My 8 year old son has had type 1 for 1 year. He went on the omnipod about 2 weeks ago. We are having a big problem with lows right before bedtime. No matter what adjustments are made to the pump, we continue to have this problem. Last night we tested before bed and he was at 127. 10 minutes later, he asked me to test him because he felt low. I tested him and he had dropped to 88. I knew where this was headed so I gave him 2 glucose tabs. 15 minutes later I tested him and he dropped to 80. I gave him 2 more tabs and tested 15 minutes later. He then fell to 67. I proceeded to give him 2 more tabs and tested him 15 minutes later. He jumped to 208!!!. By morning he was 325!!! This has been happening every night for the last 3 nights. I am following protocol but to no avail. What is going on? I feel I need to mention that my son does not eat meat other than chicken. Does he need more protein? Maybe a protein shake 1/2 hour before bed or something. We have always seemed to have this problem just not as consistant as its been lately. The doc cant explain this phenomena. Please help.
Perhaps a carb/protein combo before bed might do the trick, might hold him steady…and testing in the middle of the night. My sense is that he dipped again during the night, and good old liver kicked in. Hence the morning high. Good luck in all this…and keep us posted, OK?
The high in the morning might be due to the dawn phenomenon (that is, he’s dropping really low at night and then releasing a ton of glucose to compensate, thus causing him to go high).
What is his basal rate in the hours leading up to bedtime? You may need to tweak his basal rates during the 2 hours before he goes to bed, and adjust to have it change in the middle of the night. Are you testing him around 2am/3am?? If so, what are those results?
A good pre-bed snack is crackers with either cheese or peanut butter. I find that these snacks work the best at holding me steady (or just steadier) throughout the night. Unless I have any kind of alcoholic beverage earlier in the evening like I did last night…but that’s a different story (and probably not applicable to your 8 year-old son
I have this problem when I eat a meal high in fat. For example, I will eat a couple of meatballs, along with some sort of carb. Before bed, even if I accurately count my carbs, sometimes I will drop and take glucose to compensate…but then I will wake up really high because my high fat meal (which would have been covered, but the timing of the insulin was wrong) kicks in at like 3 AM. It’s very annoying, and lately it doesn’t take much fat to do this!
Or, it also sounds like maybe his basal rates are too low, and his bolus too aggressive? OR like Linda below said…he might be actually going low in the middle of the night too.
A CGM would definitely help see those trends!
Yes, my first question would be how close his dinner is to bedtime. (I have no idea at all of children’s schedules!). Because the way he kept dropping definitely sounds like there is insulin still active in his system. Then the glucose tabs caught up with him (and perhaps also as mentioned above, a slowly digested meal) and he went high after the insulin stopped acting. If there was no bolus within about 4 1/2 hours, then I would look to tweaking his basals.
Here is the course of action I would recomend:
First: as much as possible do not allow your son to exercise while you are adjusting the pump settings. I understand with his age that he will move and I suppose normal movement is fine. But do not have him play in a 2 hour soccer game (untill you have a better handle on the new pump). Second you have to take a very good journal/log of boluses, basal rates, BGs and carbs.
Running your BG a little high is somewhat standard operating procedure for starting on a pump from MDI, then you tighten down the control. A few days of higer BGs is OK in the bigger scheme of getting your pump settings where they need to be for optimal control. The drop you describe before bed is the most alarming part as it poses the most serious risk to his health. If hypo before bed is a usual or constant problem (since pumping) then you will need to make adjustments hopefully before you have a repeat episode tonight. If this hypo was a one time occurance you may be able to caulk it up to unplaned exercise, unknown body mechanics or improper carb count, etc.
I recomend you purchase "Pumping insulin" by John Walsh. Many pumpers consider it to be something like a pumping bible. Here are some concepts from the book that will help you. First off I am assuming your son is using humalog and it lowers his BG for approximately 4 hours and peaks in activity at about 2 hours.
To stop the bedtime hypo you have a couple of choices that you will have to decide which one seems more likely: either lower his insulin:carb ratio (for dinner or nighttime snack) or lower his basals. I would slightly guess that your I:C ratio is set too high for dinner or night snack (but your paragraph is not too descriptive). did your son's BG plummet about 2-3 hours after a meal? If so this increases the chances that the I:C ratio is too high. Quite a few T1s have more insulin resistance in the morning (from dawn phenemona) and lower insulin resistance in the evening. This could be the case for you son. For example my I:C ratio is 1 unit H: 12 g carbs in the morning (30 g carbs/12 ratio = 2.5 unit bolus) and 1:15 in the evening (same 30 g carbs/15 ratio = 2 unit bolus). I have a minimed pump and have barely played with an omnipod so can not help you with entering this adjustment if you are interested. This group http://www.tudiabetes.org/group/omnipodusers or your endo or CDE can likely help if you are not sure. REMBMBER: a larger I:C ratio leads to a smaller bolus as shown above.
The other possibility is that your son's basal rates are off. Basal rates are designed to release a small but steady stream of insulin (like a normal person who is fasting) that will keep the diabetics BG within +/- 30 mg/dl for extended periods of time. Theoretically if my basals are set right: I could wake up at 100 and not eat anything all day and wake up the next day and my BG would be between 70 and 130. If basal rates are off they can lead to highs or lows when there is no food or bolus associated with that time. Your son's basal rates could be set too high. You may need to adjust your sons basal rates to keep his BG up before bed. "Pumping insulin" recomends to adjust basal rates 2 hours before the BGs start to go out of the target range. The book also recomends a 5% adjustment for small corrections and a 10% adjustment for large corrections. I would recomend a 10% change to keep him feeling better and from going hypo until you have a better idea of his basal rates. Therefore if your son went hypo at 8 pm and your one and only basal rate is 1.5 units per hour. I would recomend that you lower the basal rate at 6 pm to 8 pm by 0.15 units (10%) from 1.5 u/h to 1.35 units per hour. The amount of time to lower the rate is a guess at this point in time.
I hope this info helps, I hope you get "pumping insulin" and I hope your son is liking his new pump!
Thank you all for your great replies! This is such a great site!
Tyler is on Novolog. His BG at dinnertime was 193. Normally, our current correction is 1 unit = 110 points. Last night, I decided not to correct the broken BG but cover the meal. He still went low before bed. It’s crazy! If I didn’t know better, I would say he is dropping his BG on purpose so he can stay up later and eat glucose tabs. His basal is 12am-6pm .25 U/hr and 6pm-12am .2 U/hr. His IC ratio is 1=23.
We have “Pumping Insulin”, I just haven’t had time to actually read it yet. I also have “Thinking Like a Pancreas” but also have not even cracked it open yet.
Tyler was on the OmniPod for one week before we went on vacation. Prolly not the wisest decision but we are running out of time to get the bugs worked out before school starts. While on vacation, he swam and played in the lake we were at for about 8 hours everyday. Lunch was later than normal and dinners too. Needless to say, we experienced a lot of ups and downs. We arrived home last Saturday night and since then is when we started having the bedtime lows. I recall having issues with this even when we were doing MDI. We haven’t been checking BG’s at 2 and 3 am but I will start tonight. The last 2 days, he has woken up in the morning over 300, I correct with a bolus and then even by lunch, he was still over 300. By dinner, he is near 180-190.
I email his numbers in to his doctor daily and sometimes they make changes and sometimes they don’t. This week is more of a normal week as far as lifestyle and hopefully we can get his numbers under better control.
I think you might be right Capin101. Maybe his IC ratio needs to be adjusted for his dinner bolus?
Tyler loves the OmniPod but hates being diabetic. He has his days and sometimes he is really down in the dumps about it.
I am glad we were able to provide you with some help. I feel for Tyler as I know its not easy. I also feel for you Sparkplug, because I know how hard my mom worked for my T1 and how much it paid off in the long run (still kicking without any problems).
I am not used to such small numbers as I weigh quite a bit more than your son. I might recomend changing the dinner IC ratio to 1:30 to 1:35. I am not sure how many carbs he eats for dinner, but this change will likely only be 0.2 or 0.3 units. I would try to shoot for the high side for your bed time test and then maybe tomorrow you can aim for the sweet spot in the middle ground?
I’ve had this problem most of my 52 years of living with this disease and I still at times have the problem. Since I’ve been pumping for years I’ve learned to adjust my basal rate to accommadate my problem. My basal rate is .8, before dinnertime I set my basal at .6 and let it run for about 4-5 hours depending on how busy I’ve been that day and that seems to solve it.