When to treat an impending hypo to head it off without resorting to glucose tabs?

Our 2-year-old has had several hypos in the last week, including a super scary one at BG measuring 49 last night. We freaked out and wound up not following the strict retest protocol and of course ended up over-treating…2 juice boxes, 1tsp honey, plus my husband gave hm various non-fast-acting carbs like a rye cracker and a tangerine. Not surprisingly he wound up super high and needed corrections all night to bring him into range.
I guess my question is:
a) At what point in CGM readings should we be giving him regular-acting carbs to head off an impending hypo before it becomes an urgent situation requiring the glucose tabs and the honey and the juice boxes? When he’s 120 and straight arrow down? 100 and trending down? 140 and double arrows down? Is there a heuristic/rule of thumb that can be used to head these off without sending his BG shooting off into the stratosphere?

b) While we will of course treat with those when the BG reads below 80, if we could avoid the hypo in the first place we could give our son healthier carbs for heading off the low. Are there some more nutritious second-line carbs that we could use when he’s, say, 120 and arrows down, – so maybe they are fast-ish acting, but just not as fast as a glucose tab? We’ve tried milk but he’s not crazy about it, anything else in the semi-nutritious category?

Does he like yogurt? A small quantity of not-too-sweet yogurt (10 g carbs) helps me, maybe with some blueberries or strawberries?

Is your son on an insulin pump? Once my daughter started pumping, she experienced less frequent lows because I could set up many different, variable basal rates to better meet her daily basal needs without having to be stuck with the one basal rate per day you get with using a long-acting insulin. Pumping also allows me to cut back on her basal rate by a specific percentage for a specific amount of time when I see her trending low, and this has headed off a few lows at the pass. We no longer get too excited about lows until my daughter hits about 55, nor do we usually give in to the urge to overcorrect. After treating a low, we wait at least 25 minutes to see if the low is coming up, unless she is still feeling significantly low.

“Sugar surfing” a la Stephen Ponder, MD, also helps to decrease the frequency of lows my daughter experiences. Whenever the Dexcom arrow is pointed straight down (unless we are in the process of correcting a high), I tell her to eat 2 to 8 carbs and keep an eye on the arrow. Double arrows down (again, unless treating a high) needs about 10 to 18 carbs.


If you haven’t heard about it, you may want to check out the book Sugar Surfing, by Dr Stephen Ponder. He also has a website with much of the same information, including many annotated pictures of CGMS and how to react to the ups, downs and curves. One important thing I learned was the term ‘watching for the bend’, as a better indicator than the arrows in some cases.

If I am at 100 and gradually going down (and verify with meter), I will have a small snack (handful of nuts, or a couple crackers), then ‘watch for the bend’. If 15 min later it is still going down and approaching 80, with no change to the slope/angle, then I eat more.
In the ideal situation, it levels out in the 80-85 range.
I also try to consider prior activity level, current insulin on board, food on board, etc. If I’m about to head out to drive, or be active, I would also treat differently.

(FYI Dr Ponders is also T1D !)


you know watermellon has a glycemic index of 140 meaning it enters the blood faster than glucose with a 100 glycemic index. How about googleing for glycemic index to find the fast acting foods. You could run an experiment when your son’s blood glucose is stable and good give him one glucose tab and see how much that raises his blood glucose. Then when he is 50 mg/dl you will know how many tabs to have him eat to bring bg up to 100. If he’s 50 mg/dl with a down arrow then give him more. If I remember Dr. Edelman of TCYOD said a 20% increase. And providing more food does not increase the rate of digestion. Chewing the tab well will increase the speed.

What about dried fruit or pudding? Bananas also work pretty fast.
Or, maybe some oatmeal or pancake with maple syrup on it…

Hi MM1,
I actually am in the middle of it, and incorporate some of the tricks. Seems like those techniques will be very useful when we get better at understanding our kiddo’s rhythms.
At this point, we’re hampered yb the fact that we’re using diluted insulin cause our kid’s so small, and I’m just now realizing (after a brief and terrifying experience with the undiluted kind), that the diluted insulin is just insufficient.

All the more reason to pump. An insulin pump can deliver incredibly tiny doses of insulin!

Hi Tia,
I can’t imagine trying to cope with what you’re dealing with for a 2 yo. Glad you are finding some things to incorporate from the book. With more time and experience I think you will get better at what works well for your situation.
Glad you found TuD, as there is always helpful advice and support.

At ‘Camp Ho Mita Koda’ Type 1 diabetes camp, they gave us graham crackers with peanut butter if kinda low. For instance if 100, but we’re at the swimming pool. Orange juice was to go to for any serious lows.

When much older than 2, look at the Airhead candy bars. While unhealthy, they’re portable and spoil proof with a mix of sugars and even starch, for a total of 14g. I’ve found nothing better in 25 years of T1D.

Sugar, Corn Syrup, Maltodextrin, Dextrose, Modified Food Starch (Corn), Partially Hydrogenated Soybean Oil, Water, Citric Acid, Artificial Flavors, Artificial Colors.

Best of luck!

Not to mention the incredibly great taste of Airhead bars! They taste so good that you just know that they are unhealthy. But they supply super-fast sugar and are great for treating lows. And they are available year-round when watermelon is out of season or for those times when you just don’t happen to have a watermelon handy…

And just give me a bag of the sour patch sweet and sour watermelon pieces - yum! :yum:

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