Looking for opinions/suggestions on what try adjusting:
My daughter eats breakfast around 7am-7:15am. Lately her bg between 9-9:30 is within 20-30 of her prebreakfast bg, but by 10:00am she goes up 40-80 and then we end up correcting at her bg snack at 10:00. I'm afraid if I adjust her I:C at breakfast she'll have a low between 9:00-9:30. Does it seem appropriate to try increasing the 8am basal rate a smidge? Is this Dawn Phenomenon or would that be much earlier in the morning? Thanks!!!
6am - .25
8am - .30
3pm - .25
Yes, I would definitely try increasing the 8AM basal a step. I'm not an expert on DP since I don't have it, but I think that is when you wake up high and then continue to rise if you don't eat.
The only thing I would suggest is change one variable at a time.
Try it a few times to get to a solid consistent number.
but i would definitely tweak the basal.
I had a similar issue of my BG spiking more than 2 hours after eating breakfast. I needed to increase the basal a little, but what made the biggest difference was changing what I ate first thing in the morning.
I changed from eating cold cereal every morning to a boiled egg and wholewheat toast and never again suffered spiking BG's after breakfast. My nutritionist suggested the change, and I'm glad she did.
You could choose a day when her BG is good at 7-7:15 and skip breakfest. Then see what it does until 10a when she would normally eat a snack. If it goes up, it's a basal adjustment. If it holds steady, it's a morning I:C ratio. (These are easiest to see if you have a CGM.) If you are concerned that bumping I:C could cause a low, you could do a "square wave" or "combo bolus" where some portion of insulin delayed.
You also might consider whether the delayed rise by 10a could be due to diet. Has she been eating more protein/fat at breakfest, for instance?
It can be tough. I have a dawn phenomena that starts about 5a. But I also have "one" that starts when ever I get up. I don't get up at the same time every day. So I basal the first one and bolus the second one. And adjust my I:C for breakfest.
Obviously, the most important thing is whatever seems to work consistently for you (her).
Out of curiosity, what does her BG look like at 4.5 hours after her AM bolus? Is it in her target range, or does it continue to go high?
Next question: What happens to her BG if she skips breakfast?
A few more: How long post-diagnosis are you? Are you still in the honeymoon phase or is she becoming a bit more brittle lately?
Finally: What insulin are you using in the pump?
Naomi's never gone 4.5 hours after a regular school morning bolus without a snack so I don't know what her bg would do in that situation. On the weekends she tends to have breakfast an hour or so later and in that situation when she's gone 4.5 hrs before eating again (rare) she's usually at the lower end of her target if not low.
On the few occasions where breakfast was eaten hours later than normal Naomi's bg actually went on the lower side and we had to treat a low at 9am once when she hadn't had anything to eat prior. Recently she had a upper endoscopy done (she's had major abdominal cramping lately and missed a lot of school) and so she had to fast prior to the procedure. We ended up giving her cake gel and tiny sips of juice along with a temp basal decrease and eventually no basal as we were trying to get her to go under at 170-190. She rode at a bg of 120 (they put her under general anesthesia)the entire time according to her Dex.
Dx was 10/28/2010, I'm thinking she's more brittle lately?!?!?
Animas Ping is our pump.
Upper Endoscopy w/ biopsies and an ultrasound found nothing. Not a big surprise. I've removed gluten and dairy as of two weeks ago(dairy send her bg to Pluto and back) in an attempt to help ease the tummy issues. I've introduced probiotics and digestive enzymes as of this last week. The morning bg's are still doing the same as I've noted above but overall they are MUCH MUCH better and fewer tummy troubles.
Thanks for asking questions and trying to help me! I so appreciate it!!!!!
Based on what you are telling us, I do not agree that Naomi needs more basal at this point. She DOES need more data however. I personally won't make a programming change on my son unless I have two clear indications that:
1). It is actually needed as shown by the data.
2). I know exactly which direction I need to go, and how far, and when.
As you can tell, I'm not a big fan of guessing. :)
To properly set basal rate, you need to see how a missed-meal causes the BGs to swing. If you have the basal set properly, during the 4-5 hours after a "missed" meal you'll stay within about 20 points of were you were when you *should* have eaten. If the basal rate is set too high (too much insulin), you'll drop. If the basal rate is set too low (insufficient insulin) you will see a rise. The caveat here is to make sure you don't have any unusual stressors present (an infection, job stress, or that time of the month) and that your starting BG is in or near the target range. If these entry criteria are not met, the test results will lead you down a blind alley and you'll be back to guessing (Ack! Pthooey!). Ideally you validate again a few days to see how your data holds-up.
Unless you are *really* out of whack and forced to instantly adjust something, I find the "lets wait and see if this is good data" ethic saves you a lot of crashing and banging.
For basal programming I like to set things so there is a slight upwards trend in the BG numbers after a few hours. This way if something untoward happens, you don't wind-up with a bad low.
I note that you have a CGM... which is a darned wonderful tool for basal rate programming. If you are like us and wear it only sporadically, make sure you wear it anytime you are playing with night time basal rates and program the alarms to trigger very early so you have time to respond. Dunno about your daughter, but my son becomes hyper-sensitive to basal changes in the 11 PM to 2:30 AM segment, so even the smallest changes can have large effects. The CGM has been a wonderful safety net for us here and eliminates a lot of the midnight nail-biting.
Edit: If you dont already have it, get the book "Pumping Insulin". It will go a long way towards answering the "is it basal or bolus that needs changing" type of questions. :)
BEST ADVICE - CHANGE ONE THING AT A TIME - with a week between. Variables outside the math formula come into play - emotions, sickness (sub-clinical infections), fat-protein content of meal, etc.
As I understand DP, it is the liver dumping sugar because the glucose in the blood is falling because a person has not eaten.
Now for a trick to try: spread the insulin bolus out. She may be going up because the insulin is used up but there is still sugar to be covered.