So, I’ve been noticing of late that when our sons BG is high (over 200), whenever we give him his correction dose + .5 or 1 unit based on what he’ll eat for the meal, that the BG doesn’t ever go back under 200…it only goes up from there. We are waiting 15 minutes prior to feeding him as recommended, but it doesn’t seem that the “correction” part of the Humalog ever does the work that it’s intended to do (take it down into the 100’s).
I’m wondering whether it’s advisable to just NOT feed him until the Humolog actually begins to work and takes him under 200…ideally, around 130 or so. Any idea what could be causing this? So, let me give you a specific scenerio.
Before meal BG = 212
Correction Humolog dose of .5 is given (between 200 - 300 = 1/2 unit correction)
Additionally, another .5 dose is given for the 22 grams of carbs he’s about to eat.
So, we’ve given him a TOTAL of 1 dose of Humolog…1/2 to “correct” his BG > 200 and another 1/2 for the food.
Then we wait 15 minutes (BG is a straight “level” arrow, btw…not double or single arrows up)
At the 15 minute mark his bg is still “level” but hasn’t moved under 200. It’s 208 now.
He eats.
30 minutes later, he’s at 225. (45 degree arrow up)
45 minutes later he is 240 (straight arrow up)
1 hour later he’s at 220 (level arrow)
1 hour, 15 minutes later he’s at 215 (45 degree arrow down)
1 hour, 30 minutes later he’s at 205 (level arrow)
1 hour, 45 minutes later he’s heading back up at 207 (45 degree arrow).
Maybe it’s just too little dosage being prescribed to give for the carbs he’s eating? The Endo is constantly tweaking this for us so maybe it’s just that the carb-to-insulin ratio is too low? If you can think of anything else it could be, please advise.
So, my main question is…should we wait to feed him until the insulin has a chance to take him under 200? (Ideally I’d like to begin feeding him at 120 or 130 as long as it’s not double arrows down.)
I can only answer from an adult perspective, so take all of this with a pound of salt as it applies to a child. That being said, diabetes is diabetes; some things raise BG and others lower it. Okay, disclaimers issued. Now:
Do you know for a fact that 15 minutes is how long it takes for the insulin to start working? That number varies greatly from individual to individual. Is that a general guideline you are applying, or have you determined, empirically, what the correct value is for your son?
Based on the scenario, insufficient correction looks like the most likely culprit (no drop after 15 minutes). Disregarding the high starting point, a rise of only 32 points (40-8) that comes back down in 90 minutes is pretty reasonable. I’d take that any day.
In an ideal world, one should correct their BG first and wait for it to return to normal, which takes 1 to 2 hours (or more). Then calculate carbs, bolus, and wait for the insulin to begin to work in an effort to time the action of the bolus insulin to the rise in BG caused by eating. I always try to encourage my daughter to correct and wait until her BG is no higher than 120 before bolusing and eating. However, like most people, she doesn’t want to wait before eating. If you’re starting out with an elevated BG before eating, you’re fighting a losing battle and will be chasing a high that takes longer to correct. With a kid, I just don’t think it’s possible to avoid this all the time. They will learn to delay gratification as they get older. In the meantime, we can only do our best.
We haven’t determined that yet, empirically. We are, right now, using the guidance advised by the Endo, (and the medicine itself for that matter.) To implement changes means that empirical evidence/facts need to be ascertained first…and the first part of that is even NOTICING that it’s happening. That’s where we are right now…we’ve noticed a potential problem and we’ll start tracking it (gathering emperical evidence for HIS body)…but I wanted to reach out to the TuD community to really find out if waiting is OK - beyond the “recommended” 15 minutes after receiving the correction unit + bolus unit.
So from what I’m understanding you saying, you think it is OK, then, to wait until his sugars get back to the “good” zone before giving bolus and feeding? I mean, logically, that makes sense to me too…I just don’t want to be doing anything wrong that could hurt him in the long run. This method would mean more shots…but that will be remedied once we get him on the Pod anyway.
I’m not going to say it’s OK, because that’s something only your son’s endo can say.
What I feel comfortable saying is that the parents of kids with Type 1 with whom I communicate (at least the ones who are fairly successful in managing their children’s D within a pretty tight range [and I have no doubt you will become one of these parents in short order]) use essentially the same strategy (as do most of the adults with Type 1 that I know): do everything within your power to keep BG within range at all times so you never need to correct and bolus for carbs at the same time. Expecting insulin to simultaneously bring down a pre-existing high and prevent the rise in BG secondary to consuming carbs (more on protein and fat farther down the line) is not realistic, especially within such a short span of time. As I mentioned previously, a correction dose is going to take considerably longer than 15 minutes to accomplish its job (how long varies from individual to individual). And, at least in our experience, a 15-minute pre-bolus time is inadequate. You have to remember that endos, for the most part, err on the side of preventing lows. But like Terry4 has said, having tight control means experiencing some (hopefully infrequent) lows. IMO, based on everything you’ve posted, what is fundamentally off in your untiring efforts to stabilize your son’s BG is the fact that his basal rate and ISF are likely too low. Hopefully this will all get straightened out sooner rather than later once you begin pumping. Keep up the hard work; it will eventually all come together and you will begin to more consistently see lower numbers.
ETA: Changed my wording in the second paragraph because when I re-read it, it came across as saying that you are completely failing and that is definitely not what I’m trying to say.
Regarding “lows” (but not specifically this scenario), we have actually become comfortable in the knowledge that his food is doing what it should be doing within his body. What I mean by that is, if he is, let’s say 100 with a 45 degree arrow and he eats 20 grams of carbs, the OLD US used to freak out IF his receiver began reading 60 or 70 (and appeared to still be going down), but after multiple finger sticks and realizing that that’s not actually his bg (it appears that the receiver lags behind by 10 to 15 minutes…at least that’s what we’ve noticed), we’ve finally gotten to the point that we don’t even pay attention to that “low” reading as long as he’s awake and playing. If he’s eaten his food, then his BG is going up and checking his blood (sticking him yet again) isn’t going to change that. So, as long as he’s playing and doing whatever he’s doing without seeming tired or what have you, we just watch the receiver now. And, like clockwork, it starts going back up, then everything is hunky dory again.
Reading your post, I’d think it is most likely his correction factor may be off. But as others have said 15 minutes isn’t really a very long time to see if its being effective or not. However with injections its really hard to dose for anything more than 1/2 units or whole units. If you are using a regular syringe you are just kinda eyeballing anything in between, and pens…well you don’t even have a chance to eyeball it. This is where pumping is especially helpful because you can dose those impossible to get increments that you just can’t do with injections. If possible, I’d do a couple of things…after a correction wait if possible and your son will cooperate 30 min to an hour…see what is happening with the correction dose. That should help determine more if you should maybe wait a bit longer when high to eat…or if the correction is too low. As you get more comfortable, and as your son gets older and obviously his needs will increase, using more precise carb counting will def come into play. I think there is great caution especially in early diagnosis and young children not wanting them to go too low…but also it’s not good to have them running high so much too. It will come together, and will become easier in time. You all are doing a great job. Hang in there.
Answering from an adult perspective also I have been told to eat a low or no carb meal with a small bolus but i often can just stay level or spike up so I have to take more insulin correction if I want to drop down and then have to risk a possibly crash depending on the situation.
Great question. You want to correct a high blood sugar. You can’t at meal time. But meal time is flexible. It is a question of life style. Does he eat when others eat or when his blood sugar is low? The diabetes part of the equation is don’t eat. But very importantly hunger may not allow you to wait long enough. In that case you eat protein and fat. Now let me introduce you to a major community knowledge. The instructions of doctors didn’t work. We were told to do various things and if we did them well enough our diabetes would be controlled. The instructions we got could not work could never work. They were meaningless rules of thumb.
I’d actually say “rules of thumb that should serve only as starting points at the very beginning of your diabetes journey”. Aaron10 makes an excellent (and well-worded) point. IMO, the overwhelmingly vast majority of PWD who have great control (low A1c’s with minimal and relatively infrequent “excursions”) are the ones who learned the (albeit complicated) “basics” and then took control of the rudder of their own diabetes ship.
Two to three weeks after my daughter began pumping (yay, OmniPod!) and was still in the high 100s to 200s (and worse), I stopped sending detailed charts to her D-team on a daily basis for instructions on what to do next (as I had been instructed to do) and did it myself, applying the knowledge I acquired from Think Like a Pancreas. Less than 10 days later she was in range and has never had an A1c higher than 6.4 (usualIy in the mid-to-high 5s, which I suspect will only improve once she exits the Puberty Hormone ride). I truly believe my daughter would have been swimming through the muddy waters of the high 100s to low 200s for another several months (or even longer) had I not taken matters into my own hands.
This highlights a point made again and again in this community, but that never gets stale: if you truly want good control for a lifetime, you must become your own diabetes expert. There simply is no shortcut. I’ve said this before, but maybe 5% of what I know about controlling diabetes was learned from doctors. The rest came from self-study and interaction with knowledgeable diabetics here.
If ONLY we were in the 100’s to low 200’s all the time. We’re now in the 80 - 250 range MOST of the time, but we see spikes above 250 and spikes below 70 occasionally. I’m reading the Think like a Pancreas now and have already deemed some good information from it. I hope to get our son’s BG in the 80 - 140 or 150 range in the near future.
This week, we’ve had 3 lows in the middle of the night. There isn’t anything less fun than needing to wake up a sleeping 2 year old and forcing them to ingest something against their will. Anyone know of anything you can give a toddler (glucose) that they don’t actually have to wake up for? Wow how that would be great…something like Glucagon, but not Glucagon because that’s for emergencies and I hope the circumstances around when I would need to use that, never exist.
Apple juice box. Fast and effective. And the attached straw is so little, that it took no effort to slide it between my daughter’s* lips and past her teeth. She’d drink as much as I gave her without even waking up!
*who was not a toddler at that time
But many parents of toddlers with T1D swear by juice boxes. Doesn’t have to be apple. Check the carb count on the side of the box. Once I got her basal rates, etc. “dialed in”, it usually took less than a whole juicebox to treat a low or head off an impending low.
When I read blogs and Facebook posts by D-parents, most of them mention that children learn to drink juiceboxes in their sleep. I’ve also read of things like applesauce pouches.
Apple juice boxes and cake gel are what we use…but when he doesn’t want to “ingest” anything…(which is never in the middle of the night), there is no reasoning with him. That’s what I end up having to do is just squeeze a little into his mouth between each scream. BUT…we haven’t ever tried it while he’s sleeping. He is a very light sleeper, but I will definitely try this next time instead of waking him up first…what could it hurt!
We’ve always used juice boxes and cake gel and they work great…it’s just the getting him to ingest part that is the nighttime nightmare (while awake)
RE Gary Scheiner’s masterpiece, I consider myself a “bible (Torah) thumper”! I’ve referred back to this excellent font of D wisdom so many times that I’m beginning to wear out the pages.
Kind of my point. Vomiting when half asleep (or half awake, take your choice) can be problematic in its own right. But in a true emergency, of course, you do whatever is demanded. I may be misinterpreting, but I don’t think most of the incidents Harold is describing quite rise to that level.
There isn’t anything less fun than needing to wake up a sleeping 2 year old and forcing them to ingest something against their will. Anyone know of anything you can give a toddler (glucose) that they don’t actually have to wake up for? Wow how that would be great…something like Glucagon, but not Glucagon because that’s for emergencies and I hope the circumstances around when I would need to use that, never exist.