need morn ing help!!

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Permalink Reply by Jan on May 20, 2009 at 2:24pm

Here is what I would do. First, I would try omitting the cereal at breakfast. Not a good time of day to eat cereal. We need an extra unit of insulin to cover cereal, more, if eating cereal in the morning. Otherwise, I would lower the insulin to carb ratio for breakfast, test hour 2, 3 and 4 to see where she is. I would be careful, whatever you decide, because we have never had to deal with ICRs of 1 to 40 or 1 to 60. That's hard!

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Permalink Reply by Lorri Strider on May 20, 2009 at 3:12pm

Vicki,
I agree with Jan: cereal for some reason never works for us in the morning; it sends Jim's blood sugars soaring everytime. It really sounds like a I:C ratio problem. How long has this been a trend? With your small ratios I would do slow changes and wait 2-3 days between changes; especially since she's at school and you aren't there keeping an eye on things. If it was a basal problem I would think that her pre-lunch blood sugar would be elevated.

Lorri

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Permalink Reply by Natalie on May 20, 2009 at 6:37pm

We have the same trend with Rory. He is on diluted insulin, 1/4 strength, and his breakfast ratio is 1:8 right now which would be 1:32, which really sounds like a lot after seeing your ratios! But he still has issues with spiking so high after eating and we have tried doing his bolus 10 mins before eating. His usual breakfast is a plain Nutri Grain waffle, fruit (usually strawberries) and milk. So I am guessing from the other comments that maybe we need to avoid the waffle? Do others have problems with this also? Or the fruit? He has had other things but there never seems to be much of a difference and that is his favorite breakfast so i was really trying to figure out how to make it work for him. On most days he needs a correction at that time and then he is back down ok by lunch. That is probably our hardest time of day too. When he spikes so high he really doesn't feel well and acts out and gets crazy and it is even harder to manage his toddler behavior. I have tested the basal rate on different occasions and it seems to be good so I think it is more of an issue with the carb ratio but how can we go any lower! It is very frustrating!

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Permalink Reply by Wulfhere on May 20, 2009 at 8:09pm

We've had this problem also with our daughter a few times. In the past, the post-breakfast spikes were the first in a general trend of highs that ultimately led to a basal increase, which brought things under control within a couple days. For the past few weeks the after breakfast spikes have started again, no matter what she eats, and as the previous times, tweaking the IC ratio was not effective. But there has not been any other upward trending this time. The past week or so, in fact, she has been trending downward at all times except post-breakfast and fairly often at bedtime. The lows, especially the first of the morning lows, have been consistent enough that we just reduced her Lantus by a half unit. She was 100 before breakfast this morning; I gave her insulin at breakfast as per her normal ratio. And she tested at 50 two hours later.

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Permalink Reply by Vicki S on May 21, 2009 at 4:11am

Thanks for all the help. Breakfast is hard - well meals in general area hard. She is a VERY PICKY eater and will refuse and go hungry before eating what i want her to eat. yesterday getting her to eat 2 eggs was a miracle! But I am pushing protein in the morning esp. bc of these nasty spikes. I am doing my best to wean off cereal in the morning . . .but hey she is 8 and picky and this is what she wants to eat and she reminds me daily that she was told by the docs and educators that once she was on the pump she could eat what she wanted - no restrictions . so I battle that with her too. I try to explain that yes - she can eat more freely - but still with some limitations. So we comprimise as much as possible!

I am going to increase her i:c this morning again from 1:40 to 1:35 and see if that helps at all. So some of you give an extra unit to cover cereal? how do you determine the amt extra? (I mean for us 1 unit usually bring her down 125 pts - in the morning it is more like 100 or 75 - but do you just experiment. ) Maybe today I will just give an extra 1/2 unit and see if that helps.

Again - thanks for all the replies and suggestions! Gotta go give a prebolus and wake up her up!

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Permalink Reply by Natalie on May 21, 2009 at 8:35am

So you usually do the prebolus with half the total and 30 mins before? Did that usually work well? For Rory we just started giving the whole bolus 10 mins before, but maybe we should try part of it 30 mins before. He is usually a really good eater for us and often wants more. So I don't think I would need to worry about him than not eating all I had figured. Today I tried giving him toast (he will eat the whole wheat low carb.) eggs, milk and a smaller amount of strawberries to see if that would help with his high spikes after breakfast but still high, 352 2 hours afterwards. And actually his breakfast ratio is 1:7 which would be 1:28! The nurse already had me bump his morning basal up a little, but I am afraid to go any higher on that because than he would be back up to the rate where we had problems with him going low if he wasnt' eating. So maybe if I try the technique you are using and get some of the insulin in his system sooner maybe we can avoid his highs. I will let you know if we have any success. And I hope you are seeing some results from your tweaking.

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Permalink Reply by Vicki S on May 21, 2009 at 9:47am

Well this morning - gave the 20 carb prebolus (yes we generally do this - not really sure if it is helping - but it is not hurting) She ate eggs, 1 piece of toast, butter, and 4 oz oj. (I needed the oj or she would have only had 12 carbs and I prebolused 20.) At snack she was still 269. (lower than most days - but still higher than i like) I did tweak her i:c to 1:35 - in 2 days I will go down to 1:30 to see if that makes a difference.

I don't want to make too many changes since school is out next week and we will be tweaking again with summer schedule . . .

I had read on another board that some parents are not too worried about the morning spike if by lunch they are coming back in range. If our spike was always in the mid 200s I might be ok - but when we are spikeing into the 300s I worry about how she is feeling and what it is doing to her body. So far no ketones are ever present.

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Permalink Reply by Jan on May 21, 2009 at 10:59pm

269 two hours after eating, that does sound like our first two years with D. Even now, if she is 200 two hours after eating, she will come into range in four hours. If she is lower than that, she will be low. So at school I adjust so she is 200 two hours after eating (and I know it's too high, but it's the best I can do). If I remember correctly, initially she would be about 250 two hours post and would come into range in four hours (must have had some residual insulin from beta cells). It is easier now. You may not be able to tweak her too low if she is at school. Experiment and just do the best you can.

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Permalink Reply by Jan on May 21, 2009 at 10:51pm

Don't do as we do! Our insulin to carb ratios after diagnosis, also at 8, was 1 to 20 during her honeymoon. Now she is 12 and breakfast ICR works at 1:8, lunch dinner and snacks can be 1:10 up to 1:15, depending. ICRs change for us, as well as basals. You CANNOT give an extra unit with the ratios you describe. Try prebolusing for the cereal by 15 minutes and ask endo how much insulin you can safely add for that cereal. She needs more insulin to cover the cereal, but I think it would be hard to figure out how much. I would add protein with the cereal to see if that helps, like eggs or bacon, or sausage. All the protein and fat may hold back the spike. I might try a plus temp basal on the pump for an hour and a half if that is easier for you. Be careful and test. One unit of insulin usually brings her down 80 points. High ISF but low ICR (she is not the norm). One unit of insulin covers 8 grams, 10 grams, and at times 15 grams. P.S. You can do a BS test one hour after eating (whereupon she may be in the 350s) and you can add insulin according to your correction factor to bring her down. For instance, I don't want her to be higher than 225 or 250 one hour post-prandial. Therefore, I know I can safely add the extra unit.

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Permalink Reply by Vicki S on May 22, 2009 at 9:23am

Oh do not worry - iwas not looking for direct answers - more or less - that this has happened to others and that we are not alone in the breakfast spike world! LOL I did tweak her basals a bit. I was looking and her total basals are about 2.7 and her TDD is generally about 6.5. So I did tweak her morning icr to 1:35 and adjusted her basal in the afternoon where we are seeing gradually higher numbers - not post prandial. I alerted the nurse today to watch and have not had a call - so maybe we are doing well. I usually get a text or call about 12:30 after lunch so we will see.

Willows ISF is 140. I know that is crazy high - but seriously even at 120isf she was dropping too fast. The endo does not think she is still making any insulin but we have not had c-peptides done to be sure -so there is still a possibility that she makes some randomly or just enough to make getting her icr, isf and basals just right!

With Breakfast I have not seen a difference with protein added or not. Her numbers still spike. we prebolus per carbs - not by units. So I usually pre-bolus her for 20 carbs and then give the remainder of the insulin based on her icr after she eats and I have fully calculated her carbs. I would never just give her a unit to help out. If anything I would give an extra 1/4 unit to help out. ( but that is just a guess) I do not like to run temp basals at school just in case they have to be turned off. The teacher is great and our nurse will come out any time she is needed - but it sometimes takes her 20 minutes to get there. willow still does not know how exactly to do the temp basal function and I have walked the teacher thru it once but generally do not liek to put too much on her.

I was just talking to Willow last night about how over the summer we will begin working on learning more of the functions of her pump. Right now I just want to finish this school year!

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Permalink Reply by Jan on May 22, 2009 at 1:19pm

From experience, I am able to give the one unit one hour post-prandial (overriding the pump) to bring her blood sugar down near the range I know (from experience) she should be at one hour, two hours or even three hours (it is almost four years now). And she has changed. Initially, she had to be 250ish two hours after eating to have an in-range BS four and a half hours later, when all Novolog wears off. Now, she can be 200 two hours post for the same to occur. At home, if she will be staying home, we give more insulin so she is 160 two hours post and "feed the insulin" at the two and a half or three hour mark. It keeps her lower than 200 but she may then have numbers like 200 one hour post, 160 two hours post, (here we will cover part of that IOB), then 150 3 hours post and 100 when all IOB is gone. Can't refine without cgms. I agree, a nurse or teacher or even the child is NOT going to do this for you so first and foremost she must be safe at school. There is no easy answer even when you learn the temp basals, tricks. There are some kids who go to 160 two hours post and do not drop. I think there are quite a few of them, from reading other posts. Unfortunately, my niece is not one of those kids. Even if we feed low glycemic foods, if she is 160 two hours after eating, she will crash by hour 4. So we do the best we can based on her metabolism.

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Permalink Reply by Dean on July 5, 2009 at 1:05pm

Hi Vicki,

On my son Matthew’s first day of preschool last August I tested him post meal (breakfast) when I dropped him off. 316. I hung out to watch his first ½ school day and was dismayed to see him moving about in a haze, not quite all there. That day got me determined to find a way to reduce the spike, not only for his overall health, but so he could have a more normal interaction with his new friends and teacher.

After doing some internet searching I came up with several techniques that have worked wonders. Not only have we been able to reduce Matthew’s postprandial spikes, but we have found that a more stable morning seems to have an effect on and lead to a more stable day. So, this is what we have found to be the most effective methods to reducing the spike.

First, super bolus. To me the pump’s absolute best function is the ability to tailor a basal profile, which we could obviously never do on Lantus, and then set temp basals as required. In general, a super bolus adds “borrowed future basal” to your pre meal bolus. In Matthew’s case he is receiving .25 unit/hr basal during the morning hours. When we bolus for breakfast we add .4 units (80% of his upcoming basal for the next two hours) and the set a temp basal of 20% (.05 unit/hr) for two hours. The “upfront basal” added to the pre meal bolus helps to reduce the spike while not adding to the overall amount of insulin given prior to the next meal. In fact, we have found the following reduced basal aids to slow any drop off/crash prior to the next meal. You can search this site or Google “super bolus” and find all the details you want. Start slow. Make sure the basal profile and I/C ratio you are using are correct first. It will take experimentation with the super bolus to find the numbers that work for you, but it is absolutely worth it.

Second, add some exercise after breakfast. I’m not talking about a big workout at the gym :) I take Matthew on a 1/3 to 1/2 mile walk and see a dramatic effect on the spike. On inclement days he loves to box on the Wii, not as good, but it gets him moving. Actually, if he over does the exercise it will make him hypo. At a recent trip to Sky City (think giant bouncers and slides) I removed his pump and still had to feed about 40 carbs, the equivalent of a meal, to keep him from going low. Exercise gets the blood moving and simply makes insulin more effective by enhancing insulin receptor sensitivity. Again, start slow to find out what has the best effect on the spike without going hypo before lunch.

Third, pre bolus as much as possible. You seem to be doing 50/50 because of a picky eater. Look back in your logbook and see how many carbs Willow is actually eating. Was her smallest breakfast day 30 carbs? Pre bolus for 30, not 20 and give the remaining 10 or so as soon as she finishes. We pre bolus every meal (unless he starts hypo with a low GI meal). On the rare days he doesn’t finish a meal we give juice to complete the carb load. Just make sure it’s not the only time you give juice. Kids love juice and it won’t take long to figure out the only time they get it is when they don’t eat! An effective table on when to pre bolus in relation to the GI of a meal is in one of the links I added below.

Lastly, Glycemic Index of the breakfast. Like you we have not removed cereal from the breakfast menu (Matthews favorites are Cocoa Puffs, Fruit Loops and Lucky Charms (just how many colorful marshmallows should be in that serving!)) However, we have mixed his cereal 50/50 with a high bran cereal since the day he was dx. The GI of relatively healthy Cheerios is 74, not great if you’re trying to control a spike, but mixed with all-bran (GI 46) and you get a more manageable GI option. Diabetes for kids is hard enough, the least I can do is try and give him what he likes, within reason of course. Use the other techniques above to control the spike and let a kid be a kid at breakfast.

One of the best sources I found in our quest to reduce Matthews spike is from Gary Scheiner with an article called Strike the Spike: http://www.diabetesselfmanagement.com/articles/high_blood_glucose/s...
And a power point presentation of the same title:
http://www.childrenwithdiabetes.com/presentations/CWDPostprandialGl...!
Although he does not address the super bolus, the information contained is invaluable. His web site: http://www.integrateddiabetes.com/index.shtml is great.
Additionally, Garys book, Think Like A Pancreas, has been our absolute diabetic guide.

Hope all this helps. I’ve been on Tu several times over the past year or so, but I actually joined Tu to share our experience with this issue. I hate the spike! Dean :)

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