So confused...please help unconfuse me

Type 1 and LADA Parents of Children with Type 1 Diabetes
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So, lately we’ve been chipping away at honing in Liam’s sugars and we’re down to 6.8% AIC right now. However, I’m puzzled about something. So, check this out and let me know if you have any ideas of what could be going on and/or any ideas for how to fix it.

So 75% of the time we are in the “good range” (80 - 180 is our range right now.)

But there is ONE time of the day that I just can NOT get “tamed”. Every morning when he eats breakfast at 10:30, inevitably, he skyrockets up to over 250. Sometimes over 300, and TODAY OVER 400!

He usually eats between 25 - 35 carbs for breakfast.

First, a disclaimer: He IS sick right now…he has congestion/coughing…just a regular cold (we took him to Dr’s to verify it wasn’t the flu or pneumonia.)

So, to try and compensate for this known spike, and for the fact that he’s sick, I’ve done several things. First, I created a separate “Sick” basal rate profile and upp’d all of his basal rates because he’s required a lot more insulin (double) over the past week than usual. Below is his “normal” Daytime insulin regimen, then under that is his “Sick” insulin regimen.

"Regular" Profile

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"Sick" basal profile

Here are the trends (highs) over the past 4 days:

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Based on previous days, I’ve continued doing a couple things.

First, I’ve INCREASED his basal rate, DAILY, within the “Sick” profile to what it is currently at .50u/hr. (I’ve gradaully gone up by 5’s from the usual Daytime .25/hr.)

Second, I’ve DECREASED his I:C ratio for this time frame from his usual 28 carbs per unit, to 26 carbs per unit.

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So, my question is…am I doing something wrong here??? Should I just JUMP UP to 1 unit/hr for this time frame and put his I:C at like 20 or something?

It just seems like the HIGHER I go with his BASAL rates during this time period, and the LOWER I push his I:C, the HIGHER his BG is! And that just makes no sense to me! Right now, his BG is FINALLY dropping, so I know the Insulin is in his body and is working. It’s just not working like I had anticipated it should…and not like it does the rest of the day (as you can see by the trending information.)

Please note, here is how his meal goes down for this specific time period.

IF his BG is above an acceptable level, I don’t feed him; instead I just correct and wait for his BG’s to be in an acceptable level first, then I bolus and feed him.

For all the trending information listed above, his BG’s have all been in the right range before eating, so we’ve been able to bolus and feed him according to the usual protocol, which is as follows:

At 10:15AM, check sugars and bolus him.
At 10:30AM, he eats.

This is the same thing we do every day for his breakfast…we finally got into a pattern of feeding him at the exact times each day as we found (and we knew this beforehand which is what led to the change) that doing this makes his body react in similar ways every day; instead of the body never knowing when it can expect to receive energy.

So he eats every day at 10:30AM, 2:30PM and 6:30PM, then he gets a snack before bedtime. We don’t do snacks in between right now because that was throwing off our basal testing.

So, any help would be greatly appreciated. I’d love to get this figured out. I have most of the rest of the day pretty well under control right now…there are occasional smaller spikes, but this one time of the day is just kicking my a$$.

I watched his sugars rise this morning to over 400 and stay there now for over an hour. It’s finally dropping, but the last time I checked his BG at 12:47PM, it was 404.

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Thanks beforehand.

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First things first. An A1c of 6.8 and 75% TIR is flat outstanding for where he started from and how recently you began this learning curve. Please let that sink in for a moment.

Now, then.

Illness can absolutely introduce chaos to the best-dialed-in regime in the world. This is doubly (triply?) true for a child. It adds a giant and largely inscrutable variable to a situation already fraught with unpredictable variables. Until he is well again, don’t get too heavily invested in any weird fluctuations that pop up. The craziness is diabetes’s fault. It’s not you!

But the bottom line of dealing with diabetes, whether uncontrolled, perfectly controlled, adult or child, is do what works. This is always and forever a pragmatic and empirical exercise. If he needs a bolus that is 2¾ times what he normally uses just to get a reasonably flat response, then that’s what you do, until things return to whatever constitutes your “normal”.

I get how infuriating it is to deal with something that just won’t obey fixed rules. For those of us with a scientific or engineering mindset, there is an irresistable compulsion to reduce a management task to a set of dependable rules that stay the same. Unfortunately diabetes simply doesn’t play that way. There are just too many variables, many of which medical science hasn’t even identified or figured out yet. It’s one example of where the real world collides with a model and the model loses.

Diabetes is a moving target. Don’t make yourself crazy chasing it. Do the best you know how to do at the present moment, learn from it, and move on with life. It WILL get better; as noted at the beginning of this post, it already has.

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Hey, so here’s my two cents: If he’s been sick, his insulin needs could even double and the rise isn’t uniformly spread across the day. Our son typically has a TDD of 8 units but when he’s sick, he may take anywhere between 12 and 15 units per day.

The fact that you’re seeing this up-and-up pattern is probably more reflective of his body’s internal workings, rather than some inverse relationship between insulin and BG just in the morning. As a short-cut, I’d just look at how much insulin I delivered over a morning to get him back down to his range, then up the basal and bolus ratios to give him almost that much upfront. It’s up to you whether you want to split it 50/50; we have found over the past several weeks that upping basal seems to have more of an impact than upping bolus, for whatever reason.

Also remember that breakfast is a beast to tame. Your body has been fasting all night; it wants to get those sugar levels up. So it will fight your insulin tooth and nail.

I wouldn’t jump straight up to 1 unit per hour, though; that seems like quite a lot. My guess is that you’ll up it some more over the next day or two and all of a sudden start seeing incipient lows, and that’s likely because your son has conquered the illness and is on the mend. FYI even non-diabetic people can run BGs in the 200s when they’re sick.

Also, CONGRATULATIONS ON BREAKING THE 7.0 BARRIER. It feels great to meet those targets, right??? Keep up the good work. :slight_smile::star::star:

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Also wanted to add: Make sure to check those ketones when he’s spiking so high. IT’s usually pretty unlikely to form ketones from just a missed mealtime bolus, but if he’s sick he may not be getting the basal insulin he needs and ketones can develop pretty rapidly. We found that upping basal worked really well to clear those out.

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I’m working my way through your comment but I have a preliminary remark about clearly expressing and characterizing the insulin to carb ratio. Please excuse if my words seem nit-picky. Clear and unambiguous language is the coin of this realm.

Be careful when expressing the insulin to carb ratio as increasing or decreasing. I’ve seen much confusion over this inverse relationship. To increase the amount of insulin that the I:C ratio yields one must decrease the number of carbs.

Perhaps a clearer way to think about and express this relationship is to say, “I decreased the number of carbs that one unit of insulin covers so that my adjusted I:C ratio increases the amount of insulin I give.”

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Yep, I understand that lowering carbs (or lowering the I:C) = an increase in insulin. And that’s why I lower the number because I WANT more insulin.

Thanks!

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I understand and I know you get the inverse relationship. I only made this comment due to the confusion some readers encounter.

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Bah, somehow my previous comment got written over instead of adding a new comment. Sorry about that!

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This is what I’ve been noticing for the past day actually. I’m seeing less insulin required so he’s heading low and needing a snack since yesterday. But I don’t want to change (move down) his “Sick” profile because, well, it’s his SICK profile! I can see going off of it and going to the regular profile in the next couple days anyway.

Thanks! It does feel good. A little “vindication” for the hard work. It’s kind of a pat on the back…you did a good job, now get back to work, kind of thing. lol

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My boy does the same in the morning. I am having similar issues. I think it has to do with the fact that he is going from an empty stomach and the amount of baseline insulin just isn’t saturated enough to compensate or the body is prepped for metabolizing food at a faster rate. I like to think of it as driving up a hill. It is much easier if you have a running start. Many times my “car” only starts putting on the gas at the base of the hill…much harder that way. There is a fine line between getting a running start and running the car off the road. Having said all of this, this is what I’m dealing with right at this very moment…

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One possible cause of high readings in the morning is dawn phenomenon.

Dawn Phenomenon

Adding another measurement on in middle of the sleep period (at least once) can gather evidence on whether this is the problem.

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No cleaning or spraying/utilizing of any chemical compounds during this time at all. I think it may be more likely, as @Robert_Miles indicated, part Dawn Phenomenon, and part just the bodies natural course of events for morning time after having fasted an entire night.

Thanks all!

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This happens with my son as well. The first meal of the day, no matter how late it is, always makes his sugar spike higher than normal. If his first meal of the day is from 7:00-10:00, the spike is even higher just like you described.

I control it by giving a higher basal rate for those 3 hours, a slightly higher ic ratio, and absolutely no simple carbs without protein.

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This can also happen to us in the evening. There have been times where he has gotten home from school at 4:00, and we had a million things to do and didn’t get to eat dinner until 8:00. His sugar will do the same thing because he hadn’t eaten since 12:00 at school.

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I have all but fixed my son’s issues. I feel like I’m really beginning to gain an understanding of proper basal/bolus rates and this has dramatically cut down on his spikes. The recommendation given by @Tia_G really opened my eyes and helped me tremendously (among other people’s amazing advise.) I noted how much “correction” I was being forced to give Liam after his morning meal and adjusted his basal/bolus rates to account for that correction up front (increasing his Basal rate and Bolus rates so that he’s getting this insulin up front instead of after the fact after he’s spiked.)

Since making these changes, Liams’ BG’s haven’t gone above 250! And today, it’s only gotten to just UNDER 200! There is more work to do, but I feel like I’m understanding now and beginning to make moves that I wouldn’t ordinarily have known to do, but they are making all the difference in the world to my son!

@Kristian_Milliner, maybe you should give what worked for me, a try?

So thankful for everyone here. Always.

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I’m glad you have found something that is working! I have developed so many anxiety issues over the years because when my son was first diagnosed 8 years ago, we didn’t have the pump or CGM. We never could find a basal insulin that actually worked, and his sugar would spike really high after meals even though it was in range after the bolus wore off. Upping the ic ratio to keep the spike down only made his sugar low afterwards. Morning was always the worst, and the one thing that could have solved this issue was being able to have adjustable basal rates.

Since getting on the pump 5 years ago, I have gotten his spikes under control. My main issue now is that he is moving into the preteen years and wanting to only eat high fat foods, and he is “starving” every 2 hours. Those high fat foods are making his sugar high for like 8 hours after eating. Corrections will not bring those highs down.

I try to limit high fat foods, but I give in a lot because I don’t want him to feel left out at school events and with friends. I am just now learning how to extend out insulin for other foods besides pizza, but it is a slow process of experimentation.

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Yes, just the other night, my son (only 2 right now of course) had 1 cup of mashed potatoes because he loves them (like his mother.) I forgot to do the usual “extend bolus” that I always do for these types of foods and we felt it later. I usually do 25% up front and 75% over the next 2.5 hours, but since I forgot to do that, and only gave his full bolus up front, his system had 1.3 units IOB and he kept inching low for 2 hours so we had to give him juice over and over again for this mistake. I usually always extend bolus for pizza, pasta and mashed potatoes (anything that takes a long time to digest), but when we forget to do that, wow does it hurt later. We were fortunate that the “spike” after 2 hours didn’t happen on this night, but we had to constantly fight the lows from occurring.

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My experience with eating a high fat meal is that the meal takes much longer to digest but I am satiated and not looking for a snack after two hours. Of course, my metabolism hasn’t seen its teen years in quite a few decades! I’ve noticed that the “starving” sensation between meals is more often a side effect of high carb meals. Your son could also be experiencing bursts of growth hormones.

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@Kristian_Milliner, since you’re child is pumping the answer to the high fat foods is simply to learn to use extended boluses. When I have a high fat meal I always do an extended bolus over 4 hours.

This really does work. However, it takes a bit more attention and is a little more complicated than a simple impulse bolus.

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I feel I’m a little behind in what I should know about giving extended boluses. My son had texture issues and we had to go to a speech therapist at the age of 2. He didn’t start becoming interested in trying new foods until the age of 5. Except for pizza of course, lol.

I also never experienced any prolonged highs after eating out until now. PB sandwiches even are a problem now and they used to not be. I guess his body is changing and it’s taking him a lot longer to digest fats than it used to.