimes there is confusion that basal insulin and bolus insulin are not working together.
So even though you gave the same correction, in one case he had a slightly higher basal, which also moves his blood sugar down.
In one case, you said he would be flat, and in the other case he was trending down. So I would not be surprised that one case gives you a bigger drop than the other.
The other thing to keep in mind, is that there are so many things at work, and so many factors, that the numbers don’t always add up exactly like you would expect. Dosing is always a best guess, it isn’t always exact. As long as you are learning and making adjustments, that’s what we all have to do. And I think you came to the right place to ask and learn. This place is full of very smart people that can help you.
Thanks Eddie. My doubt is why there is such a big difference with the spikes for small difference in the basal rate. If the basal is 0.1, 1U of bolus is like water, he spikes to 270 and stays there, and is very hard to make it go down if the basal for the next hours continue in 0.1.
If his basal is 0.15 the spike will be only of 50 points with a smooth drop with 1U.
The problem is that with a basal rate of 0,15 all morning he will not be flat, he will be trending down.
I try with a higher bolus, 1.1 and a basal of 0.1 but is the same, is not that I replace the 0.05 of the basal into the bolus is going yo work.
O dont understund if the basal is low (with 0.1) or that I have to give even bigger boluses.
I would like to address a few things you mentioned here. Hopefully this is some information you are looking for.
I will give you some imaginary numbers for illustration. Suppose 1 unit drops my blood sugar 50 points. But that might only be true if I am at 150. If I am at 250, 1 unit might only drop it 30 points. If I am at 300, 1 unit may only drop it 20 points. As your blood sugar gets higher, your body can become resistant to insulin.
The next thing you mentioned, you compared a basal of 0.1 and 0.15 units:
Yes it sounds like a small difference, 0.1 versus 0.15. But that is actually quite a big difference from a perspective of percentage. That is 50% more! As a comparison, that would be like an adult changing their basal from 0.8 to 1.2. That would be a big change for an adult!
The difference in basal, 50% more, given over the course of hours, would seem to make a big difference.
There are a lot of different opinions and ways of doing it. So I can just state that this is my preferred way of dealing with it. Others may have a different opinion…
I think a pattern of trending low is safer than a big spike, and the need to give a big bolus to lower the big spike. The problem with a big spike is that you have to fix that with a big bolus!
But if you have a low trend, to me that is much easier to fix, and much safer. A sip of milk or a bite of a banana can stop a low trend. I think that is safer.
Sometimes the math does not make sense to us. We want to understand everything from a numbers/math perspective. And over time, it will make more sense. But the body is so complex. We are trying to do by hand what the brain, and pancreas, and liver, and everything else are supposed to do. And it may not always make sense to us.
The important thing early on is to learn “what” you need to do to have good blood sugar. The “why” part of it comes along over time.
Did I answer your questions, or am I missing something? I can try better, or maybe get the help of people here smarter than me.
I am not a doctor, and I have no experience with children with diabetes, but my understanding, like @Eric2 said, I think, is that you want to start with basal rates that will keep him as flat as possible. Since you already know what basal rates will get there, you’re ahead of the game.
Now you have to work on the verifying the correct bolus and correction rates. If 1U is too little to handle that 25g-carb breakfast, maybe you should try a 1.5u or 1.25u bolus instead? That will not cause a longer-term downtrend, like a change in basal rate might, but better handle the fast carbs of the bread. Start slow and test to see how it works.
Similarly, with the correction. In my experience, as @Eric2 also said, the higher my BG, the higher correction has to be. Again, leave the flat basal and work with that – If a 0.05 increase in basal helped, then likely a similar 0.05u increase in correction might help – so try a correction bolus of 0.45 and see if that helps.
And please, remember to test – even more when you are making changes.
The simple answer to your question, nothing! I’ve heard that the definition of insanity is doing the same thing over and over again and expecting different results. For diabetes, the definition of insanity is doing the same thing over and over and expecting the same results!
As people with diabetes ( and caregivers!), we use crude tools when compared to a healthy blood glucose metabolism. Many things can drive blood sugar higher or lower that have nothing to do with insulin and food. So, we are left with our approximate formulas and our wits. Diabetes is not a set-it-and-forget-it disease. It demands that we pay attention and if we don’t it will grab our attention in rude and uncomfortable ways.
Writing things down like you did for this post is a great way for you to help manage your toddler’s diabetes. Just know that a formula will not consistently produce the same results each time. You’re better off thinking that the formula can get you close so that you can then take other, smaller actions, like micro-bolusing insulin corrections and making small carb corrections for trending lows.
Some of us call this surfing. It acknowledges that diabetes is a dynamic condition and you need to trust your observations and take appropriate and timely actions. Diabetes is a moving target. When you accept this reality, then it frees you to accept the erratic and unexplainable, take action, and continue to watch.
I started treating my diabetes when I was diagnosed at the age of 30. Your son’s needs are different from an adult’s. You will wrestle with many things common to a growing child including the growth spurts and the accompanying growth hormones.
I think you are doing well. Your’e organized and keeping good records. Good luck. You can do this!
That doesn’t seem too bad, actually. TWO HOURS after a meal, it should return to the pre-meal sugar, approximately. If your reading was 100 pre-meal, and 150 two hours after the meal, I would call that right on target (trying to be more precise than that might be unreasonable, you’ll learn whats reasonable for your son in time). BG can be expected to spike after a meal. That is just going to happen. If you get a 200 point increase an hour after eating, or 250, that’s by no means unheard of - you will see higher increases for certain foods than for others. Not all foods will produce the same result. The same food will often even produce different results. Depends on the individual. Remember that you only make adjustments for meal bolus, based on the reading that is taken 2 hours after eating and the one that is take immediately prior to eating. Otherwise you will see all kinds of variation and your data set will be silly. Timing matters.
If your basal is flatline, dont touch it. That means its working. You want to adjust only one at a time. Basal first. Get that flatline. Meal bolus second. Spend a week getting basal flatline, then spend another week seeing what can be done about the meal bolus. Dont feel like it has to be perfect all the time. It may do you good to see how much the system fluctuates, day to day, when you dont change the insulin levels. Thats important for understanding how the system behaves ‘normally.’
If you are changing bolus and basal and correction all at the same time, it is my opinion that you will create such a complex system that you cant reason through it. Simpler is better. You will be more successful in the long run and there will be less risk.
Consider a Dexcom. Never correct more than once in four hours, if possible. The system will become ‘unstable’ and ‘unpredictable.’ Exercise extreme caution if you do.
I am not sure that I understand your cases 100%, so I will ask for some clarification as I go. My kid is T1D - buit he is 12, so a lot older than yours.
If I can read your cases correctly, then your basals are properly set. If they are as close to steady as possible, then you are good on basal. So the question is the boluses.[quote=“libustrina, post:1, topic:58634”]
BREAKFAST CASE 1: BASAL: 0,1 U/hr (with this basal he will be flat all morning)BOLUS: 1 UCARBS: 25g (2 slice of bread)
SPIKE: +150 points (from 100 to 250)
Need 0,4U more to correct
[/quote]
The basal should not be used to help you correct a meal. Since it is stable, you are good. The only thing to use to correct this meal is bolus. You can do 2 things:
If you needed an extra 0.4 U of corerection after the meal, it probably means that your bolus was too small and you probably need to adjust your bolus higher. Maybe you can try 1.4U of bolus in this case?
If the spike was too high but it came back to the right level afterwards, you could inject the bolus earlier than the meal (for my son, it is pretty much never less than 20 minutes earlier, and sometimes up to 40 or 60 - but this is very individual - for your kid and for the meal). For us, I would consider a 100-150 spike pretty high, but for some meals that’s just what you get.
Can you give more precisions on the spike? When did you measure the spike?
[quote=“libustrina, post:1, topic:58634”]
CASE 2: BASAL: 0,15 U/hr (with this basal he will trending low but slowly)BOLUS: 1 UCARBS: 25g (2 slice of bread)
SPIKE: +50 points (from 100 to 150)
Slow drop, needed 4g carbs to stop the trend down.[/quote]
In this case, you started with a basal trending down. It may be easier to correct for the meal, but that is not the function of the basal, which is supposed to keep you steady. In general the meal should be not corrected wtih the basal.
This only means that your correction was not well tuned to the drop needed. If this happens regularly, you probably should adjust your correction rate upwards so that instead of bolusing 0.4U for a 100 point drop you bolus more. These ratios change all the time, so you have to tune them constantly.
That’s good but now he is trending down all the time. You may be better off (a) adjusting his basal to have an even trend and (b) increasing his correction bolus.
Essentially:
basal is for keeping the trend steady
bolus is for meals and corrections.
when the bolus ratios are always too short or too long, that means that they are wrong (or that your kid’s D has changed) and they need to be adjusted up or down the next time.
We adjust our meal and correction ratios all the time, sometimes from one day to next, although in general every few weeks.
EDIT: as a note, I noticed that @Eric2 mentioned the idea of having a slightly down trend in the basal. I also like it for my kid during the day (not at night), but slightly only, and only when his CGM is working, not when he is finger-sticking. My endo does not like the idea, and always wants us to have a steady BG if we can get there. For my kid, when he is in class, he does not always check his CGM often enough and will occasionally get low on a low-trending basal.
If you want to talk this through, feel free to PM me, and we can talk (or I can put my wife on the phone if you’d rather).
@libustrina, I am a numbers guy, and many times I don’t understand the Why in my son’s D (although I am also not as experienced as some here). So you may not always be able to make sense of it all in terms of understanding Why. But the most important is to be able to make the system predictable in the way you use it - you need to understand the How:-)
So my suggestion would be: if 0.1 basal is what you need to keep BGs steady, use it as a baseline and play with the bolus until you know what you’ll get. The right bolus is when it comes back to the same level +/- 30 (although I try to aim for better than that). Once you get the right bolus (or carb ratio), then you can play with the timing of the bolus. Most people pre-bolus 15-20 minutes or more, which will match the speed of the insulin to that of the carbs coming into your child’s system. But for you the # minutes may be different, more or less - of course depending upon the meal too.
For instance, if you regularly need a 0.4U correction for this meal, then your bolus is definitely not big enough and you need to adjust your carb ratio (how many units per carb ingested). Maybe you’ll find out that you need to increase his carb ratio by 50% (or more, or less).
The Dexcom changed our live as parents. I can’t agree more.
I agree with this as advice to new patients, because it can be dangerous to do that: when you “stack” insulin you end up getting faster action, but later on you are at high risk for lows.
However, FYI, we often stack insulin as a routine strategy when we need to. But we keep track of IOB (Insulin On Board) very carefully. So, imho, this is good advice early on - but later on you may want to reconsider. Again, YDMV:-)
Just to clarify, for me a spike is what happen between the first bite and 2 hours later, no matter if he end up in range 2 hours later. But usually if the spikes is of 150-180 points it wont end up in range 2 hours later.
With MDI was very simple for us, 2U of Levemir in the morning and 2U in the afternoon. The meals were always the same doses, 1U of Novorapid for a large meal and 0,5 for small one. That is what you can do with pens, you cant give 0.4 or 1.2, so if 1U was too much for the meal we just give him a bigger dessert or a cookie or something else. That worked pretty well, we got a 6.7 A1C and no spikes over 200 in a normal day and no lows at all.
With the Omnipod it all became so much complicated, too many variables to adjust. We worked to have the basal right (flat when he is not eating), but the spikes on the meals were terrible (starting at 100 and spiking to 250-270). We didn’t change the usual 1U / 0.5U for meals, because our endo told us that changing the carb-ratio to give him more insulin on each meal would be too much insulin for a small kid, and that made us afraid to increase the dose of the meals. So we start playing first with the timing (15 min, 20 min, 25 min)…didn’t work, then we start playing with the basal thinking that maybe it was not right our “flat basal” and he needed more during the meals (simulating a levemir spike); and that worked…but only for the meals!..so that is when I end up asking my self where is the problem…bolus, basal or the pump.
From all your comments I think that the problem is the bolus. I will try bigger boluses…and watching him with terror while he is eating and with a glucagon in hand…ahahaha
Thanks to all, I will let you know in a couple of days the results of the test!
Ohh and we are using Dexcom G5 since first month of dx! It’s great!
As Michel pointed out, yes a flat BG is always preferred. I should have been more specific!
Flat, if you can do it, is preferred. If I can’t be perfectly flat, then slowly trending down is better during the day when I can keep an eye on it, and slowly trending up is better when I am asleep, for safety…
Interesting. I am wondering if your endo is T1D or glucose-normal. I have noticed that, at the pediatric diabetic clinic where we go, T1D personnel is a heck of a lot more aware of what really happens - to the degree that I am starting to ask for only T1D staff when I can.
Parenting a T1D kid can be pretty tough. I have it a lot easier than you because my son was 11 when diagnosed. You are the hardest hit of us all:(
I know exactly what you mean. We are laughing but not… We do have the glucagon ready. Good luck to you really - this is such a tough thing to learn, but we all end up getting there! The process is pretty hard though.
Keep a good check on your own state of mind and your partner’s too. We parents need to remain both physically healthy (all these nights up…) and mentally strong. It’s half the problem right there…
Can’t wait to see what you come up with over the next couple of days.
I’m just guessing but…Does someone have an opinion if what I’m saying has any merit? As I understand it, you don’t have to have the same basal rate, you can preset it hour to hour. If .05 is too course of a permanent change, perhaps have a few .1 among the .15 to keep it steady…rather than a slow fall?
Or could a temporary % basal rate fix it easier? I can’t imagine chasing a falling BG would be much fun with a toddler.
My guess with the basal…Say a toddler is on about 1,000 cal a day, about half of an adult amount. So a 25g CHO would be equal to a 50-60g adult breakfast. If it is spiking too much and hard to do, even with a pump, perhaps try 15-20g CHO and make up the energy with a bit more proteins and fats would be better?
Wanted to make sure you saw jack16’s post about varying the basal rates from one hour to next. Going between .1 and .15 is very close to being at .125 all the time. It’s just splitting the two. Perhaps that would be something to try at some point when you are comfortable with it.
The other thing is that for me, when I went from injections to the pump, I did have to make adjustments in bolus amounts. It’s not like that for everyone, but it’s possible you just have to fine tune it and consider that they may be different. I still don’t know why my bolus amounts changed! But they did.
Hi @libustrina, I have an almost-3-year-old who has been on a pump for about 6 months.
A few thoughts, though of course everyone is different:
When they are this little, and newly diagnosed, they use such low rates that it’s very possible that your son needs something in between 01. and 0.15 units per hour to be completely flat. That means that you can either program alternating sections on the pump (.1 for one hour, .15 for another, etc.), or you can just live with a slightly higher basal rate and be willing to give him a snack a few hours after a meal, knowing that the basal rate will make him drift down. I think hoping for a “flat” basal rate works better if they are using more basal insulin total each day.
It is indeed true that at higher blood sugars, it takes much less insulin to bring down blood sugar. For instance, below 100, 0.1 could drop my son 40 points. If he’s above 300, getting a 40 point drop might require 0.3 or even 0.4 units. In between those two ranges, it might take 0.2 to drop him 40 points. People become very insulin resistant at high blood sugar, and more insulin sensitive at low blood sugar.
What I would say is that basal insulin seems to give us “more bang for our buck” than giving the same amount of insulin in the form of meal or correction boluses. So we err on the side of having a slightly higher basal rate, and then back off on how much bolus insulin we give. I’m not sure why, but my theory is it keeps the liver from producing more sugar and dumping it into the blood stream. So I conceptualize it more like an “on-off” switch: you want the basal rate to be high enough to turn that liver-sugar production to “off.” It may be that 0.1 units per hour is just slightly too low to stop that, and so it’s producing a ton of sugar that then takes more total insulin to ferry into the cells.
One problem with this system, though it does accomplish the goal of a perfectly flat basal, is that we’ve found our basal rates may need to be tweaked at least every few days to once a week. When you have a PITA basal profile with a gazillion different settings it makes you reluctant to change things (or maybe that’s just us). Might be a bit better with Omnipod, but with our son, we have a 15-20 minute window each day to access his pump for basal profile changes, when he takes a bath. Otherwise he’s just too squirmy and trying to change settings when he’s moving around feels too risky.
You are right, it is probably much harder when you have a young one attached to the pump! But if he is squirmy and moving around, that’s a good sign that you are doing it right, because that’s how two-year olds are supposed to act!
I talked with my wife about the flat basal and bigger bolus and she was a little frighten about that. Some times kids do not want to eat and she does not want to be running offering all kind of foods or candys. I guess that if the basal is lower the effect of a bigger bolus wont be higher, so I will give it a try later some weekend. Now, my son is going to kinder so the schedule is very predictable, we have 0.15 from 7AM to 8AM and then 0.1 until 12. Thats seems to be working well, there are no spikes and stays flat after the breakfast.
I will start with jack16 idea this weekend. It’s a good idea, maybe the basal change every half an hour and a litle more bolus can work.
Tia_G I liked your theory of the liver … that explain a lot! And thanks for the advices.
WestOfPecos, yes the endo is not T1D. She is very good, we have change 4 times of endo the last 6 months, becouse most of them do not understund how is the day to day of diabetes in such a small kid. Maybe they have experience with teens, I do not know, but their advices were pretty bad ones … and in fact they seemed afraid of caring a little boy. This endo gives us good advices and has a lot of small children as patients, so she knows the “small things” that make a difference. I think she was a little over protective on this one.
“Parenting a T1D kid can be pretty tough.I have it a lot easier than you because I was 11 when diagnosed.You are the hardest hit of us all :(”
We all have it hard !! It is crappy at all ages.
Thanks again!! I will let you know the results of my experiments!
