Only…DKA IS a sprint…
Well, yes. That’s why the 400 caused lights to flash and bells to ring.
Later—once you have time to relax and breathe—a book you may find interesting is Cheating Destiny by James Hirsch. It speaks to your circumstances quite directly.
Again…conflicting information that leaves me just confused. You’re saying stack and @Jim26 is saying don’t stack…
As has been said by many…T1 in Toddlers is like a different disease…and THAT is what causes me to take pause in “stacking” insulin and ending up putting him into a coma, or worse…
So many books on my list that, even months ago, I don’t think I would have ever thought about reading…now these books are all I want to read…
I didn’t make myself as clear as I could, either, I guess. What I was getting at was, 400 is too high to let go no matter the person’s age. Certainly small children (and the very old) react differently to things, so caution is indicated. Caution, in this case, means very small doses and close monitoring. That’s not the same as just waiting it out. That’s what I was trying to convey. Didn’t do a very good job. 
Very little doses is still stacking…since, at this juncture, we’re doing MDI’s… 1/2 units is as “low” as we can go…we’re anxious to start pumping because we feel this will really provide us with a much more flexible management for him. Even the ability to create different profiles for different scenarios that require different doses…
We’ll get through this…and we’ll figure this out. We have too…I have 6 children and they all mean the world to me, and I love them all more than my own breath…but this one…this one has melted my heart since day 1, and I would die if anything happened to him. Quite literally die…I have to figure this out for him.
So it hurts when anyone even hints to any “lack of care” on my part…I cry constantly when I am alone because I wish I could take this from him…
A pump is almost certain to make a major difference. Good luck with it. Again, it bears repeating that the chaos and amorphous cloud that seems to surround this right now is temporary. Take it from the thousands who’ve been there and done that.
And do keep that book on your “someday” list. It was written by a father in almost precisely your situation.
P.S. “Stacking” is an emotionally loaded word. The mental image is of piling on too much insulin. But look at the reverse side of the coin: if the insulin on board is inadequate (too small) to do the job, then “stacking” becomes part of the solution, not part of the problem. Provided that care and caution are exercised. It’s just one more example of the basic rule that with diabetes, hardly any rules are absolute.
If you only have time for one book, please get this:
Believe me, this will be the single most useful book for you at this point in your journey. It will answer so many of your questions and clear up a lot of your confusion. This book is worth making time to read. Then it will become a useful reference for questions you will have down the line.
Just to be clear, Cheating Destiny is 10 years old and a bit out of date regarding technology and standards of care. Where it’s valuable is in negotiating the emotional minefield. Hirsch is the father of a diabetic child (not a toddler, but the emotional hammer blow is pretty similar). He is himself T1. You might think at first that that would make it easier. It doesn’t—for him, at least, it makes it worse. There’s a lot in there about . . . just plain coping.
Understood. Still sounds like something right down my alley.
I think you need a more timely response when responding to events like a +300 mg/dl sustained level. Maybe your doctor cannot give you this but perhaps a diabetes educator or other qualified individual can help you work through these mini-crisis – at least until you become competent enough to make decisions yourself.
I would definitely raise the issue of diluting insulin with your doctor. This is a very rational response to an insulin sensitive toddler.
“Stacking insulin” has acquired pejorative status between health care advisors and patients trying t control blood sugar in the real world. There is nothing wrong with stacking insulin when it is done carefully and deliberately, with your eyes wide open and emergency glucose at hand. I will argue this point with anyone. Waiting for three hours to deliver a correction can also be a very dangerous tactic.
You and your wife are wonderful parents. Your willingness to learn a whole new discipline so quickly is testament to that fact. Try not to let this get too intense for you; look for some ways to build in some down time. You are doing everything you can. Give yourselves credit!
7 Likes
Hi ClaudandDaye,
It’s so hard, I totally get it – And I think those who are horrified by the 300s and 400s have probably never tried to control BGs with a toddler who uses such tiny doses that they are still hugely inaccurate. The half-unit dosing limitation means that basically every meal or correction bolus you are giving could be off by about 45 percent of what your toddler actually needs. It’s just such a hugely inaccurate dosing regimen that there’s no way to aim for a narrow target. I contend it’s actually mathematically impossible.
Beyond that, toddlers eat almost the same number of calories as I do, and yet they weigh a fifth or an eighth of a petite woman…it’s no wonder that they’re so sensitive to carbs (many will keep the same carbFs till they are teens, for instance) and that their blood sugar is so variable. I think that, while of course a 300 or 400 is never an okay or good number, it’s also inevitable with toddlers at least occasionally and that you’re right it’s not something to be blamed for. It’s so hard to figure out the tricky balancing act of high/low with such crappy tools. Also, they can’t recognize or treat their own lows, and their brains are still developing, so every new parent is told to avoid low BG at all costs.
On the other hand, I think you will all be happier once you embrace the fact that going low-- especially for a toddler who is on a CGM – is essentially something you can plan for and avert and is 99 percent of the time NOT an emergency even if it does happen. Once you get used to the arrows and trends on Dexcom, you’ll realize by the time he’s, say 100 and straight arrow down or 125 and double arrows down (or some personalized set of numbers for your son) that you need to give him a fast-acting carb or test his BG, and will be able to avert the low altogether. While I don’t advocate “feeding the insulin” as a regular matter, I would be willing to do that if your son is in the 400s and you’re worried that correcting it could drop him low. Doing that (i.e. giving potentially too much insulin and then planning for a low) every few weeks is not the end of the world, in my opinion.
Also, when you’re just starting out, endos really drill into your head the fear of lows – they talked about brain damage and seizures and express trips to the ER. The truth is, however, that there is NO conclusive evidence that even fairly severe lows (below 65 or even ones that cause seizures in kids) are incredibly damaging for kids in the long-run, whereas there IS evidence that high BGs cause long-term complications and may affect brain development (for instance, the brain does not need insulin to ferry sugar into it, so it’s marinating in high sugars in some proportion to your circulating BG, whereas it does have protective mechanisms to ferry glucose to the brain or even power most brain metabolism with ketones when BG levels drop too low). Lows feel awful and are scary for everyone involved, so obviously do try to avoid them, but I would always trade an increased risk of a low for less time spent horrendously high.
I think that most ENDOS are wrong on this one. So in my opinion, what I would do in that situation is really take the risk of facing a low, and just know that you can stop it. I don’t fully understand how the Dexcom AP algorithm works, but my sense is that it’s almost exactly real time when numbers are changing slowly and the most behind when numbers are changing rapidly. If I assume there’s a 15-minute lag between a finger prick and interstitial glucose reading, oI will sometimes look at the number on Dexcom (say, 155) , the rate of change (say, 25 points from the last five minutes), and then take that rate of change and multiply by 3 to get a rough sense of what the BG might potentially be at that moment – in this example, the true BG could actually be closer to 80. At that point I do a finger prick and then if low or trending that way, I feed a fast-acting carb and can usually avert a real low before it happens.
Also want to add that our son was on diluted Humalog (1:10) at first and its properties were totally unpredictable and its onset of action totally blunted. It’s also a PITA to get it. You can’t just buy it in the pharmacy and compounding pharmacies often have limited hours, and it doesn’t last as long as undiluted. So you’ll spend every few weeks scrambling to make sure your undiluted doesn’t expire or run out before you can get more. In general we found Humalog to be somewhat unstable and to have undesirable tail effects (where all the insulin kicked in towards the end of the DIA, which is the opposite of what you want). So if you can get approved for another insulin, along with a pump, your situation may improve dramatically.
Take heart, it’s such hard work and you guys are doing a great job.
Also, do I understand correctly that you have 6!!! boys? I am kind of in awe. I have two and feel like my life has a constant soundtrack of banging and screaming and fighting and wrestling. So my hat is off to you for that reason alone.
3 Likes
Yes. I have six. A daughter who is about to make me a grand dad (she’s 22 and 12 weeks pregnant now). She’s my only daughter and from a previous marriage. My wife and I only have boys…five of them. 13, 10, 8, 2 and 4 months of age.
Thanks for your information! What insulin do you think is a better bolus for toddlers than Humalog?
I think this is one instance that illustrates the difference between kids and adults with diabetes. It really doesn’t take much at all to push a Type 1, especially a child, into 400 territory. And while, yes, it should be monitored and corrected, it’s also not the type of number that’s going to resolve in an hour or two or even four. So, to a certain extend you have to correct and then just watch for a few hours to see what happens before deciding on the next course of action.
With such a young child who is newly diagnosed, I definitely think you should have an endocrinologist or some other member of your diabetes team who you can contact to get immediate advice when needed.
1 Like
We do. We can contact our Emojnndo anytime we have concerns. We did that today.
Thx all.
We use Novolog and like it a lot better. But it’s a lot more $$$ so your insurance company may want proof of “failure” on Humalog before you can switch.
1 Like
All of what Jen said. Honestly, looking at your son’s dexcom graphs, you’re really NOT doing that bad. Yes, spiking to 400 isn’t good, but he’s not staying there for half the day and to some degree with a small child it’s almost unavoidable - especially with a 1:45 carb ratio. That makes him both very sensitive to carbs (spiking him higher and faster than someone bigger), and very sensitive to the insulin needed to cover those carbs, a combination which is just going to be more volatile than the average adult commenting on this thread who needs at least 3X more insulin to cover the same amount of carbs and probably doesn’t drop 100+ points with one unit of insulin.
A lot of T1 management is unfortunately “wait and see” and there isn’t a whole lot of ways to get around that currently.
1 Like
Are all of these spikes related for mealtime spikes? If so, the problem may be that your 1/2 unit does is just too low and when you think you are giving a 1/2 unit your son may at times get no insulin. Since you have meals without these spikes it suggests that a 1/2 unit might be in the right range and supports the misinjection theory. While Humalog does last up to 5 hours it’s main action comes in those first two hours. If your son is 400 mg/dl two hours after a meal it is unlikely that the tail of the insulin action is going to be sufficient to bring him smoothly down to a normal blood sugar.
Think about it, your endo gave you the guideline to correct with a 1/2 unit for blood sugars in the 200-300 mg/dl range. That suggests an insulin sensitivity factor (how much a unit of insulin drops your blood sugar) of between 100 and 200. If you had fed your son and NOT given him insulin and he ended up at 400 mg/dl your endo would have suggested correcting with a 1 unit or even 1 1/2 units. Take away the 1/2 unit he “might” still have on board (but really doesn’t) and you still need to do a big correction. A blood sugar of 400 mg/dl at 2 hours after a meal likely means misinjection and warrants a correction even if insulin was given properly. Maybe not the type of correction you would give for an elevated fasting blood sugar, but “some” correction. I would advise you to talk with your doctor to see if you can develop a better plan to deal with these large blood sugar excursions. Perhaps he would agree to a correction plan that conservatively subtracted the “entire” mealtime bolus which would account for 100% stacking.
3 Likes