New pumper, help with adjustments

My daughter just started pumping about 3 weeks ago. Things are settling out, but I am still fine tuning everything. Here's where I need help. The last couple days, her numbers have been as follows breakfast 12.2, am snack 12.5, lunch 11.6, pm snack 12.1, supper 11.1, bed 7.4

Her target is 6-12mmol for her age, so we are running in the top end mostly and I typically like to have her under 10. What I am wondering is those numbers are consistant, so do I need to increase the ratios? or the basal? The pump has not suggested/given a correction on any of those numbers and the bolus returns her to where she was at 2 hrs later.

She is 4, so she eats pretty much every couple hrs or so and I cannot to a daytime basal test where she goes 1/2day without carbs. (my clinic has advised agaist this as well).

Your thoughts are greatly appreciated!

12 (216) is definitely too high. You are right that basals need to be fine tuned first and then bolus. I never basal test myself but just look at the patterns: If I'm high 2 hours after a meal it is likely the bolus. If I'm high in between meals, waking or at bedtime then it's the basal. Then I tweak the basal rate for the period 2 hours prior to the problem time.

Having said all that, I would think it would be pretty hard to ascertain what's going on if she eats that often! My question though is that you described those numbers as related to meals but then you said she "returns to where she was at 2 hours later". Generally 2 hours is when we check for our pp numbers, so when did you get those highs? Was it at one hour? If so you probably should pre-bolus say about 15 minutes before eating, rather then increase the ratios.

We do pre bolus, and those numbers are 2 hrs pp. Her snacks are 2-2.5 hrs after her meals, typically. So if she is 12 pre meal, she is 12 2 hrs pp, etc. Those numbers are still considered in range for her age group, not technically high. We don't correct anything under 13 at this point

I agree the snacks are typical for kids. You are very fortunate to prebolus, I know a some parents of littler ones who post-bolus after meals so they can more accurately assess what was eaten. If the 6-12 is the 'goal' that's input into the pump, it won't suggest a correction. I am not sure what I'd do with a kid but I sort of suspect that it would involve me becoming a helicopter parent and at least trying to work with a lower target. If you aren't happy with the numbers > 12 or > 10 or whatever, I think that it's ok to make very small, incremental adjustments to the bolus ratio and see what happens, ideally in a sort of controlled condition.

If the numbers move a bit, and I'd say 12 is an ok "safety" net, it will show you whether your suspicion of the ratio is correct or not? The smallest increments for me will sometimes produce a drop that's pretty significant, like 30 points. A lot of times, my "experiments" aren't very scientific and I'm probably more careful with carbs when I'm experimenting and that kind of thing.

I understand not basal testing but maybe you can use the AM fasting to observe it but that's sort of dicey with all the DP stuff going on?

I'm not sure why doctors give parents such high ranges. 216 is extremely high; studies show that complications begin to accumulate at anything over 140. She has many years to accumulate damage. My suggestion is to get a second opinion or to do your own research. The only reason to maintain children higher would be to avoid lows and you certainly would have a lot of latitude before that becomes a consideration.

I think it's very challenging with kids. I met some people last weekend, friends of mine from high school (3 y.o. daughter w/ T1), my friend Annie from our running group ("promoted" from T1-T2 recently), my friend Rick (25 years of martial arts experience and T1...) and his daughter who's 4, also T1. It seems that kids are a lot harder to control. I was 16 and sort of ran my own show from the get go but I think a lot of parents are very much exasperated because the kids are so sensitive to insulin, dropping very precipitously from 250-50 with corrections. So using 140 as an upper threshold (which I do myself...I freak out when I hit 120...) may not be realistic. I think that little kids may not be able to describe stuff when they're crashing out the same way. MrsAcidRock can usually tell with me but my friends all reported some "well, she seemed quiet so we checked and it was 39..." things?

I wonder if weaker insulin might be a useful solution, so the doses could be adjusted more precisely? If you are only taking 5U of basal/ day, it's sort of impossible to make a 5% adjustment without the smaller, pumped increments and even then it's tough.

That range is the widely acceptable norm for kids under 5. I beleive I have read others say that in the US it is 100-200. The reason is because brain development continues until the age of 5. Too many lows has been proven to lead to impairment and learning disabilities. Once they reach 5, the range tightens a bit and then again around 8yr old. The second reason (as AR mentioned below) is the great sensitivity children have. So no, there is not a lot of latitude. My daughter's ISF is 11 (that is 198!!) so even with small doses, she can plummet quickly. With MDI I could not safely correct anything until it reached 20 (360) or she would be low before 2hrs. Also, she cannot tell when she is low, as is common in young children/toddlers. This was my main reason for moving to a pump, the ability to give smaller doses.

Children are incredibly difficult to manage. Their activity is sporatic, their eating is sporatic, they are constantly growing, and then they there are puberty hormones to throw things off. I am well aware of the compications of diabetes. No one on here needs to be told.

Our "target" is set for 8 and it should correct anything over 10.5 now, but often it won't based on IOB. Thank you for your help AR. I think I will go with some no carb type snacks or even scrabbled eggs for a meal. That may help be get a better idea on what's the contributing factor.

You might consider making a tiny correction (.05to start) when your daughter is at the high end of your range to see whether it can safely bring her down a little bit. Insulin on board calculations aren't magic; I learned that when my pump gave the message to check for ketones and then suggested a correction of .05 units because of IOB.