Gymnastics bolus for toddler

So this may not be your area of expertise, @Eric, but since you’ve been so helpful with @daisymae’s workout plan I thought I’d ask if you have any insight into how to bolus for my son’s gymnastics class.

It’s not really aerobic exercise and sometimes I question whether it is even exercise, with all the waiting around to use equipment, the dawdling and the times when he just isn’t into it. And yet it seems to have a dramatic impact on his blood sugar.

He’s 3, and right now his workout is anything but strenuous. It’s a lot of waiting in line, a few moments of jumping on a trampoline, swinging on a bar, balancing on a beam, and maybe a few forward rolls and obstacle courses. It lasts about 50 minutes. It’s definitely less activity than he gets typically running around on a playground.

The problem is that he both goes low in class and then spikes super high after.

Here are the basic details:

Breakfast typically at 8-8:30 am, sometimes as late as 9am
Breakfast I:C ratio: 1:16
total breakfast carbs: 40-50 g, typically pancake, waffle or french toast
Morning basal rate: 0.3 units/hr
Class is at 10am - 10:55 am.
By the time he starts class he is typically heading down --he could be in the 130s or 120s. We give him part of a cliff bar (10-20g) to prevent a low, unbolused, but it doesn’t usually stop the low. He may drift down to about 65 or even, as today, 55 (he didn’t eat all of his pancakes for breakfast). We have to give him a glucose tab during his water break at 10:30.
About 10:30 or 10:45 he does start drifting up. His pump is on during this time but his openAPS is typically giving him a 0 temp basal for most of the class, meaning that over the course of an hour or two it’s subtracted about 0.6 units from his total basal delivery for his breakfast bolus.

If we try to underbolus for breakfast he will go high and will stay high; he will not enjoy class. Same goes for situations where he’s low. Only about 1 in every 3 classes does he wind up in range for the whole class. It’s frustrating because he really enjoys class when he’s in range and clearly does NOT when he is out of range.

About 10 minutes after class ends, he starts a precipitous rise up to about 300 over the next 1.5 hours. If he’s already above 80 after class I will try to give him a bolus, but it’s tough because sometimes he’s still in the 70s when I start driving home and is already in the 150s by the time we park. Today for instance he’s currently at 280mg/DL + 13, but I bolused him when he was 149 with 1 unit.
His lunchtime I:C is typically 1:22 and his ISF around this time is usually about 230.
Sometimes at night he runs low about 12 hours after the class in the middle of the night, but not all the time.

Any ideas how to bolus him so he doesn’t go high or low during class? Unfortunately we can’t really avoid him starting class with food IOB because this is the only time slot for the class, and unless we serve him breakfast at 6am he’ll still have a lot of insulin left for his food.

I figure the first goal is to deal with the low during class first, then figure out how to avoid the after-class high. I also suspect I’d feel more comfortable bolusing aggressively after class if I didn’t have to wait for him to rise from a low.

Also, doing things with basal prior to the class has limited effect because he’s on an openAPS algorithm which essentially shuts off for the hour or two after the meal, turning his food bolus into a superbolus. WE could turn off the openAPS and put him on a manual temp basal but we try to avoid that because it mucks up the logic of the algorithm. At this point I’m not sure what kind of temp basal he’d even need.

Thanks so much – not sure if this is in your area of expertise but you probably have some ideas! My initial thought was to reduce the I:C a bit for breakfast, give him the extra carbs for class a little earlier, and maybe bolus him 1.2 units at the 45-minute mark during his class – but I’d really rather not interrupt him during class either. My goal is to help him enjoy class as much while drawing as little attention as possible to things that would take his attention away from it.

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Quick short bursts of activity use a different energy system. Even if it doesn’t seem like much for us, for a toddler those little actions are going to use a totally different energy system than if he was just walking. Things like jumping on a trampoline or doing an obstacle course will use the ATP–CP (adenosine triphosphate, creatine phosphate) system.

They type of activity he is doing, the excitement and hormones, and the fact that he has had no basal during all that time and it is not too surprising that BG would rise.

For the low during class:

If I have to run shortly after a meal, and I know I will have IOB, you better believe it will be a very small meal! Small meal = small amount of insulin.

Little mistakes mean little consequences, but big mistakes mean big consequences. So if you have a smaller meal or less carbs, you would use less insulin, you have less likelihood of a big drop. Maybe a smaller drop or smaller rise.

So possibly doing a smaller meal, or doing a low carb meal and reducing the amount of insulin and IOB would be helpful. And then you can make up those carbs after the class or at lunch.

For the rise after class:

I do not know all the implications of making changes to your openAPS, but I will say that if something is not working, making a temporary change seems to be a good option.

If the rise is fairly consistent, and you were to program a basal increase to happen at 15 minutes before the end of class, that would prevent the post-exercise spike. And if a BG test right at the end of class showed no imminent rise, he can have a small carbo treat, which is also nice for him (especially after exercise).

So the benefits would be:

  • If his BG was going to rise, it helps prevent that, or at least slows it down.
  • If it looks like there is no rise, he gets a treat.
  • The fact that it is planned 15 minutes before the end minimizes risk. Usually you have at least 15 minutes before insulin starts to work.

As a general rule - a little bit of insulin before you need it, does much more than a lot of insulin after it is too late. So this is just a preemptive strike.

I would actually make the “basal increase” look more like a bolus. Generally insulin pumps don’t let you program a pre-set planned bolus (for safety reasons). So this would be a large basal increase for only 15 or 30 minutes, programmed to happen 15 minutes before the end of class. So even though it is a programmed basal, it is actually more like a bolus.

This is perhaps more convenient than going over to him during the class and doing a manual bolus and hitting the buttons, right? Or maybe you can do it as a manual bolus when he waiting in line.

Hopefully that makes sense.

From my experience, I do something kind of like this for myself. I regularly take insulin when I have 1 or 2 miles left. That allows me to get something right when I am done, rather than having to wait.

We’ve had all our sons in youth soccer which is a great workout… But we’ve held out doing this for Liam…And I’m not sure why now. I was afraid for him… But with the CGM and letting the coach know I don’t think there is a reason he couldn’t do it. If Samson likes kicking balls around and chasing other kids, soccer may be something he enjoys. At the three and four year age range it’s not so much soccer as much as just running around and staring at butterflies as they pass by.

My other sons have enjoyed it.

It’s basically impossible to get your kids into the “soccer tot” league here in the city; it’s just so competitive. Plus we have a rule for our own sanity that at this point that the kids can do activities at the same times and places for now – the leagues for 3-year-olds and 5-year-olds are mystifyingly different, and at different times and places. I don’t have the bandwidth to take them to separate lessons at this point. The advantage of gymnastics is that a) our older son needs to take it to address some of his motor skill issues anyways b) Samson already does “gymnastics” moves all around the house, like swinging on things and c) they are in different classes but at the same place and time. Wish we had the resources to have each child go to their own specialized activity but that’s not in the cards at this point.


Thanks @Eric. We’ll try reducing the carb load before gymnastics. My thought is to do avocado on English muffin – usually about 21 g of carbs, and maybe the fat from the avocado will help sustain him a bit during class. We don’t do low-carb breakfasts because they make my son spike to 300 and require way more insulin than just letting him carb-load.

Then I think we’ll try giving him an elevated temp basal during class when he has his water break (around 30 minutes in to a 50 minute class). It’s 20 minutes before he finishes, so not ideal but I don’t want to disrupt him on the mat (also parents are not allowed on the mat). We can leave the openAPS at home or out of range during that time; it often is anyways if he’s on the far side of the gym.

Will let you know how it goes! Hope to kick this pesky pattern soon. I don’t want crummy blood sugars to mean we are reluctant for him to do activities, so it’s really worth our while to figure this one out.

That’s kind of interesting. How do you dose for that? There are some people that dose fat and protein at a lower percentage than they do for carbs.

Good luck with it!

So we don’t usually dose for it because we don’t serve it. Partly that’s because Samson hates most low-carb breakfasts: no eggs, no sausage, occasionally some lox but only a negligible portion. If I had to guess, I’d probably just figure out how much I dose for a calorie-equivalent meal of mostly or predominantly carbs and bolus about 3/4 of that amount. Who knows if that’s right though.

The only low-carb breakfast he likes is yogurt, and we have found we don’t need to bolus as much if we just load it up with carbs like honey, oats and berries. He likes it better that way anyways.

How much would you bolus him for after class? Last week he spiked to about 300 from a low of about 70. So I was thinking of maybe 0.7 units?

His basal rate at that time is 0.3, his carbF is about 1:22 and his ISF is about 240.

That’s tough because it is largely a matter of experimentation and a lot of “it depends”.

As a general rule, for adults, if the activity is fairly consistent and moderate intensity, you would not worry about 1 hour of basal disconnect, and would only replace anything over one hour (90 minutes of activity, replace 30 minutes of basal). And you would replace the basal at a percentage of the normal amount, depending on how hard you worked.

But the other thing for me is at that I always carb-up right away, so putting back a small basal is insignificant for me, since I am taking a big bolus for big carbs.

Since he is consistently going up after class, I would aggressively bolus and have a food treat ready. When you see that slope start to level out and turn down, be ready to give him some carbs. Your number of 0.7 sounds reasonable.

My general inclination - at least for myself because I am a bit more aggressive with it - is over-bolus and eat, rather than under-bolus and struggle through a long high.

Well, I wouldn’t call it a success but it is heartening that we did something different and got different results.

HEre’s what we tweaked for this week’s class:

We tried to serve a smaller carb breakfast about a half-hour earlier than we usually do – avocado and english muffin, which is about 22 grams of carbs. However, Samson was really hungry and asked for a second half, and then he seemed like he was drifting towards low before class, so he got a 1/4 cup of milk – total was bout 37 grams of carbs before class, only bolused for 33 grams.

His rise began just as he started class. And he didn’t take a drink break until almost the end of class, meaning I couldn’t bolus him until he was already 195 arrows up.

So he still went high – this time, during class – and stayed elevated (260s) for about 1.5 hours, despite getting an additional 2 units of insulin over the course of those hours AND going on a 1-hour long hike (pretty intense for him, as he ran the whole way and it was hilly) in Glen Canyon afterwards:

The portion corresponding to his gym class is the sharp rise from 10am to 11am. He only started dropping once we arrived at a playground from the hike, around 12:45 pm.

Not sure what I should try next – I guess one possibility is that the rise I’ve been seeing is actually a delayed spike from his breakfast, in which case, the issue is that he’s digesting his food really slowly while exercising and the food is outlasting his insulin. So I am going to try serving breakfast even earlier – maybe at 8am rather than 8:30. That way, if there is a rise from food around 1.5 hours after he eats, i’ll catch it while he’s at home. The downside is he’ll be exercising with a fresh bolus on board.

I can also try serving food at the same time, but try giving him a relatively big bolus earlier in his class (maybe 15 minutes in?). The other thing I’m going to do is give him or encourage him to drink a lot of water before class and then immediately after. I suspect he felt a little dehydrated, which is my best guess as to why a huge hike afterwards didn’t drop him down quicker.

That’s risky because the insulin could be kicking in while he’s still active, and it sucks because I’ll have to go bolus him while he’s on the mats during class (instead of during his fountain break) but I think it may be better than letting him get to 200 in class. The difference in his behavior and enthusiasm between the first part of class, when he was in range, and the latter half, when he started to get high, was really dramatic. Could be he just got tired but I suspect it had to do with feeling crummy.

@Eric, do you have any other suggestions?

Also to clarify: This trend seems to occur ONLY on Saturdays.
Here’s the last 90 day trends for M-F, followed by the last 90 days worth of data for Saturdays only:

Saturdays only.

One of the things I have noticed personally - if you were to look at all my BG history, there is a specific time where I seem to have the worst BG. Generally the only time I see any kind of high BGs is post-exercise. That is something that is really overlooked by so many of the usual diabetes recommendations you see. It is a tough time.

Your pre-class breakfast - I am a big proponent of sufficient carbs for exercise. But those carbs can be given anytime on the day or days leading up to the exercise. They don’t have to happen right before. But I am also a big proponent of no IOB during exercise.

Because he has to eat breakfast shortly before the class, I think the best thing would be to keep working on the low carb breakfast.

Also - what is something you never see in a formula on any insulin pump - is the thought that he may need some insulin for non-food events.

I do this frequently, and it is not something you ever see advised - sometimes I will take insulin before I run. Not based on a high BG or something I ate, but because I know what the exercise will do. This is something that takes time to become comfortable with. And is something that should only be done slowly and gradually over weeks and months.

Also, this is just an separate observation. When speaking to a recently diagnosed T2, they were telling me how wobbly and awful they felt when their BG got down to 70. I found it odd - I feel great at 70. But then I realized, they were so used to being 300 for months and months, that 70 was totally different for them. Of course they felt bad at 70, they were used to being 300.

So the point is, these awful BGs for him, they will eventually become less of an impact on how he feels. I don’t like 200, but I can now function at it. I have become somewhat used to the feeling. Same for lows. So over time, the body becomes more accustomed to those bad BGs. Eventually they don’t feel as bad.

But I am also a big proponent of no IOB during exercise. Because he has to eat breakfast shortly before the class, I think the best thing would be to keep working on the low carb breakfast.

The problem is that there is literally no way to accomplish this for him in the mornings. Any low-carb breakfast will use at least 2 units of insulin for him. His breakfast today, which larger than his normal weekday breakfast, used that much.

When he was first diagnosed I tried everything under the sun, from eggs to sausage, to full-fat yogurt to almond-meal pancakes to chia-seed pudding, etc. All of it caused horrible spikes and made him terribly insulin resistant for hours. I finally just accepted that his body needs carbs in the morning to get going, or else it interprets the situation as starvation. He becomes insulin resistant, dumps glucose, etc. It really is a threshold; a bowl of yogurt with 9 g of carbs will cause a 300+ for 2 hours; a bowl of yogurt with some sweeteners at 23 g will not, and requires less insulin. I also feel crummy telling him he can’t have more of something if he’s hungry, so it’s hard to just cut him off just before his gym practice.

I guess if we want no IOB, the easiest thing to do is to give him a regular, high-carb breakfast like oatmeal, but just earlier. Like 7am. This is not ideal because we do like to get a later start on the weekends, but I’ll give it a try. Given that openAPS essentially super boluses and then 0 temps him for hours, this could result in almost no IOB when he starts his class.

I definitely suspect the gymnastics class will still require some kind of non-conventional bolus though, but I’m getting more comfortable at this point anticipating some rise in class and bolusing way more than would normally be called for.

I am also very puzzled that his hike didn’t do anything to drop his BG. To me, that’s the weirdest thing, as when he runs around at the playground he usually drops like a stone. Do you think it may have been the hot sun and dehydration? He finished the water bottle early on in the hike, and then the anticipated water fountain midway was broken, so we didn’t get a chance to fill up.

I am have not experience any situation personally where dehydration caused a problem with insulin resistance. But I will say that 100%, every time, dehydration will totally screw up you CGM readings. Did you do BG checks also?

I understand that. If that is the case, than embrace the breakfast carbs and let’s focus on timing and alternatives. Earlier breakfast, limits on amounts with some low carb additions to fill his belly. I have had success with two hour pre-race breakfasts.

And then there are all kinds of out-of-the-box alternatives that don’t involve the pump. Like a quick pen bolus if needed, which takes about 5 seconds with practice, and is just a quick walk-by and “hug” for now when he is 3, but when he is older he can self-administer. It is much quicker than the pump reconnect.

Okay, so this day was very confounding. I would almost call it a success except that I don’t understand why the pattern was so different. He did throw a fit at the beginning of class at sat it out for about 10 to 15 minutes before he perked up and started participating, so possibly that affected the results slightly because he didn’t exercise for quite as long. Though he was working pretty consistently when he was in class.

Here’s the rundown:

6:15 a.m. – Samson looked like he might go low so we went ahead and immediately served him an English muffin with cashew butter and some orange juice – total of about 34 grams of carbs.
Calibrated and he was about 30 points higher than his sensor suggested. 97 mg/DL instead of 67 mg/DL.
he was flat in the 90s or so until about 9am
9am – 100 mg/DL
10am – Gymnastics class starts and he’s about 150 mg/DL. Over the course of the 50 minute class he rises to 174 mg/DL – so not a big rise, a little higher than I’d like as a starting number but to end 20 points higher seems perfect or totally fine to me.
10:50am – class is over so I bolus 1.0 units based on his recent pattern of rising after gymnastics. Also, because he has a birthday party immediately after I figure that cake, pizza, and candy can easily offset any potential low that would occur.
11:30 am – he’s actually dropping rapidly and is now 135 mg/DL, so we serve him food – chocolate coffee cake, slice of pizza, M & Ms (it’s a birthday party, so clearly not awesome food but whatever, he should get to eat junk like the rest of the kids occasionally)
11:54 – Sensor goes insane, registers a drop of -40, -40, and he’s now in the 40s according to Dexcom
12:15 pm pm – Sensor back in the high 70s. No idea what his true number is at this point because he’s running around and not testable. He slowly rose from then until about 100 mg/DL at 1pm, went up a bit into the 150s over the next hour.

After that, his sensor basically went nuts so I really can’t say what’s going on now. We just tested after the sensor said +99 to 319 and it turned out he was 219. So we’re going to change out when he wakes up from nap.

Pluses: He didn’t really rise much at all in gym class. I also noticed that at the tail end of his meal IOB’s DIA, he began to rise up about 50 points, so it’s possible he either needs a very slightly higher basal (tricky, because the trend only seemed to occur for about an hour and a 50 point rise might turn into a 40 point drop if we raise his basal rate by 0.025 per hour)
The other explanation is that he really digests food slowly enough that his meal bolus outlasts his food. Which could explain why he was spiking so high during or after gymnastics all those times – from delayed carb digestion, both from breakfast and the bars we were giving him…

Minuses: I don’t understand why he didn’t need a huge bolus after class like he did the past few times. It’s very possible the sensor was just failing and so his crash after lunch was artificial, but even so he definitely didn’t go high. He always runs a bit low during a birthday party – we bolus him continuously and he can basically just continue grazing and eating without going high… so it’s possible that simply the magical excitement of a birthday party has this effect and it canceled out the effect from the gymnastics? Or perhaps the rise I was seeing was never from the gymnastics at all, but from the food?

Any ideas what went on @Eric, and what I should try next time? Just wait to bolus after class only if I see a rise? In which case, how would you suggest dealing with this in the future, @Eric? It’s not feasible for us to serve him a breakfast at 6am every Saturday morning – for one, he often doesn’t get up that early and for another, there are some days where he’s running high in the morning, in which case we wait till he’s in range to start eating.

So if we serve him breakfast at 7am or 8am, he might still have IOB, and how would we handle it?

This sounds like my Dexcom today. I am a big proponent of BG testing. I had a rise after exercise today, my Dexcom was 80 points off of what my BG test said. Relying on the Dexcom is risky.

The other thing…I posted about this on a different site a long time ago. About using different feelings and making a prediction about your BG at all times before you look at your Dexcom or check your BG meter. And I think the same can be used by parents. If you see him running around and having fun, he’s probably not too bad. I mean, if he was really dropping 40 points in 20 minutes, you would know it!

Do they have regular water breaks scheduled during the class? I have always found that it is much faster to treat a low than a high. Treating a low is so much faster. If you are able to increase his basal, any opportunity at a water break could be a quick BG test and a few sips of juice if needed. It really sounds like an increase in basal is what you need. From what I recall and looking back at this thread, so far I don’t see a problem with low BGs when he is in the class, right?

Thanks @Eric,

Do they have regular water breaks scheduled during the class? I have always found that it is much faster to treat a low than a high.

So, they do seem to have one regular break – but sometimes it comes 40 minutes into the class, which is when it’s almost over. So I wouldn’t feel comfortable with a baked in low that assumes a regular water break.

From what I recall and looking back at this thread, so far I don’t see a problem with low BGs when he is in the class, right?

About 3 months ago he had a pattern of going low during class, and we then treated with a bunch of carbs during class, followed by the extreme high post-class. So before the pattern was: eating breaking at 8am or 8:30am, lows in the 60s-70s that wouldn’t come up in class, treated with two or three glucose tabs, followed by a sharp rise around 11:15 am. We decided his breakfast bolus was too aggressive and raised the carbF by 1 point, and since then have not had those lows around 90-minutes after eating, but were still getting the post-gym spike. Today the post-class spike gone, though he did rise before/during class.

That’s why I suspect it has to do with the food, rather some underlying basal metabolism that is independent of his food (a concept I see as a useful tool but not physiologically sensible anyways).
My logic:

  • The same rise does not occur on the weekdays when he’s on a different schedule.
  • The spike seems to come about 3 - 3.5 hours after the mealtime insulin is first delivered.
  • Also: it’s possible his rise today during class was less extreme than past rises because his meal was mostly carbs – so basically it was mostly processed in three hours by his bolus insulin, without a lot of fat or protein to cause a delayed spike. The other spikes might have been bad because avocado, pancakes, waffles, etc. – those are all high-fat foods.
  • It’s possible that the gymnastics class may delay digestion for foods we give him in class: So he doesn’t come up if he’s low during class because his body is diverting those resources to his muscles for all his exercise… then once he’s sitting in the car his stomach gets to work.

We can definitely do an elevated temp basal during class to account for that 1-hour rise even if it’s actually caused by food (probably less risky than doing a straight bolus?)…but I’d hesitate to change his programmed basal because for the weekdays he doesn’t seem to have the same pattern. Current basal is about 0.3 units per hour during that time – If he seems to be rising I could definitely set a 1-hour temp basal during class or whenever he first starts rising of 0.4 units per hour?

The other thing…I posted about this on a different site a long time ago. About using different feelings and making a prediction about your BG at all times before you look at your Dexcom or check your BG meter. And I think the same can be used by parents. If you see him running around and having fun, he’s probably not too bad. I mean, if he was really dropping 40 points in 20 minutes, you would know it!

I think this is a good point. And assuming he hasn’t had a streak of bad lows, Samson is pretty good about still being able to feel his lows … though he sometimes mistakes being hungry and tired for being low. I can also tell often times just by looking at him if he feels low… there’s just a certain look about his eyes and a tightness about his mouth, and his skin feels clammy, which it did not today. So I think today if he had really been in the 40s we would have noticed some change in his demeanor.

You mentioned that today he sat out for the first 15 minutes. That can also be a contributing factor for the less extreme rise, right?

Is it really hard to have a different basal setting for Saturday versus the rest of the days of the week? I understand the appeal of loop, but if it is hard to setup for different days, that really seems to be a limiting factor. I know as my kids went through weekend sports, how it would seem to be different for kids on Sat/Sun versus Mon-Fri.

How easy is it to change a basal rate while he is in class? Like on a break?

If you think about 30 minutes of basal, that will have a minimal effect on causing a low, but can have a very big effect on preventing a high later.

Suppose you have 2 different pre-set temp basals. You have your normal, but you also have a low temp and a high temp. Based on your remote Dex readings and how he looks and what was happening before class, you can make the judgement to either leave him at normal or change it to high or low. And you hit that temp basal at whatever time the break happens.

Even if you guess wrong, 30 minutes of the wrong basal would not be a disaster. But if you pick correctly, it seems like it would help you a lot for the hours that follow the class.

Moms are always the best CGM. My mom was CGM before CGM was CGM…

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Is it really hard to have a different basal setting for Saturday versus the rest of the days of the week?

It’s not hard per se; I’m just worried that we’d forget to switch it back between days. We often do forget to make changes we know should be made (for instance, we are slow to switch to his “sick day basal program” or back, or every morning we suspect his carbF is too low but then forget to change in teh 10-minute window his pump is off.)

The loop adjusts to whatever you have entered into the physical pump – if he’s on a Saturday basal, it will use Saturday’s numbers as baseline and adjust based on them. The loop is only an impediment to issuing a temp basal if it’s on . We can easily turn it off for gymnastics by simply unplugging the little computer.

It’s pretty easy to set a temp basal right before class. Changing it on a break is easy; except if his break comes too late in class. When he’s not on break, it’s very awkward to go onto the mat and disrupt the class to change settings. But if he’s dropping low I can always plug the openAPS in again and it will probably issue a 0 temp basal anyways, without me having to go on the mat. If he’s going high it’s a lot tougher for openAPS To kick in because it takes a while to realize what’s happening.

Forgive my lack of understanding in all the nuances of the loop!

But of sounds like this would be a good ideal. Have a Saturday program setup, pre-programmed to have a higher than usual basal for either the whole time of the class, or at the very least, for the 2nd half of class. Then if it runs, great. But if the loop detects he is dropping, it will over-ride your program and adjust the basal to prevent a low.

How about that?