FUDiabetes

Parent of T1D: need advice tuning treatment of child on MDI


#1

Looking for tips on stabilizing daughter’s BG. We use novolog & levemir pens and G6. Predose 95% of the time and recently split our levemir dosing. Still seeing some intense spikes and dips and riding high often. Any advice on calming the line?


#2

Welcome, @CodyA !

How long ago was she diagnosed? And how old is she?

We have a lot of parents of T1s here! My son is 14 and was diagnosed when he was 11.

Feel free to introduce yourself here if you want:


#3

She was diagnosed October 2017. Just turned 5. Thanks for the support!


#4

So she is likely out of honeymoon right now. When are you out of control, typically? It is at special times of the day, or after meals? What meals?

Are you comfortable setting up her basal yourself, or is your endo doing it? Do you adjust your ICR?

@ClaudnDaye, @TiaG, what are your suggestions?

@CodyA, have you considered a pump, btw?


#5

Michel’s questions are pretty important, my son is 16 and we are having worse and worse control despite taking pretty aggressive measures. The growth hormones are for real. But there are things that can be done. We just need a wee bit more information. I also noticed from you other thread that your daughter is about 1.5 years into the T1 journey. That might be one explanation, i.e. that she just finished her honeymoon and now the whole control paradigm is on you guys rather than her body playing part of it.


#6

So glad to see you made it.


#7

Yes we try and tweak basal accordingly so we are good doing so if/when needed. Spikes are given after breakfast and usually after lunch too. We don’t have a strict ICR and alter dosing depending on current BG as well as how we’ve observed certain meals have affected her BG in the past.
We usually try and pre bolus 20 minutes (on average) before meals. I try and use her Dexcom as best I can on when to have her start eating.


#8
  • If she was diagnosed 1.5 years ago, likely @Chris is right and her BG control is totally based out of exogenous insulin. So it must have become harder to control her recently.

  • if you can keep her roughly in control away from meals, particularly at night, it probably means your basal control is good.

  • If it is typically after meals, there is a fair chance it is a bolus issue. But that is not automatically certain, could be a daily cycle issue too.

A few questions:

  • Do you know for a fact her insulin activates after 20 minutes? It seems short to me, particularly for breakfast (but lunch too). Do you know how to test for how long it takes for insulin to activate?

  • Are you familiar with the technique of waiting to eat until you “turn the corner”?

  • Totally understand the need to customize her boluses based on specific foods. But, for me, I would have a very hard time doing anything without a good understanding of typical ICR. For us, for instance, we use a separate ICR for each meal, and tweak it to fit specific foods. But they are, in general, small tweaks, with some exceptions (pizza, pasta etc.). So I would seriously consider using ICRs.

  • What kind of carb diet do you follow for her? What typical number of carbs per meal?


#9

Hi @CodyA, welcome! We have a 4.5-year-old who was diagnosed in March 2016, so going on 3 years now. Our son had no honeymoon to speak of, really, so things were a roller coaster from pretty early on. But I’m happy to try and help troubleshoot if it’s helpful.

A few questions: What is your daughter’s total daily dose of insulin? How much Levemir and how much short-acting?


#10

Breakfast is tough, because no one that I know has time to prebolus and still wake up at a reasonable time. Our lunch and dinner prebolus is between 45 minutes and an hour. So that seems really short to me.


#11

That’s why for me, eating low carb breakfasts I don’t need to prebolus for is usually my best bet.


#12

That is what we do as well. My son eats 80-120 carbs a day, but breakfast is between 0 - 6 carbs.


#13

For us, we pre-bolus our child for breakfast before waking him up: that is how we go around the timing issue. Our morning pre-bolus is 45 minutes, so just enough time to get up, shower, get ready for school and breakfast.

For 2 years we thought he could not handle a large breakfast, but we found out he actually can. Right now he takes between 13 and 25 carbs but we plan to experiment with an increase, so as to allow a run in the morning.


#14

Breakfast is usually longer if we can but still see that spike. Lunch and dinner I try my best to use the Dexcom to see when the insulin kicks in. In a perfect world I like to introduce food when it hits 80-70 and headed down.

Our Levemir dosing has changed. Used to be 5 units in evening and then increased to 7. Now we are transitioning to a split of 6-7 units in evening and then 2-3 units 12 hours later. I would say we average 14-20 units short acting (novolog) in a day.


#15

Do you use a cgm? If so do you try to roughly hit a particular reading when taking in food?


#16

So you have one big issue as I see it. So, I love your approach, if we dose right and my son heads down from 80 when we give him food, we get a pretty flat line. I will say that we almost always dose more than is expected for the meal and then have him eat out of the low at the end. With that said, my son is 16 and that works for us, and if we get into trouble he has no problem eating as many carbs as it takes to get out of the low. If I was the sole reason my daughter was alive and she was 5, I am pretty sure I would be more conservative than I am with my older son’s recommendations.


#17

That is very nice! You should be able to measure how long insulin takes to activate for your child. It will likely be between 40 minutes and one hour. You just need to see how long it takes to go a significant, maintained downward pattern from the time you inject. There is a typical number, and how long it actual takes in every instance may vary (may be longer, rarely shorter).

Once you know how long it typivally takes, the next step is to pre-bolus by that long. Then you just need to look at her CGM and see when you see her actually “turns the corner”, is when you see the elbow of the BG starting to go down. Once that has happened and she is in an appropriate part of the range, that’ s when you give her food.

But— be careful you don’t wait too long: if we wait until my son is 70 to have him eat, he always goes low because it often takes 15-20 for carbs to start making an effect. So, as @Chris wrote, you need to be conservative in that respect

If you already are waiting until she turns the corner, possibly the reason for your postprandial peaks is inexact ICRs or carb counting? As I mentioned, we always use ICRs (insulin to carb ratios) to dose. It is much easier for us to dose home made food because we know exactly what goes in it. I assume you use a scale to weigh the components of all her meals? We do.

@tiaG in this thread has a child almost exactly your daughter’s age: she is a perfect person to help you! Kids your daughter’s age are notoriously difficult to balance well, and subject to quick BG moves.

Yes. We wait until he turns the corner, then it depends upon the angle of the curve. I would say typically around 90. But, for your child’s age, you may need to be a touch higher? If it is a big bolus it needs to be higher than a small bolus (because the slope of the curve will be steeper). The key, of course, is to make sure the BG is going down for real: that the insulin is activated.

Of course, if she is not in range when you pre-bolus, you will need to inject more than the ICR indicates:you have to add a correction as well. But I am sure you do that already!


#18

I bet you are right about ICR. I think our timing hits fairly well when we utilize cgm and our long acting just needs a few adjustments. But my guess is we are coming up short on our ratios.

We have noticed levemir life is no where near what it says it is. If we notice continual high BGs we change the vial and tend to have some luck calming her blood sugars down a bit.

Thanks all for the help!


#19

You are totally right! There is an interesting activity curve for Levemir on FUD that shows how long it typically lasts, based on your level of use per hour: the less you use, the less it lasts :frowning: With a small child with low insulin need, you may only have a smaller number of hours than you want. I am on my phone so posting links is difficult, but you can probably find it easily with a site search.

On FUD we have made lots of experiments with insulin degradation. We have found that insulin degrades much less that manufacturer recommendations indicate (check threads by @Eric and @Chris for instance). So I am not sure that a vial.change would often make a difference?

However, on the site we see that balancing a toddler or young child is probably the most difficult task of all :frowning: We, parents of older children, can give some ideas, but the parents of toddlers and young children will be ideal! They can give you very practical and concrete thoughts. @TiaG and @ClaudnDaye, in particular, have a wealth of experience and success, so their advice will be precious!


#20

Good morning Cody. My name is Harold and I’m father to Liam who is now 5 years of age and was diagnosed at 2. From everything I’m reading it sounds like your issues are with I:C ratios. If he’s relatively flat when fasting, then it sounds like your basal rates are good. Morning meals are most diabetics worst meal of the day because there’s always that big spike due to the body processes in play during that first meal after a long fast. If you are comfortable with your basal rates, I would recommend working on your I:C ratios and dialing those in.

The problem with MDI and young kids is that the units that pens dose are often too much so you end up feeding the insulin. I would recommend getting your daughter on a pump because the dosage possibilities are much smaller, which is what small kids like ours need to get the bolus rates as accurate as possible. Liam uses the Omnipod (tubeless) and has been using it since he was 3 or so. I’d be happy to help you, give you info, or answer any questions you may have about the pump, or anything else.

I’m not familiar with Levemir - when we were doing MDI, we were on Novolog and Lantus. Lantus seemed stable and able to keep his basal needs met. Liam is just now leaving (we believe) the honeymoon stage, after 3 years…he has previously been on a TDD of between 5 and 7 units, and now he’s gone up to between 9 and 13 units TDD per day. So we’ve just recently (in the past couple weeks) been dealing with increasing his rates, testing and all that.

Anyway, welcome and this is a great place to learn and grow - I continue to learn every day! Looking forward to interacting with you in the future as you dial in your daughters insulin needs.