Post breakfast highs!

I am so ready to pull my hair out trying to figure out the best way to cover breakfast for my son and avoid such high spikes within the two hours after eating. We try adjusting the carb ratio and basal, normal vs dual wave or squared, trying to avoid specific foods. It is just so frustrating when one day something seems to work well but then it doesn’t the next time! It’s like there is a delayed insulin affect. It does nothing until 2 hrs later. This has made it difficult with morning snack at preschool. Some times we just end up taking him home because his bg is too high for a snack and meltdowns occur and it is just chaos. Sometimes I can attribute it too bad site or insulin nearing it’s expired date but most of the time I just can’t figure it out. Does anyone have any thoughts or any ideas on what has worked for their child? Rory is 5 years old now, uses a Medtronic paradigm 522 pump, has started using the sensors and CGM a couple times a month.

Hi Natalie:

I have so much respect for parents of children with diabetes you guys have to be tough. My dear parents had 2 of us, type 1s, to deal with and I am so grateful for them as I'm sure Rory is/will be to you.

I have limited pump experience as I've been on the medtronic pump a full two weeks today and have been struggling with DP and high morning blood sugars. Your situation seems to be a little different as it seems Rory is spiking after breakfast. Is he usually in a good range before he eats? Have you tried changing the timing of his bolus maybe 15 minutes before he eats? You seem to be doing all the things that make sense to adjust for this, and I know this is tough on the both of you. I really wish I had better advice, but I'm sure you'll get plenty of suggestions pretty soon.

Hang in there, I know it’s tough.

I don't have a ton of advise for you, but a lot of empathy. We are right there with ya! We do MDI with my 3yr old, and post breakfast is terrible! Same thing, two hrs later she has skyrocketed, but then quickly comes down and even with a 15CHO snack she is nicely back in range for lunch. Its that darn breakfast foods! It doesn't seem nearly as pronounced spike at supper either. We started to pre bolus breakfast by 15mins to give the insulin a head start. It has helped for sure. Still more of a spike than I would like to see, but better. Also, I was doing the same thing and not giving a snack when she was that high. Our endo and diabetic team told us to try not to control numbers with food so much, because they are kids and they need to eat to grow. I was so focused on the number that I totally forgot about that! Talk about diabetes giving you tunnel vision! If snack time at school is an issue, would it be possible for him to have a snack with the other kids but have a "zero value" snack instead? You could give parameters that if he is over a certain number he gets veggies or meat or cheese, but if he is under that number he can have the regular snack. Good Luck, I feel for ya. Hope you keep your hair!

Thank you. He usually is in a good range before breakfast. He seems to stay pretty steady overnight and early morning. We have apparently figured out good basals for those hours which is nice. We have tried the bolus 10-15 mins before. He is a good eater and we don’t have the worry of him not eating the meal. Even that hasn’t seemed to make a difference. When we have delayed breakfast to test the basal it seems to be good also. I am sure once preschool is over we can have the summer to work on it more before he starts kindergarten this fall. Thanks for reading my rambling. It is nice to vent now and then.

Good luck with your pump! How do you like it so far?

Sometimes carb to insulin ratios are not steady throughout the day. For myself, for example, I take one unit of NovoRapid per 10 grams of carbs. But in the evening, my blood sugars tend to go high after supper. My insulin to carb ratios are different then. It takes some experimentation, I think, to get it right.

I agree with Chris, that his breakfast ratios might have to be different than his other meals. Mine for example are 1:5, 1:10 and 1:19. But one thing you don't say is what he eats for breakfast. If it's cereal, I think you are going to continue to struggle. My favorite breakfast was granola, fruit and yogurt pre-D. I tried every kind of cereal in the market after, including all the "high fiber/healthy, etc" ones and no matter what, even taking extra insulin I ended up high. Cereal is now off my list. I generally eat some form of eggs for breakfast. Many of us find we have to limit carbs in the morning.

I think it is worth to investigate the reaction to at least three different analog insulins: apidra, novolog and humalog. These insulins are different in their action profile because their genetic sequence is different. The best outcome would be to find the one that has such a rapid onset that the spike is much smaller. It just takes three vials and most endos have samples to give to their patients. Of course you need to test more thus I would recommend to use the weekends. Many have claimed that apidra is the fastest insulin. This makes it a good candidate to start with.

One problem with children is that they have pretty good and fast absorption of the digested food. With the loss of our insulin production we have also lost the capability to produce pro-insulin. This pro-insulin will separate into insulin and amylin. So by injecting exogenous insulin we are missing amylin. This hormon will tell the stomach to delay its emptying to give the insulin a head start. In addition it will tell the liver to reduce its release of glucose. Without amylin we are always absorbing the glucose too fast. The amylin can be injected too - the drug is called symlin - but I am not sure if it is safe and recommendable to use it for children.

we are having the same issue, i noticed it esp. this week as jacob was on school vaca so he was testing everyday at 2-3 hours post breakfast for snack, mostly in the 200's, during school he goes 5 hours without eating so he may be spiking then settling down by his pre lunch reading, he is usually good at school. one thing i have tried is to bolus 15 minutes before and include some protein even if it is just a full glass of milk. i am eager to here some more replies to this. and yes he eats cereal most days, a bagel's (small 25 carbs) response is no different, i am of the attitude to change the insulin regimen to work around his food choices for now if possible. i have increased his I:C ratio but am hesitant to be to aggressive with him going so long without eating during school, ( we've set things up so that he could skip snack, god forbid he do something everyone wasn't doing!) we have a md apt next week with a new clinic and i am really looking forward to a new level of care there ( joslin diabetes center) and if i gain any new insite i will pass it along. where he is testing for snack at school i would increase his ratio and try bolusing 15 minutes before if possible! best of luck. amy

His endos felt we had too high of a carb coverage and had us back off Ob that and increase the basals. I ended up having to increase the carb coverage eventually because that just didn’t work. He currently has the same carb coverage for all meals, 1/8 (but he is still on quarter strength humalog, diluted, so his real insulin would be .25/8 or 1/32, which always seems too low to me) I don’t know if that makes any sense. His docs say when his total daily insulin is more than 10 units he will be switched to full strength.
They have never mentioned the other types of insulin. Would that even be considered since he uses a pump? He definitely absorbs quickly! The sensor shows spikes very quickly.
Cereal has been a typical breakfast food :confused: I have really tried to get away from it but family doesn’t always comply and stay consistent. Cereal of course is so easy in the morning before school. But I know we need to make that change, it is hard with kids. He does like peanut butter toast and hard boiled eggs, milk, yogurt. I guess it is just a matter of staying consistent with what works. I want to take a week to make the same thing and maybe gradually increase the bolus until it gives the best results, after testing that the basals are stable. Thanks for all the advice. We are still having a bad day :confused: I may be bald by the end of the night and he is fed up today too. It is so hard on him and such a struggle to get him to cooperate on days like this.

i can only imagine what it is like with such a little one, it is so unfair! hang in there, here is hoping tomorrow is better, i'm currently waiting to see if jacob is coming down sometimes he is high after a pod change.. so you are not alone, your plan sounds like a good one, my familiy is on the cereal wagon to, so hard to make changes or even to say no, jacob wanted icecream for his bedtime snack with bs of 240 i know he is going to come down with a good bolus but i have a hard time being bad cop and saying no, i'm like ok just wait a bit after you bolus and i'll get you some after 3 more glasses of water! and he is 13 he knows i cant imagine with a child to young to really understand best wishes tomorrow will be better and todays misery will fade kind of like labor pains, bless their little souls and ours! hang in there, amy

I've read about the "superbolus", where you cut out some of the post-breakfast basal and add it into the bolus, sort of the reverse of the dual/ square wave idea. I haven't ever had much success with the dual or square waves. There's not any directions that I've seen and my experiments have never worked. I usually bolus for about 5 extra G of carbs but I also cheat by eating eggs, not hugely popular w/ kids?

I notice w/ myself that a lot of days, if I start out "ok", my BG will still run up, sort of on it's own. I like to get up, test, have coffee, etc. (read Tu nighttime dispatches...) and then shower and then test again to see which way it's going? If it runs up, which isn't unusual, I can take that into consideration.

My daughter always spikes after eating. She has been T1 a little over two years and is 10 yrs old. She boluses before she eats but always stays btw 200-400 in the 2 hours after she eats. This does not affect her in a bad way(ie. mood, disposition, general feeling of well being). She does seem to spike higher after eating foods that are considered "high glycemic". Her endo does not have a problem with this. The endo tells me that a spike after eating is normal, and that it is better for her to have slightly elevated numbers as opposed to trying to keep her lower and having low blood sugars which adversely effect brain function.
The thing I always to try to remember is that diabetes control is more of an art than science. That is to say that you can do the same exact thing every day and get different results. I try to trust my and my daughters intuition and adjust as needed.

We have only ever had success with dual waves when covering pizza (from Pudgies and specific size slice) Again today the nurse suggests dual wave at breakfast but that just doesn’t make sense to me with him spiking so quickly and a normal bolus not taking effect soon enough how would delaying part of it would help? So then suggested to increase am basal. So we will have to test that with meal delays.
He used to eat scrambled eggs when he was younger and first diagnosed but then stopped. But now since Easter he has liked hard boiled eggs so that has been very helpful.
I have never heard of the super bolus, but I can see how that may be helpful at times. It just seems like there is some degree of resistance or something in the morning maybe because his basal has been lower and just increases at 7am and he is up and eating by 7:30. Tomorrow we shall see how things go. Thanks so much. Thanks Amy. We had a similar issue here, with struggling with Rorys highs finally changing the site and getting a snack and my 4 year old getting the ice cream out for her snack. I really didn’t want Rory to have it since we were finally getting him under control and Ava saying “I ate all my dinner” so she wants the treat. And she just loves to show Rory what she is eating! Lol

I would get rid of the treats too but I am sort of a food dud and do most of the grocery shopping. I always ask the other team members, MrsAcidRock and junior if they want anything from the store but, if they ignore me, no treats besides mine!

I'm a little mind-boggled by this. You are ok with blood sugars between 200 and 400?? Her endo does not seem to have a problem with this, but he is not the one who will be suffering from severe complications down the road!

I wonder if this is at all related to the Dawn Phenomenon. It might be worth asking the endo about.

Currently not overly concerned. I have not had any experience with her in the last two years where she has not spiked after eating. Her A1C is under 8. When I have tried to increase her Novolog to combat the spike, she has had a black out low. The research I have read to date indicates it is not unusual for children to be higher after a meal. If you can provide information that can help me help her maintain lower BS without black out lows, please provide.

I'm sorry, mojavenation, I don't understand your not being "overly concerned" Spikes of 200 to 400 on a regular basis are not ok. She has many years to accumulate complications and if that is a regular event for her she is in danger of having life altering complications in adulthood. And an "A1C under 8" is quite high. You list your current A1C as 9.4 in your profile; that is extremely high! You need to work with your endo to find ways to balance her basal and bolus doses so that she doesn't spike that high, without of course, putting her in danger for extreme lows. A couple suggestions would be doing basal testing first to make sure her basals are right; if basals are not right, then you can't begin working on bolus doses. After doing that, then the goal is to make tiny changes in bolus ratios to see if you can achieve less spikes, while not going low. Ratios might need to be different for the different meal times. Another thing to consider is what she eats. You are right that different foods will affect her blood sugar differently. Do experiment with foods until you find those that are easier to bolus for accurately. As Type 1's we can't always perfectly control our blood sugars and highs do happen. But to accept highs of 200-400 pp on a regular basis is not ok. If your current endo thinks that is acceptable, you need to find a new endo. You say your daughter's "mood is not affected" by highs, but her longterm diabetes management is. Not to be too blunt, but are you willing to accept kidney damage, loss of limbs and loss of eyesight as "normal"?

I know starting out our endo told us only to check before meals and bedtime, don't cover highs closer than 4 hrs.,..So at first I wasn't even checking after meals. He was only 1 and I didn't want to have to do more checks than necessary. But one day I did and he was in the 500s within those 2 hrs!! It was scary! But yet he would be down to a near normal number by next meal. They told us the same thing to not worry too much about the highs at this age. I never felt comfortable with those highs and I can imagine it isn't good to rise so quickly and then drop so quickly. :( I can't even imagine what that must feel like. But target ranges for glucose control and A1C are different for children. We really have to do whats best to avoid dangerous lows. Rory is getting better now with letting us know if he needs a snack but kids may not always be able to communicate that well. I can remember a time him going from an active bouncing around the house toddler to floppy and barely conscious! Very scary! Mojavenation, is your daughter on a pump? The pump really helped us bring down his A1C and have more control over the basals. When we were doing injections we would try to increase the Lantus just a bit but then dealt with more lows, went back and then had more highs, very frustrating! The pump has been great for helping with that!