Like you guys, we are pretty aggressive about keeping our son from being low – this is in large part why I think a 5.something is unattainable right now.
I agree that lows are horrible, no good, very bad, etc. I don’t think there’s solid evidence showing that mild lows harm brain development, even in toddlers, but certainly severe ones do. And even if lows were physically harmless (I suspect they’re actually considerably more damaging to adults than we previously thought too, likely leading to cardiac autonomic neuropathy), the quality of your family life when you’re always trying to fend off lows is horrible and unsustainable. We realized a few months ago that having baked in lows was really making our lives stressful even when our son’s average A1C was looking great.
But i do think there’s a balance where you don’t have to tolerate lows or quite so many highs either. One thing I’m wondering: Do you have set guidelines for treating lows at certain thresholds based on Dexcom readings? For instance, we have a little flow chart that the teachers at school follow: If he’s less than 155 double arrows down, less than 125 straight arrow down, less than 95 sideways arrow or less than 80 straight across, they give him a low treatment, wait fifteen minutes and then repeat if he’s not rising. Through experimentation we’ve discovered that this keeps him from going truly low (i.e. less than 70) about 9 times out of 10. It probably causes false positives and overtreatment about 3 times out of 10.
You would think this would not actually help with lowering A1C but for me it’s huge, because it often keeps us off the roller coaster. And knowing the guidelines are pretty solid, I can be a little bit more aggressive with insulin dosing when he’s high or I anticipate a high because I know these rules are actually pretty conservative. The downside is that these rules mean he often gets over-treated for lows at school and may spike up to 190 after he dips below 95, which is especially frustrating when you see a 92 sideways arrow that is minus three and you just know it would have been a soft landing. We tolerate that because, like you, we think lows are worse than highs – especially at school. The rules aren’t perfect but they’re pretty good and just having those rules has reduced our frequency of lows without much increase in average A1C.
The numbers will be different for everyone; these thresholds would be WAY too conservative for an adult or even a teen i suspect. We don’t always follow them (especially at home and at night when he has negative IOB and is drifting 78, -1), but it makes me feel so much more comfortable with giving him insulin and so it indirectly helps me keep his BG down. And the rules are easy enough that even daycare teachers who basically don’t understand what diabetes is at all can understand them. It also means we can leave our son in the care of my parents or my husband’s and know they’ll take care of him adequately.
As for the bolusing: I would basically try prebolusing routinely some tiny amount. We do 0.2 an hour before breakfast often and it works well. IF our son doesn’t want to eat, a single glucose tab or a few jelly beans can be given with no fuss and he’s sent on his way. We also sometimes use an extended bolus for the meal and cancel mid-way if he throws a fit. We haven’t seen much difference between, say, prebolusing 0.2 and then bolusing for 1/4 of the meal upfront and the remaining 3/4 mid-way, and bolusing for it all right before the meal. We never do the prebolus, wait 30 minutes thing we used to do either; it may prevent a spike initially but the insulin runs out too soon for us and he has a later rise which is trickier to bolus for. WE always prebolus for breakfast, which is the exception. That’s because no matter how stubborn my kid is, he will always eventually eat the breakfast.
Also, what we’ve found works is to basically ignore our son’s temper tantrums. (I’m sure you know this by now with 6 boys). But basically, if we ignore the temper tantrum, even in those minutes where it feels like an eternity and he has insulin on board, it usually resolves in 5 minutes and it often turns out he was “hangry” and will start eating promptly. I had to really train myself not to panic but it’s been a lot better somehow.
Final thing I’d mention: Does your son eat at least every 3 hours? If so, I would program a more aggressive carb ratio and schedule snack times for when his BG is on a downward trend, about 2 or 3 hours later. I know it’s tough to feel like you’re, like Eric said, a hostage to insulin, but in our experience our kid just eats enough snacks, frequently enough that I really never consider that 4-hour or 5-hour DIA window anymore, except at bedtime.Maybe your kid is pickier and more erratic as an eater. Ours is pretty easy. He’s gotten to be more of a threenager lately but he has a pretty normal appetite.