FUDiabetes

Help with bedtime snack/bolus

Hi all,

Let me briefly introduce us. My son was diagnosed with T1D in October, roughly 6 months ago. He’ll be 8 at the end of this month. We are still currently on MDI and do have Dexcom G6.

I’ve been pulling my hair out with bedtime snack/bolus. Often just 1/2 unit of insulin (humalog) is enough to cause a low an hour or two later, even if he’s high going into the snack and gets 10-15 carbs. For example, he may be 220 going into the snack, he’ll get 15 carbs and 0.5 units insulin and 1 and 1/2 hour later he’ll be 100 with an arrow (sometimes 2) down.

If he is in range at bedtime snack, I’ve been keeping the carbs at 6-8 so as not to bolus for because I’m exhausted dealing with lows when we all just want to go to bed. He will have a glycemic response to those carbs, often bringing him up over 200, but he will come down on his own through the night (likely honeymooning)

His sensitivity factor through the day is 70; I increased that to 150 and still have problems. Because of the issues we are having, I’m not confident in his carb ratio at that hour, but have been using a conservative 1:50 (daytime he’s between 1:15 and 1:25).

A favorite snack of choice is either honey roasted almonds (about 6 carbs) with FairLife chocolate protein milk (only 2 carbs but about 15 G protein). I go with that if I don’t want to bolus (but it will raise his sugars). He also likes peanut butter crackers (about 18 carbs) also with the FairLife milk. He had that last night with a BS of 188 going into snack (finger stick-of course a dexcom sensor failure last night) and I gave 0.5 units humalog at 8pm. By 9:15 he was at 98 (again, finger stick). Because of his trends, I gave him another PB cracker, figuring he’s dropping, and even if he wasn’t I like him over 100 at night. 20 min later he was at 80. I went ahead and gave him 5 skittles. By about 10:30 he settled around 150, verified by both fingerstick and the new sensor kicking back on. So it seemed the extra crackers and skittles were about right. He dropped from that and settled around 115 the rest of the night.

Had I not bolused for his snack last night, we would have avoided the low, but he very well would have gotten well over 250 or more and parked it there for hours before coming down a bit on his own, and he likely would have only come down to 180-200.

Another factor I’ve considered is IOB. Dinner and bedtime snack are our closest meals, usually only 2-2.5 hours apart. So I’m wondering if IOB from dinner is having an impact (albeit not enough to fully cover a snack). It also seems to be complicated by what he had for dinner. A few days ago he had tater tots at dinner. He was quite high at snack time (over 220). I allowed a generous 20 min prebolus and then he had his crackers/milk, and again only 0.5 unit. He came gently down to 150 and stayed there- no spikes or more drops. It was great, but I couldn’t help but wonder if a delayed spike from the tater tots was helping him out.

I just don’t know what to do. I’m tired of the dreaded lows right at bed time, but realize heading to bed with highs isn’t great either. But since we are on MDI, 0.5 unit is as small a dose I can reliably give. And I don’t want to limit his snack choices, I’d much rather be able to confidently dose for his snack of choice!

Sorry for the long post, and thanks in advance for any input! I’ve learned so much already reading through many of the threads here!

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Welcome to FUD! Sounds like you have a good handle on things and are asking all the right questions. The first 6 months after diagnosis are exhausting, congrats on surviving that.

First question is how sure are you that his basal is correct? It sounds like it might be close, but have you actually checked? Once we dial basal in correctly and check with a delayed breakfast for two-three hours on one day and eat dinner right before bed the next day, checking to ensure he is as close to level as possible. Only then do we work on meal corrections, also breakfast and dinner may have different ISF values.

For bedtime snack, are you doing this because your son is hungry or because you are trying to have a level night? If it is because he is hungry, can you go with cheese or some other zero carb snack? Adding carb digestion to an equation that is going to get really complicated with growth hormones isn’t always helpful to see what is happening. If it is not because your son is hungry, I would skip this snack. It is complicating things.

edit - edited one paragraph for clarity.

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Hi @diabeatit2020, welcome to FUD. You are in the right place! There are a lot of parents here.

Yes, this is a big deal. It really makes a difference. Based on my dinner, I sometimes adjust my nighttime basal. More carbs for dinner means you will most likely need either less carbs for the snack or more insulin at night. When you have more carbs, your liver has more “cash to spend”.

One thing that can help is a slow-release carb at night. Those won’t cause as much of an immediate BG spike, but will continue to release carbs for several hours. There are a lot of different types and flavors, but here are some examples:

Belvita Bars

Kind Breakfast Bars

Extend Bars

So the other thing might be to look at how you are doing MDI. Like to examine the regimen you are using and see if adjustments might help.

Can I guess? Is it Lantus at night for your basal?

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Thanks for your input! We never did bedtime snacks before Diabetes and only began at the demand of the CDE. And now that the habit has begun, my son seems to look forward to it (likely if he’s really hungry or not). I have thought about a later dinner and skipping snack entirely.

He’s on 6.5 u of Lantus at bedtime, around 8pm. I only have experience evaluating basal with his morning numbers. He generally wakes around 120, but sometimes higher if we had trouble with the higher sugars at night. For a few weeks he was around 150 in the morning. If I dial up his basal any higher (I’ve tried 7 units) he drifts low over night (even at 6.5 he may drift low over night if he just has the almonds)

How can I more accurately assess basal? Does it seem like he needs a higher or lower basal?

With the extend/ Kind bars, would you recommend no bolts with the snack (unless high?)

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Welcome @diabeatit2020! I’m sorry you’re currently sleep deprived - I hope things improve for you soon! I am a father of a 7 year old who was diagnosed at 2 years of age and we were doing MDI for the first year or so and then we switched to the Omnipod pump system to help our management of his diabetes as well as his A1C. We are currently using the Dexcom G5 and will transition to the G6 as soon as all our G5 supplies have been exhausted.

I can relate to the sleepless nights and I sympathize/empathize with how you are feeling right now but it sounds like you have a great understanding of things.

As far as nigttime snack alternatives, to go with the recommendation @Eric made for the Belvita bars, for our son, we use the Belvita Sandwiches. 1 full sandwich is 16 carbs and depending on Liam’s BGs, we give him 1/2 or a full sandwich for bed.

Have you considered going to a pump to help with the BG management? That move really helped us with the roller coasters we had been experiencing with MDI and helped us “to some extent” with the sleepless nights.

What helped us THE MOST was transitioning to the Omniloop system. We use a branch known as “FreeAPS (Microbolus)” which gives small boluses every 5 minutes if necessary to help keep Liam in the range that we’ve set for him. Before transitioning to loop we had a decent A1C and low/severe low %…7% A1C and 3% or so low/severe low %, and since dialing in loop we now have a 5.6% A1C and he is only low/severe low 1% of the time.

The very best management decisions that I’ve made for our son are as follows (in the order of what I consider the most important):

  • 1)) Starting to use the CGM…before that, I didn’t sleep…I would look at Liam and, not knowing his BGs, I would literally never sleep…I would check his BGs every 30 minutes because I was afraid he was going to die in his sleep. Having the ability to see the BGs has made my quality of life so much better.
  • 2)) Starting on a pump (we use Omnipod because it’s tubeless, but others like other pumps)…having the ability for the pump to administer the insulin really helped us manage Liam’s diabetes better and helped eliminiate some of the shots (he used to hate the many shots he’d get every day).
  • 2)) Moving to Omniloop (linked above)…Yes, I know I marked both starting on pump and moving to Omniloop as 2nd in priority…for me, both are equally as important for us. After Liam got on loop, his bg’s, A1C, TIR, SDs, everything improved drastically.
  • 3)) Downloading and using SugarMate. SugarMate’s main function that I use all the time is it’s ability to “call you on the telephone” when you cross below whatever “low” number you indicate you would like to receive the phonecall for. This allows you to sleep peacefully because if the childs’ BGs cross below that threshold, you know you’ll get a phone call (and phonecalls are the only way I wake up because the alerts just don’t register with me after so many years of hearing them.) Also, with SugarMate, I am able to see Liam’s BG’s all night long on the big Television in our Bedroom so that me, my wife or Liam can all just wake up, see the TV and go right back to sleep (or take action if necessary.)

Note: You could download/use SugarMate right now because it’s a CGM app and has nothing to do with using, or not using, a pump.

If you have considered transition to a pump and/or looping, it sounds daunting, but it’s worth every minute I spent transititioning to these things.

I wish you the most luck in whatever decisions you make and we are all here rooting for you and your son! If you have any specific questions you would like me to help you with you can always send me a PM and I’ll respond promptly!

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Yes, Lantus is the basal, currently 6.5 u at 8pm. I found at 7 units he was drifting low over night more frequently. Currently he wakes around 120 in the morning, but we have had weeks where he’s be around 140-150, sometimes seeing a rise by breakfast (currently he doesn’t seem to be as affected by the ‘dawn phenomenon’ as much and stays pretty steady till breakfast)

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Thank you! Believe me, I very much want to switch to a pump for many of the reasons you stated but our medical system seems to enforce a year long wait since diagnosis before being switched to a pump.

Dexcom has helped with sleep as I can check anytime without having to get up, and the assurance of the alarms. But dealing with these fluctuating sugars right before bed is stressful. I don’t get much help from the CDEs when I call. You never know who you’ll get (there’s a whole bunch and it depends who’s on call that day) and they all just focus on numbers without looking as any of his individual nuances. So it’s been frustrating. Hence my search for help elsewhere :smiley:. He’s next endo appointment isn’t until mid April.

I do have Sugarmate, but I don’t use its alarms and still rely on dexcom follow app for alarms… I’m a light sleeper so it works for now.

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Yeah, see I knew that without your telling me, right? :grinning:

With Lantus, a few options to consider might be to either switch the single shot to the morning, or to break the shot up into 2 doses.

If you do a single shot in the morning, like say 8am, you will most likely not see any lows at night anymore. Even if he is trending low at bedtime, the Lantus will be out of his system around 4am, so it’s a little bit safer. He might wake up a bit high, so you’d need to give a small rapid insulin bolus when he wakes up.

If you break up the shot into 2 doses, you have a little bit of control over different amounts of basal during the day vs night. It isn’t total control, but a little bit.

For example, if he eats a big dinner you might give a little more Lantus at night. If he has an active day planned, you would give a little less Lantus in the morning.

So for example, maybe you start with 3.5 in the morning and 3.0 at night, or something like that.

Does that make sense?

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Yes, the 1 year wait seems like something that is pretty standard from what I’m hearing and observing but that transition will help you SIGNIFICANTLY. In the meantime, read and continue learning as much as possible so that when that time comes, you are well informed and ready to jump ship immediately from MDI to whatever pump you decide to go with. Also, take some time to get well-versed on the looping technologies offered by many pump companies as well as the DIY versions (which is what we use).

Brighter days are ahead! You’re doing all the right things…unfortunately, with small kids our kids ages/sizes, it’s nearly impossible to get rid of the roller coasters with MDI. Moving to pump/loop is going to significantly help you with your sleepless nights AND flattening those roller coaster curves. Trust me! Many parents here who are now pumping/looping also had those sleepless nights and to a large extent, we are now able to sleep “somewhat normally”…I say somewhat because there are always trouble spots that we encounter and will continue to encounter due to the nature of the disease in such small bodies.

You’re doing great! Hang in there! Things are going to get better. Read and continue learning everything that you can…my goal is to become as knowledgeable as I can about diabetes so that I’m able to pass along THE CORRECT information to Liam as he continues growing. We have several “book” recommendation posts here on FUD…here is one such link.

There is a plethora of knowledge here in FUD and we’re all rooting for you and will help you to any extent we are able.

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I would definitely try @Eric 's suggestion to move your Lantus shot to the morning, that should help for all the reasons he mentioned. Once you are able to get on a pump you will love the ability to micro-dose insulin and fine tune basal, and you will likely end up looping in some form, whether that be from the algo’s that the pump manufacturers are releasing or on your own like @ClaudnDaye. Because you son is older, you are likely to be happy in either case.

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Welcome! I know it can be really frustrating at the beginning, and with MDI and finger sticks, it can be hard to pinpoint what’s going on. My first question is how much does your son weigh?

To help out, I have a few other questions:
When does he eat dinner?
When is his bedtime snack?
If he gets snack uncovered, goes a little high, then comes down on his own, how long after dinner is he coming down on his own?

Just as a reference, my son is nearly 7 and uses about 5 units of basal a day. He’s been diagnosed since he was 2, so no residual beta cell function, and is about 45 lbs. So to me, a honeymooner using 6.5 units of basal seems a wee bit high to me, but of course everyone’s mileage may vary and it could well be spot on.

The basic trick for assessing basal is to do a basal test. One night, give him a simple dinner (something you usually give him) and no bedtime snack. Then, if he starts the night in a reasonable range (70-180ish), just watch his numbers from about midnight on. If he ticks up by 30 points or more his basal might be too weak. If he drops by 30 points or more his basal might be too strong. The tricky part is that his basal might be appropriate at some times of day but too high or low at others.

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Yes, I have considered changing his basal to morning delivery for the reason you stated (being out of his system overnight). And Yes, I have thought about splitting his basal to morning/night (mostly bc I’ve read on other forums that people do that) but haven’t felt comfortable doing that “on my own”. And I can’t say that I even thought about the reasons you mentioned (greater control over basal if needed, decreasing low trends at night) but it totally makes sense. Would I expect to need to adjust any of his meal doses during the day? Or would have 3.5 u morning dose be working the same as his full dose at bed time does now?

If I switched to morning delivery, how would I do that? Skim the lantus one night, expect higher over night/morning that day, and give the lantus the next morning?

I’m guessing if I split the dose I’d just start with half at his normal bedtime that he usually gets it, then the other half in the morning? You mention a need for a correction bolus in the morning- would I just admister the correction first thing and then only bolus for his food at breakfast (as to avoid stacking?)

So grateful for all your input!

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He is about 68 lbs, will be 8 years old at the end of the month. We typically eat around 5:30, then I push bedtime stack as close to that as possible, around 7:30-8, mostly bc I get nervous with IOB at night and I want to be alert enough to deal with the fall out if need be (I don’t like falling asleep until i know how that nightitme IOB and stack is looking like it will work out). I’m thinking, at least in the short run, moving dinner to more like 6:30, and then no snack or a no carb snack if he really wants one- I think that may help.

THe last time he got an uncovered snack, it was only about 8 carbs (honey roasted almonds and the fairlife protein milk). He was around 135 at snack time around 7:45 pm. He peaked around 220 at 9 and was back under 180 around 11. He continued to drift from there and hit 80 around 2:30 am. I have my low alert set to that and I give him 4 oz of milk. That picked him back up to about 130, and he then drifted again to another 80 at 5 am. I gave him 3 oz of milk then as well to get him through to breakfast, and he was 97 around 8:30 am at breakfast.

Thank you for the basal test suggestion, definitely worth doing. And yes, it does seem tricky. There are times it seems his basal needs may have been more, but other times it seems more accurate.

Again, thanks for all your time!

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Based on your description of him going low repeatedly well after about 11:30pm (assuming he ate dinner at 5:30pm, his dinner bolus should be out of his system by then), it does seem like the basal is too high, at least for nighttime.

I’d try @Eric 's suggestion of either splitting up the dose or changing to morning, given that Lantus has a small peak in activity (it’s stronger at some times than others). If lows are still happening, you may need to lower the basal dose.

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The issue with basal is that it assumes his activity levels are nearly the same day to day, which is very difficult for an 8 year old. Even without factoring in sports and other activities that change. The unfortunate reality is that you are trying to tailor a therapy in a constantly changing environment dealing with an unknown amount of variables. Well, we actually know how many variables, but it is hard/impossible to take all of them into account with the tools you are using.

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Yes, for sure. Even with the same meal and the same starting blood sugars, results can vary quite a bit from one day to the next. It has been difficult bc with my son most of his activity is rather spontaneous- one day its nice and neighborkids are out so he’s quit a bit active, the next day not so much. Or one day he’s wrestling with his sister, the next day not so much. It’s nearly impossible to predict or plan for, let along all the other variables at play. Everybodys input is givine me hope that a pump will improve the quality of our life, thought it may still be 6 months or more away for us. Right now I just feel like his diabetes dominates everything, and I worry going into summer how to keep him feeling normal- getting to have ice cream when the other kids are, smores at the fire, etc. Under our current regimine and guidlines from the CDEs, that will be nearly impossible. So I was hoping to start on pump therapy sooner rather than later and begin that learning curve (not perfect, I know, and really only as good as the info you input, but still much more flexible than we are now).

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OMG, I can relate SO much to this. lol. Because Liam (my son with Diabetes) has 5 brothers, it occurs often in my house that things will go from being fairly quiet to suddenly a herd of buffalo passing through the house as they chase each other and play. We trained Liam to always pop 2 sugar tablets before beginning the horse-playing with his brothers so at least now he has a little to offset the chance of a potential low as a result of the unplanned playing. But he doesn’t do it 100% of the time so I still have to listen/inquire as I hear the buffalo’s running through the house laughing and playing.

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The funny thing is, I called our CDEs about 2 weeks ago with my frustrations with this nighttime issue. Got no help except to change is ISF for evening (which I had already done). The CDE was more concerned with his morning numbers (around 140-150 at breakfast at that time) and wanted me to increase his basal (which I have not). It was very frustrating that they didn’t take the time to look at the whole picture.

He generally wasn’t dipping lower, but he was also going to bed with much higher BS, and staying there longer. That night he was in range at bed time and I didn’t want to “mess” it up with more insulin, so I tried the uncovered nuts snack. So either his basal needed to be knocked back that night or he should have had more to eat (although, I have read- perhaps here!- that you shouldn’t have to “eat for your basal”.). I’ve stuck with the 6.5 at night bc it generally works ok (granted as you have all pointed it there probably seems to be a better way to deliver his basal that I will have to try).

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Our Endo / CDEs / Nursing practitioners were ZERO help with “day to day” management of Diabetes for our son…this is why we all created FUD. To get REAL, PRACTICAL wisdom from other diabetics who have been there and done that.

Honestly our Endo has two purposes…write prescriptions and keep an eye on any potential problems that may stem from having diabetes (neuropathy, retinopathy, etc.,). I don’t ask our Endo for advice and I often have to school them on the “real world” where diabetes is concerned. Our endo would have been happy with Liam living in the 200 and 300’s…disregarding the very real and significant issues that this causes later in life as a result of the extended hyperglycemia. It’s all about liability imo.

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100%. It never fails, too, that we’ll do lunch or dinner and I’ll give him the planned full bolus. Then immediately after he’ll hear neighborkids and his sister will be running outside like crazed maniacs, and I’m left thinking “great, full bolus on board and now total energy burn out. great.” I just can’t predict these things, and if I try, as in cut back on the bolus, he ends up sitting around.

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