Help - sudden drops in BG

I need help with with regular sudden drops in my daughter's bg levels. My daughter is turning 4 next week. She began pumping at the beginning of this month with an animas ping. Her numbers which were all over the place have gotten to be very predictable now which I am LOVING! But there are 2x a day when her levels absolutely TANK. She eats a bedtime snack around 8:30pm and depending on her level then she will eat anywhere from 10 to 20 carbs. From midnight to 4am she rungs HIGH - like 350 to 400s then sometime between 4am-7am she falls. As in she is typically between 80 and 120 at 6:30am for breakfast. Which is good, but if you let her sleep in til 8am she will be around 50. It is such a dramatic drop. Same thing happens right before lunch. At 9:00-10am she has a 20 carb snack even though her BG is typically around 300 because at 11:30am she falls and will end up between 80 and 140 as long as she eats a 20 carb snack. If she skips the snack she will be around 40. So her before meal numbers are not bad by any means, but the 300 to 400s scare me. Plus by 9:30am I would think her breakfast carbs and insulin would have done there work and she would not be so high. She eats a variety of things for breakfast and snack times, but no matter how high protein, high fat, low fat, or any other combo of factors for digesting food does not seem to change these numbers. So far her medical team has been really hesitant to address the high numbers, because if we get them down then they are expecting her numbers at 6:30 and noon when she eats to be much lower. Both times when she is tanking is when her meals and bolus from her meals have worn off, but yet we can't really blame her basal numbers because look how high she is a night. Plus anytime we lower them for these times the numbers still tank and then she is high the rest of the day.
We do have a variety of Basal settings throughout the day:
10pm to 3am - .3
3am to 9am - .25
9am to 3pm - .15
3pm to 10pm - .2
Can anyone please explain to me what is going on and what do I do to combat it? She is unaware of hypos, and half the time she gives no indication of the low we only find out because we are testing her before her meal.
Thank You,

My son will be 4 in may and has been on the Omnipod for about 8 months. One thing I have noticed with his breakfast #'s, he will go really high (2-350) and then plummet- though the drop usually falls after the two-hour time frame. He will then be low or in the low 100's before lunch. I have found that splitting his breakfast into two portions (though bolusing all at once) helps prevent him from going so high and dropping so fast. I have also changed a lot of the foods he eats at breakfast and stick to the ones I know that do not effect him as much. I also try to bolus 10-15 mins before he eats to let the insulin get a head start on him, though if he is on the lower side 80-100 I wait less time.
I would aslo suggest doing a basal test- which is hard for such a young age, but really gives you a good starting point on where to work off from. Basically, you skip breakfast, and test her sugar every hour until lunch (assuming you have a good waking number). She should not rise/fall more than 30mgdl between checks. That way you can see if the basal is either too high (she drops) or too low (she rises). If she goes above 200 or below 80, stop the test and try again another day.
As for the nighttime numbers, since she is on the pump she should not have to eat a snack before bed, though most children do. I would try the basal test overnight and see what the results are. I have notice (especially recently) that my son will start with a low night basal (.05) from 9:30-11:30, but needs .20 between 1-4am. I believe it has a lot to do with the "dawn phenomenon" and growth hormones. He is back to .10 at 4am and has good waking numbers. We have 6 different basal presets.
I recommend buying the book "think like a pancreas", if you have not already read it. It provides a lot of insight on determining basal/bolus rates and much more.
Another thing that has been VERY helpful for us was getting the Dexcom CGM. It wakes me up when he is dropping fast or low- and prevented uncountable lows for us (he no longer can feel either). It really helps assist with his day to day management and my comfort levels when he is in the care of others.

Good Luck!!!

I do need to ask this question: when she's in the 300+ range (midnight to 4am, and 9-10am) are you correcting those highs, or are they coming down by themselves? Also wondering if you bolus for that bedtime snack. Personally, I find that when I snack before bed, my sugars run high all night. I think movement throughout the day gets the insulin pumping through the body, and staying dormant while asleep keeps the insulin pooled up at the infusion site.

I'm first trying to first tackle that midnight high, which drops to 80 by 6:30 or 50 by 8 am. It could be due to either an overaggressive correction factor, or it could be due to wrong basals.

Without considering the actual BG's and corrections (because I don't know what the corrections are) and just looking at the basal rates, I find it concerning that the highest basal rate of the day is when your daughter is asleep. Typically the highest basal would be just before waking to tackle dawn phenomenon. I think part of that .3 is covering her bedtime snack and the rest is bringing her down low overnight.

Give me a little time, and when I'm able, I'll take a closer look and see what I might be able to figure out. Meanwhile, I feel obligated to give you the standard disclaimer, simply because of the young age of your daugher and the sensitivity to such tiny amounts of (and adjustments to) insulin. I'm just hypothesizing -- please don't make a change unless it makes sense to you and to your doctors.

I have to give you a ton of credit, by the way. Taking care of a young child with diabetes is a daunting task, indeed, and you're right on top of it. Nice work!

Just looking at your basals, your "highest" (though not by much) is from 10PM to 3AM. You note that she jumps really high from 12-4, then goes low. The basal period that effects 12-4 is approximately 10PM to 2AM, so I would try raising that period up, slowly, a bit at a time, but my guess is you need much more then. 350-400 is crazy high! I would end that time period at 2. Then after seeing how those changes work for awhile you might find you have to lower the amount for the hours after when she goes too low. But you might find that when you eliminate the highs, there will be no sudden drop afterwards as it might be a reaction to the highs. Make sense?

In general, just look to the patterns you see of when she is too high or too low and then raise or lower the basal two hours before. Do it in gradual amounts. You might have to further break down your time zones too as you are covering large chunks of time when her needs might vary.

I don't understand why your medical team is afraid to address the high numbers, being afraid of lows hours later. It doesn't work that way. That is the big advantage of a pump, we can set our pumps for different basal rates for our needs through the day and night. How well does your team understand the pump? If you don't already have Pumping Insulin by John Walsh I encourage you to get it. After awhile we all realize that we are better able to tweak our numbers than our medical team.

It sounds like you and your daughter are going through a rough time. I would bet that her growing body now requires a different amount of insulin at different times of the day. What type of insulin is she on? In order to make any adjustments you need to know about how long it takes for the insulin to peak in activity. Humalog peaks for me just under 2 hours after I have taken it.

I must stress that I am not a liscened to provide medical advise and you need to consult with your daughter’s medical team. That said I feel very bad for your daughter and will make a suggestion on what I would do if I was experiencing this.

Basal testing would be my first goal. To basal test you fast and check your BG every hour or two. There must be no IOB and no food that will still impact your BG. The idea is that if your BG starts to go out of target then you can make adjustments to get it back where you want it. I make basal adjustment 2 hours before the problem, or the length of time to my peak insulin activity. I do not know how possible basal testing is with a 4 year old. Hopefully you can at least do basal testing overnight.

I would bet that your basals are off at points in time and that you likely need to adjust your I:C ratio as well.

Here is how I would adjust my pump: (I am assuming the smallest basal adjustment is 0.05 U/hr)
10p-1a = 0.35 (keep early morning BG lower)
2a-6a = 0.15 (lower BG crash)
7a-8a = 0.25 (helps with DP and IR in morning)
9a-2p = 0.15 (original)
3p-9p = 0.2 (original)
I would also lower my I:C ratio for 9-10am snack and consider it for the 8pm snack.

I will adjust my rates and leave them that way for 2-3 days to get an idea if they are working before making another adjustment (that is assuming that they are not obviously incorrect). Please take care and check your daughter’s BG often to make sure she is ok.

I am really loving everyone's help! I do understand that none of you are doctor's and before I make any changes I will and do consult our medical team. (Our actual Dr. is awesome and will work with me to make changes and sees the need, the nurses...well not so much.)
To answer your questions to better help: She is on Humalog at this time.At this time we are NOT doing a correction bolus for the highs because we are hoping to tweak her basal rates so that we don't have these highs. Thus, when these high numbers come crashing down they do so by themselves. Her bedtime snack and her mid-morning snack do not get a bolus at either. She has recently been accepted into a study in which she will wear the iPro CGM unit 1 week every 3 months. We won't be able to see the numbers until after that week but we are hoping that can give us even more insight.

Her correction bolus rate is .5 for every 50 over 200 all day except breakfast it is .5 for every 50 over 180. This was an attempt to get her snack time sugars down, but since she is always in range she almost never has a correction dose at breakfast. Her i:c ratios are Breakfast 1i:15c breakfast, 1i:30c lunch, & 1i:25c dinner. After lunch and thru her nighttime snack she is running 100-250. A pretty good range for being 4 yrs old and considering where we were at with MDI much better consistency.

As far as a Basal Test goes...Just doing one overnight seems doable. At what time would her last meal/snack have to be in order to start at say 10pm? Obviously her last bolus of insulin is at dinner time.

Again Thank You all so much for your help! and your support!

I would do a large dinner no later than 6pm and start checks at 10. Still check at the two hour after meal to make sure she is in her range before starting the basal test. obviously if she is low, treat and start another night. if she is in range at 10 pm with no food or insulin on board, I would check every hour and record the results.
I would also make sure to do the test on a normal day, where she didn’t have excessive activity or exercise as that can throw off nighttime numbers…

i also want to mention that we were instructed to bolus for all foods, which you may want to inquire about.

I find that out too If I want to eat something before bed I am correcting a LOT to get my bs back down before bed. I try not to eat after 8 pm, esp anything with any kind of significant carbs. I think you are right that during the day you are much more active and get that insulin circulating, whereas at night you are more dormant, and harder to get that bs back down.

I have to ask why is she snacking at night? Being on a pump or even MDI should eliminate if her basals are correct the need for a nighttime snack. If she's hungry I can understand as sometimes u do get the munchies for something. But she really shouldnt be NEEDING a snack at bedtime on a pump if her basals are right. She might be eating to heavy of a carb snack before bed, and then really spiking because of it. I find if I want to snack later at night, I eat a couple of string cheeses and it satisifies that craving for something and because they are less than 1 gram of carbs per string cheese, it doesn't spike my bs.