I need help with with regular sudden drops in my daughter's bg levels. My daughter is turning 4 next week. She began pumping at the beginning of this month with an animas ping. Her numbers which were all over the place have gotten to be very predictable now which I am LOVING! But there are 2x a day when her levels absolutely TANK. She eats a bedtime snack around 8:30pm and depending on her level then she will eat anywhere from 10 to 20 carbs. From midnight to 4am she rungs HIGH - like 350 to 400s then sometime between 4am-7am she falls. As in she is typically between 80 and 120 at 6:30am for breakfast. Which is good, but if you let her sleep in til 8am she will be around 50. It is such a dramatic drop. Same thing happens right before lunch. At 9:00-10am she has a 20 carb snack even though her BG is typically around 300 because at 11:30am she falls and will end up between 80 and 140 as long as she eats a 20 carb snack. If she skips the snack she will be around 40. So her before meal numbers are not bad by any means, but the 300 to 400s scare me. Plus by 9:30am I would think her breakfast carbs and insulin would have done there work and she would not be so high. She eats a variety of things for breakfast and snack times, but no matter how high protein, high fat, low fat, or any other combo of factors for digesting food does not seem to change these numbers. So far her medical team has been really hesitant to address the high numbers, because if we get them down then they are expecting her numbers at 6:30 and noon when she eats to be much lower. Both times when she is tanking is when her meals and bolus from her meals have worn off, but yet we can't really blame her basal numbers because look how high she is a night. Plus anytime we lower them for these times the numbers still tank and then she is high the rest of the day.
We do have a variety of Basal settings throughout the day:
10pm to 3am - .3
3am to 9am - .25
9am to 3pm - .15
3pm to 10pm - .2
Can anyone please explain to me what is going on and what do I do to combat it? She is unaware of hypos, and half the time she gives no indication of the low we only find out because we are testing her before her meal.
Thank You,
Ellen

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Replies to This Discussion

May need additional Basal rates for more specific hours.

Obviously, my 16 year old is much older than your little one. But, conceptually I thought this might help and you could run it by your endo first.

When my son went on the Omnipod, we fine tuned his basals by doing testing when he was fasting. He did not or could not fast all day but we would pick different times of the day - morning, afternoon, evening and even overnight - and were able to get his basals tuned so that if he did fast all day, his basal rates kept him at a steady 100 ( his target) 24 hours a day. If he was low or too high, we stopped the testing and adjusted his basals for another test day.

I don't know if they do this with children so young because the stress of not understnding that they cannot eat may totally negate the testing.

So now when my son is very high or low, we know that it is exercise which makes him low 6 hours later like clockwork or a fatty meal that can affect him hours later, a bad bolus estimate or stress. We feel pretty confident in his basals so that has allowed us to fine tune his bolus ratios for each meal.

Luckily, he is a consistent eater eating mostly the same thing or similar things for breakfast and lunch. Dinner is usually high fat and has a lower ratio to compensate. If we do test my son at an hour after a meal, he is up to 100 points above his premeal. Our endo is OK with this and says that is normal as long as he returns to target by 2 hours - this is what his bolus ratios are set to accomplish.

It is all such a juggling act. Good luck to you.

From the time my son was 2 until about 10, his post breakfast BG was always high, with it dropping right before lunch. At the time, we were not pumping. Knowing what I know now about pumping, I think you need more/different basal windows. Of course, you should always check with your medical team...these are just the kinds of things I would try if it were my son.

Sounds like she needs more insulin in the post-breakfast time and less in the pre-lunch window. That way you would do less eating for the numbers and more eating simply because she is hungry. The other thing I would consider is whether her IC ratio at breakfast time is right. She may need more insulin then than she does during other times of day.

Also, if she is dropping between 3 am and 8 am, then you do not have very much variance during that window than her nighttime high window. Perhaps adjust that basal amount to better suit her needs.

For my son, we always make one change at a time and wait 3 days to determine if the change worked for him or didn't. If you change too much at once then you don't know what step helped and what step did not.

Keep in mind that it is really hard to get this just right, and even harder given her age. I never knew what stable numbers were until my son was about 8 and we had moments of sanity (themes that he wasn't growing) where we actually got numbers we expected :-) In my experience there is huge volatility in numbers in very young children.

Hi Ellen -

My question - have you tried not giving her a snack at bedtime? with the pump she should not need one (in fact she should not need to be on any eating routine through out the day). If she wants a snack perhaps try a non-carb snack so you are not adding any insulin to the mix beyond the basal - that way you can track if the basal is where it should be. Once you get the basal rate set you will then have a clearer picture of her carb/insulin ratios and if they need to be adjusted.

As Hockey Mom says - doing carb fasting is the best way to figure out basal rates. My son with D began pumping the week he turned 4 - 13 years ago! and we did this by picking a window in a weekend day - like wake-up time through lunch, then the next day we would do lunch through dinner... Malcolm would eat eggs, cold cuts, sugar free jello etc. I am happy to give you more suggestions if you would find it helpful. During a carb fast you check bgs every 30-45 minutes to get a really clear snapshot of what the basal rate is doing.

A bit off topic...your daughter might really enjoy a book called "A special kind of pump" available for free downloading at www.grandmasandy.com - disclaimer - this is my wonderful mother's website and she wrote this book for Malcolm when he began pumping.

Let me know how I can be of help!!
Barbi
kid with D - Malcolm dx@2, 1996.

While the carb-fasting method might help, it's also the case that protein and fat will raise blood sugar a little bit. But, the basal should mostly cover that rise. If you fast with no food at all, you'll need to cut your basal more (this is based on personal experience in an adult; I never had my kid fast). If you try it, try to give the normal amount of fat/protein to test basal rates, and just have her skip the carbs. If possible. Or just increase the fat/protein as little as possible.
The early morning drop is bizarre; try increasing the 9pm-3am basal and decreasing the 3 am-9am basal?
The drop before lunch is probably the combination of breakfast and morning snack working together. Insulin can last hours longer than you might think, despite the general "insulin on board" settings (they can be wrong). Especially if there is exercise at that time. Have you tried bolusing 15 min. before she eats? That can help decrease those spikes. Do it even earlier if she's high, at least a half hour (e.g., long before the morning snack). Or, try giving no carbs or bolus at the morning snack, just fat/protein, no insulin either. That might prevent the later lows, since you won't give more insulin. Don't correct it either, and see how much it goes down. It could be correction boluses that are too high; do you correct either of these highs? if so, that could be the source of the problem (if you are entering in the 300 BGs into the pump, then the pump will be giving a correction).
Anyhow, my 7 year old has had T1d for over 5 years now and when young he also would spike and fall pretty regularly. It does get better as they grow up! Really! good luck!

Also, a continuous monitor really helps in little kids! I'd highly recommend it.

My son is the same age. His CDE told me that children that age often become insulin resistant in the early part of the evening, ~9 pm - midnight, and then (because of hormonal shifts) the insulin resistance fades. so what it sounds like to me is that the .3 rate you have going till 3 am either goes too long — because don't forget, the insulin that goes in at 2:30 peaks at around 4:30-5:30, and that's probably a large part of what's bringing her back down — or else the 3 am to 9 am basal is too high for too long, and maybe you need to bring her down to .20 at ~6 a.m.

As for the problem during the day, that sounds to me like her carb ratios are too low — meaning, she's getting too much insulin for what she eats, and when it peaks, it brings her low. BUt it's weird that she goes so high in between. Are you giving her the insulin far enough in advance of food, or are you still at the stage where it's hard to tell what she'll eat? Because that kind of pattern (shooting high and then dropping low) usually happens when the child is getting too much insulin, but getting it right when she eats or shortly after she eats instead of 10-20 minutes before she eats. If she's on a pump, one way around that problem is to use either the square bolus function (so that you can give her the insulin for her carbs over a set period of time, and shut it off midstream if she doesn't eat everything), OR give her a "dual wave" bolus where she gets insulin for half her carbs up front and the other half as a square bolus.

Eric's basal pattern goes like this:

12 AM -6:30 AM = .20
6:30-8:30 AM = .25
8:30-1:30 PM = .30
1:30-8:00 PM = .25
8:00-9:00 = .30
9:00-11:30 = .35
11:30-midnight = .25

When we give him a food bolus, we generally give him a standard (quick) bolus about 5-15 minutes before he eats, depending on whether he's in the lower part of his range or the higher part. If he's at 80 or lower, we'll often give him a 30-minute square bolus to give his BG a chance to rise a little before the insulin kicks in. If he's eating slowly or not interested in his food, same thing. Right now, because he just got through a GI bug, he's low a lot when he eats so we've got a rule that EVERY bolus is a square bolus until further notice.

I rarely get lows in the morning, and most of the time I don't get highs overnight either. Right now I'm struggling to find a setting that will capture his early-evening highs without sending him low before bed.

And I also think a CGM could help. I've gotten a lot of good info that's helped me adjust his BGs from Eric's CGM. And having an alarm that will go off when he's shooting high is terrific for my peace of mind! No matter how often it wakes me up, it's a darn sight better than lying awake all night worrying.

Hi Ellen. Prior to my son going on the pump, I could've written this email EXACTLY. We have battled these same two "problem areas" for years. I can tell you our experience and what's helped for us, but it's still a struggle. This reply might get long...sorry. Let me first show you his ratios and basals for the day.

I/C ratios (keeping in mind we are only allowed 4 with Omnipod)
12am-9am 1:15
9am-3pm 1:35
3pm-7pm 1:45
7pm-12pm 1:35

Basal rates
12am-4am 0.25
4am-10am 0.45
10am-1pm 0.35
1pm-7pm 0.25
7pm-10pm 0.60
10pm-12am 0.25

Basically we found that he is most insulin resistant in the morning for his breakfast dose. He needs much more insulin at breakfast AND it seems to work a lot more slowly, so not only would he go really high after breakfast, but he would also drop fast after about 2 or 3 hours. We compensated with a high ratio and a higher basal rate in the early morning, and by lowering his rate back down at 9 or 10am, we have avoided the sudden drop in BG we used to see at this time. We have had some luck with lowering his basal to 0 from 9am to 11am if we know he's not going to have a morning snack.

The evening/nightime issue was a little harder to solve in the beginning because most doctors and nurses didn't believe or understand the problem we were having. I think the evening issue may be isolated to young children so it's not often addressed. What we found was that my son's BG would be on target at bedtime but spike from 9pm to 2am, and then return to normal with a correction dose. We found that this problem seemed to be related to his early bedtime. He was eating a snack at 7:30 and going to bed at 8. If he skipped a bedtime snack OR stayed up really late, he didn't go as high. So I'm guessing that eating and immediately going to bed can cause some high BG, probably from the lack of activity. We have very successfully solved this by upping his basal from 7pm to 10pm and using a higher I/C ratio for his evening snack. Keep in mind, we did this gradually AND that we have to watch carefully if he does decide to skip a bedtime snack or do something other than sleep at 9pm!

I hope this helped. The bad news is that there will probably always be problem areas to work on. The good news is that a pump allows you more flexibility to do so. Email me directly if you have questions. Like I said, we have experienced exactly what you are going through for 7 years. My son is now 9 and things are more consistent, but still a little crazy at times. Good luck!

Allison

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