How to NOT spike (so much) after a meal?

Parenting a D-Child Toddler
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Why do people spike? Because the food metabolism does not match up perfectly with the insulin delivery. Different foods come in at different rates. Sometimes insulin comes in at different rates too, depending on things like pump site, temperature, and activity. It’s tough to match these things up perfectly!

The temp basal is just to give the insulin a head start. If you bolus for the meal, you don’t really need the temp basal to continue to run. Just for clarity in trying to figure out the numbers and what he needs, it would probably be easier to have it run only until he starts eating, and then use a bolus.

Again, insulin is insulin. Once Liam starts to eat, his body doesn’t care if the insulin was delivered as a temp basal or bolus. But just do it in a way that makes it easy to keep track of and adjust. I think just having the temp run up until the start of the meal is an easier way to keep track of your adjustments.

That answer depends on the type of food and how quickly he eats! Some foods run longer, and that would generally match better with a longer extended bolus. Some are quicker, so you’d want the bolus to be delivered more up front.

There are 2 things to consider with an extended bolus - the length of time AND the amount you are delivering at the beginning of the bolus.

This is just a matter of experimentation. There is no Endo in the world that can give you a better answer to what works for Liam than you will have after trying it a few times. You have to try, and then adjust.

For me, I have almost never used an extended bolus for more than 30 minutes. Other people use them for hours. It just depends on many things - food type, how fast you metabolize, how fast you eat.

Try, record what you did, record the results, adjust, try again.

Again, all the things I said above :arrow_up: apply here.

I can throw out some random recommendations and try to sound like I am an expert. “Well Harold, I would recommend that you deliver 50% of the insulin up front, and the remaining half of the insulin should be an extended delivery for 1 hour…” But I would just be guessing!

So try something, test, keep an eye on the Dexcom, test some more. And adjust and try again.

General recommendations:
Work on having his BG in a gentle downward slope and getting close to low BEFORE he starts to eat. Be aggressive with the bolus. Save dessert for after the meal so that when he starts to drop from the aggressive bolus, the dessert levels him out. No need to follow a meal with glucose tabs. Follow a meal with dessert, but just use the dessert as a BG correction.

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Thanks. Yes, we’ve experimented a LOT over the last year and have found 50% up front and 50% over the next 2 to 2.5 hours works best for Liam (for some foods…such as pizza)…but other foods that we would think should be extended the same (mashed potatoes for instance) end up being different…so much to know and “customize” on a, pretty much, per food type basis.

What we haven’t been great at; however, is RECORDING these changes. We’ve started this up now so that we can track what changes we’re making…it really doesn’t help to make tweaks if we can’t remember what tweaks we actually make (in case we have to revert back, etc.,) So, lots of room for growth on our part.

Now we have 3 separate logs…

  1. Snack Correction Log - anytime we have to give him a correction, either bolus or snack/juice to bring his BG up/down to back within range, we annotate it here.
  2. Pump Change Log - any tweaks we make with basal/bolus regimen, we’re now logging in here…from week to week. Sunday is our “review and analyze” day, from the previous weeks data…looking for trends (highs or lows) that we need to adjust.
  3. The CGM / POD “change out” log. Chronicles all CGM, POD changes as well as when we begin a new Insulin vial.

Thanks!

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Sorry, we were responding to TiaG’s recommendation below:

The way we understood this is that this is BEFORE the meal and it’s in addition too the meal bolus? So we were looking for clarification on what a pre-meal extended bolus is, how long it would go, how much extra, etc.,? This all seemed to pertain to giving EXTRA insulin, pre-meal. My questions weren’t specifically related to an actual extended bolus as we already know how to use these, and we use them often.

We might have just read her comment incorrectly…both sounded like they were references “before meal”, but now that I look at it again, the “before an anticipated meal” part might have only been pertaining too the temp basal. Please clarify!

Thanks!

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Can I suggest one other thing? It looks like the upper warning on the CGM is at 180. Why not set it much lower? You don’t have to treat at 120, but if it is moving up quickly, or looks like it will start to get out of control, it’s nice to have an early warning sign.

I treated at 120 today because I knew it was going to keep going. It’s not always necessary, but it is nice to be able to do that before the high gets out of hand.

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Our difficulty is that with a 3 year old…any small tweak we make (even something .05 more), can significantly impact his BG’s later on. Our running principle has been to bolus, wait 3 hours post meal and correct if necessary. If the post-3 hour BG is +/- 30 points from his Pre-meal BG, then we tweak I:C or other adjustments as necessary. For a 3 year old, we really can’t (at least not that we know how too) just add insulin during or after a meal without serious crashing of BG’s later on.

If there is a way to treat him somehow as we see him spiking upward to a point we’re not comfortable with, without the post-meal lows that inevitably follow, then we’ll certainly entertain those ideas. I don’t think that works for a grown up will work for our son because you’re dealing with multiple full units of correction bolus whereas a simple .05 for our son may be the catalyst for a low.

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Right, that was something else I wanted to ask about. What is his average TDD? Everything - basal, bolus, corrections?

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Between 6 and 8. Usually 6.5

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Oh my gosh. I am sorry, I didn’t think of this sooner. Sorry, sorry, sorry… I am stupid for having overlooked this.

You should consider diluting. You’d have much better control!

To put it in perspective, what you are trying to do with the current minimum settings on a pump with Liam is about like me going back to 1/2 unit increments. That would kill me on most days! Seriously! First off, please forgive my oversight.

Next, please consider using a diluent. It is not difficult, almost trivial to do. The only trick is just remembering the insulin doses are changed. You could get such better granularity with him. You could give a tiny little bit of insulin. You could be so much more precise. Imagine being able to correct with 0.01 units!

It’s free from Lilly, and pretty easy to use. I have used this stuff a bunch with syringes!

Anyway, I can give you all kinds of details and info if you want to try this.

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I have looked into diluting previously but had put it on the back burner until we ruled out human error on the regular undiluted insulin. I still can’t say with 100% certainty, even after analyzing data and tweaking so many times over the last year, that our issues just aren’t human error still. I want to be sure I’ve tested all variations of regular insulin delivery before going to dilution.

It is definitely something that I may have questions about down the road though!

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For now, let’s forget about differences in correction factors or IC ratios or total carbs eaten when comparing adults to toddlers. Just for illustration, let’s look at TDD. That’s an easy example.

Suppose an adult takes 100 units a day. And Liam takes 6.5 units a day. Comparing Liam’s minimum dose increment of 0.05 to what the minimum dose would be for the adult (we’ll call it Adultmin) would look like this:

0.05/6.5 = Adultmin/100

What would it be like for the adult? A minimum dose of about 0.77 units. That’s not a small increment. That’s like going back to the 70’s when they didn’t make 1/2 unit syringes.

EDIT:
So basically for the adult to be working under the same constraints as Liam, if he wanted to correct for a rising BG, the adult could take 0.77 units, 1.54 units, 2.31 units…
That would not be preferable for the adult. By diluting, you’d get much smaller increments relative to what Liam is using.

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we used diluent at the beginning but it makes the insulin more unstable, so diluted insulin works for just a week versus a month out of the fridge, and in our experience it made the insulin work much more slowly.

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Yes, it is best to mix it as needed, instead of in big batches.

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Do most adults actually use 100 units? I thought most took closer to 30-50 unless they are insulin resistant.

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It varies greatly. I don’t use anywhere near that amount. I was just using that number to draw a comparison between a young child using a 0.05 increment and what that would be as an equivalent for an adult. And my example wasn’t even complete, because I guarantee Liam’s IC ratio is much lower than an adult’s.

Even with the smallest increment I could get with pens or syringes (1/2 unit) I still needed to dilute to get more granularity. It just helps me greatly to do that. It’s one of the best things I came up with (and I say I came up with it because, well, no fully diabetic-dead pancreas-T1D-adult that I know of uses diluent that I have come across). It was my idea, certainly not an Endo recommendation. But I love this option.

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And my example wasn’t even complete, because I guarantee Liam’s IC ratio is much lower than an adult’s.

Our son’s I:C ratio is 1:15 for breakfast – is that dramatically higher than an adult’s? From what I’ve read, children tend to have more aggressive carb ratios given their TDD than would typically be expected for an adult, while having weaker ISFs. Obviously not quite as high as for adults, but still not negligible carbFs.

Also, our son also uses 6.5 - 8 units a day and I actually don’t think the granularity is a huge issue. The natural variability in our son’s response to the same foods is such that having the ability to bolus by 0.005 would make no difference in our son’s blood sugar management. The difference in the amount of insulin he needs for a typical breakfast, on identical days, in which no other factors are different, is usually 0.2 to 0.3; when he’s sick it can be more than double. We recently had two random days where, for breakfast, our son needed a carb ratio of 1:11, down from 1:18. That huge variation would absolutely swamp a difference of 0.05 and having the ability to tweak by 0.005 would actually probably be a detriment, because the amount of insulin we could stuff into the pump would start to be insufficient for more than a day or two.

Not saying that for people seeking real fine-tuning of their BG, who are working to keep themselves between 70 and 140, that the ability to do true micro-nudges is not an advantage. I just suspect that for a kid his age, given the gains they’re seeking (i.e. a huge drop in A1C or to simply get out of the 300s every day), the extra dilution will add more complexity but wont’ truly add more granularity because it’s swamped by other variables.

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Most of the general guidelines I have heard are that it is much lower for kids. I know it does vary greatly from individual to individual (mine are actually closer to a kid’s values than an adults, based on the charts they have).

I know all these things depend on individual preference and many factors. But,

I am not sure I agree with this point however. I am not sure of what numbers you are using, but the OmniPod pump holds 200 units. If you’re son uses 8 units a day, and you dilute it by 20%, you’d be using a total of 40 units of volume per day (still only 8 units of insulin, but 40 units of liquid). 40 units a day would last the 3 days of an OmniPod with no problem. But a 20% dilution would let you go from .05 units to 0.01 units.

Not saying this is what is needed, just trying to get the math straight here. Did I misunderstand?

I guess it all depends on if someone thinks smaller dosing is helpful. On a pump, smaller dosing seems great because you don’t need to take an extra shot or anything. The little guy doesn’t even know he’s being given extra insulin. It’s painless. But it all boils down to if you think it would help control the peaks and valleys.

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@Eric, sorry I forgot you could dilute by an arbitrary amount. When I was using diluent, it was at a 1:10 ratio, because we were using syringes. I guess a 50% dilution would be a different story.

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Yes @TiaG Some adults ( me for instance) take way more than 100 units/day. And I’m sure it’s from insulin resistance because I wasn’t always taking this much.

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Right now he’s on two different programs. Breakfast is 1:22. The rest of the day is 1:26.

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So 1 unit covers more for him than for almost any adult. That means it gives you even more benefit if you can give smaller increments. And on top of that, he doesn’t eat as much as an adult.

It’s a worthwhile comparison to look at it in terms of how it compares to an adult. This is simply a “for instance”, not using real values. Imagine for an adult, 1/2 unit or 1 unit is the difference between eating one piece of toast or two. No big deal for the adult.

But for Liam, since insulin covers more carbs, the same difference between 1/2 a unit or 1 unit is the difference between 5 slices of toast or 10.

That may sound like a silly example, but that’s actually close to the difference in how an adult can increment a bolus amount, and how you can. Relative to many adults, Liam is taking 1/10 to 1/20 of what many adults take.

BTW, earlier when I said “lower” for IC, I was speaking of the ratio as a fraction. i.e. 1/22 being lower than 1/15 or 1/10, which are fairly common ranges for adults. I probably didn’t explain it well when I said “lower”.

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