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

Parenting a D-Child Child
21

I will also tell you how we do breakfast meals. After 3 years, we’ve tried it all…and what works best for us is to, first off, have a higher I:C and basal rates the morning time, for the breakfast meals. With pumps, you can set different bolus rates for different time frames (which you already know since your wife is on a pump right now)…so during the hours of breakfast, we have a higher I:C than the meals for the rest of the day.

On top of this; however, we also do other things if necessary. And I say if necessary because, for us, it’s not needed every day. We don’t restrict Liam’s carbs at all for breakfast or any other meal. He’ll usually have a Eggo waffle (sometimes with syrup on it for the waffles that need it), a cup of milk and an egg (some days the egg). Some days he eats other things, but that’s typically his go-to breakfast.

We consider ourselves “sugar surfers”…we “manage the moments” rather than going by strict I:C’s, timing regimens for meals, etc., Liam can and will eat anytime during the day and we “manage the meal and moment.”

So, depending on the morning meal and how his sugars are behaving, we will do other things to avoid the huge spikes (that are always over 250, but if not treated correctly, can go up to 400 or higher), such as:

  1. Do an extra extended bolus to give him extra insulin over a specific period of time. So, for instance, I may give him an extra full unit with zero up front and everything over 1 hour. We’ve found this helps offset the huge spike that occurs frequently after meals. Because we’re talking about him being high after morning meals (sometimes over 250), the increased unit helps fight that high (the higher the BG, the more insulin it takes to combat the high and bring his BGs back down). As long as you’re paying attention to the trends, you can treat quickly enough.

  2. IF we know that a particular meal regularly wrecks Liam’s BG’s, we’ll also turn on a temp basal. Depending on the meal, we have different temp basal programs created…an especially bad meal that always spikes significantly, we’ll do 95% more basal 1 hour before the meal and we’ll keep that going for between 2 and 4 hours after the meal.

There are so many strategies that people use to combat huge morning spikes. Some go low-carb, some do other things. We choose to just let him be just like his brothers and work on refining his insulin regimen to just make it work. A combination of an extended bolus + temp basal if needed COMBINED WITH vigilance in watching the trends usually works for us. During any given morning meal, we usually go above 200, but rarely above 250 and we come right back…and, if necessary, give another snack. Sugar surfing means reacting to the moment…so if he’s coming down fast, we just correct with carbs. If he’s going up fast, we correct (aggressively) with insulin.

2 Likes
22

Can I ask the timing and amount of your levemir doses?

2 Likes
23

Hi @CodyA! I’m back on a pump now, but I was also using Levemir and Novolog recently. I see @Eric was headed in the same direction with his question about the timing. It took some tweaking to get my Levemir timing right, and I saw some serious spikes before I did. It might have nothing to do with what you’re seeing, but it’s easy enough to find in a pattern. Just a thought.

1 Like
24

Thanks for all that info. I listen to the juice box podcast and he talks a lot about using an extended bolus. I feel like that would be a great benefit of a pump just not sure we’re ready to make that jump.

Today is going much better. Working on our ICR and I really think a new vial of levemir makes a world of difference.

2 Likes
25

Right now we are doing some big tweaking. Used to be once a day. Past few days we have moved to 7 units in evening (approx 7:45) and 3 units approx 12 hours later.

1 Like
26

One of the great things about Levemir is the shorter duration allows you to customize the basal amounts much better for different times of the day.

Here are the estimates of Levemir durations based on units per kilogram of body weight:

Dosage amount (units / kilogram) Average duration
0.1 units/kg 5.7 hours
0.2 units/kg 12.1 hours
0.4 units/kg 19.9 hours
0.8 units/kg 22.7 hours
1.6 units/kg 23.2 hours

Make sure you convert body weight to kilograms.

Here is a link, but it is not worded very clearly:

RESULTS:
Duration of action for insulin detemir was dose dependent and varied from 5.7, to 12.1, to 19.9, to 22.7, to 23.2 h for 0.1, 0.2, 0.4, 0.8, and 1.6 units/kg, respectively.

3 Likes
27

Hi @CodyA – so one thing I’ve done to figure out ICR. Give the same meal every day for a few days and see where you end up three or four hours later. Now give the same meal every day but in a larger amount. Are you winding up even higher than before, 3 or 4 hours later? That’s a sign your ICR is off, and it can give you some insight into how much it’s off as well.

Here’s an example with some random numbers: Let’s say your daughter eats breakfast at 100 mg/DL, you have a carb ratio of 1:20 for breakfast, you dose for 40 grams of carbs, so 2 units of insulin. Four hours later she’s 200 mg/DL instead of 100. So she’s 100 points off from your target BG of 100 mg/DL (just to give nice round numbers).

Next day you dose for 60 grams of carbs, so 3 units of insulin, and 4 hours later she’s 300 mg/DL instead of 200 mg/DL. So the extra 20 grams raised your daughter’s BG an extra 100 mg/DL, so each gram of carbs added 5mg/DL to her BG. How much is the ISF(which you may not know is correct, but let’s assume it is)? Let’s say it’s 200 mg/DL per unit of insulin (again, just for nice round numbers’ sake).
That means she’d need an extra 0.025 units of insulin for each gram of carb. So for a meal of 40 grams, she’d need 2.5 units of insulin instead of 2. That translates to an insulin to carb ratio of 1:16.

That kind of math. Of course it’s just a ballpark and you can always just edge things down a bit until you end up with good numbers…but this kind of back of the envelope calculation can give me a sense of how much tweaking is really going to be necessary.

Because we use a pump, a lot of our strategies are likely going to be different from those you use. For instance, we NEVER prebolus. We bolus for Samson’s meals when he is immediately sitting down, and for lunch or dinner, we might even bolus after he eats to prevent the food-strike/low blood sugar/frantic feeding of glucose tabs dance. If we prebolus his food outlasts his insulin and we see a flat line initially and a slow rise in hours 2, 3 and 4 – and the results in terms of average BG are identical. So we tolerate bigger spikes without worrying too much about it, as long as he’s back down in an hour or so. The other strategy we have used in the past is to prebolus a tiny amount – say 0.2 units – about an hour before he eats. Then when he sits down, bolus the remainder. We do that because having a downward trend before eating seems to be enough to suppress a dump of glucose from the liver, which is all we usually need to prevent super long, drawn-out spikes. And also, prebolusing, like we said, usually results in the food outlasting in the insulin for us.

We also use Loop, which is an open-source closed loop insulin algorithm for the Medtronic pump. So for breakfast, I suspect we have a more aggressive carb ratio programmed than we actually need, and then Loop automatically sets a zero temp basal for the remainder of the meal. Every breakfast then eventually becomes a “super bolus.”

The other thing I’d say is that you could theoretically time and split the Levemir dosing in a way that you’ve got a natural, gentle downward pull on her BG right around breakfast, and then you won’t need to be as aggressive and precise with the prebolus. That all depends though on timing – it would be kind of a pain to have to give her a bolus while she’s sleeping every morning, for instance. But @Eric is a real expert on figuring out that timing. It could help a lot for the breakfast spike.

The other strategy we make a lot of use of is micro-corrections when he’s a little high. If it’s been an hour since his last bolus I might give him, say 0.2 or 0.3 units to just bump him down a bit. I don’t wait the 3 hours to prevent stacking. That said, we use a pump so a lot of these strategies are tougher to implement with a pen. (Stacking is more of an issue and also, you don’t want your daughter to be poked any more than necessary I’d imagine.) Also, if your daughter’s in school you can’t do much fine-tuning of boluses after the fact, as you’ll likely have to adhere to a care plan, etc.

Great to have you on the site. I hope we can be helpful.

3 Likes
28

Thanks so much. Today for lunch I calculated around 1 unit for 12.5 grams. She started eating at 100 with one arrow down on Dexcom. So I think my timing was fairly good. 2-3 hours later she was at 240 or so. Like someone said we have been ok with spikes if they come down but have not been coming down lately.

Sometimes I feel like her insulin requirements are so high.

2 Likes
29

@CodyA, every kid’s insulin needs are different. I know that our son was using 8 to 10 units a day (3 years out from diagnosis). Now he’s using closer to 11 or 12 – he had a stepwise jump literally in the last few months, were it seems overnight that he just needs more. Meanwhile, @ClaudnDaye’s son seems to need (if I remember correctly) like 5 to 8 units of insulin. And he’s just a few months older than Samson at 5 now. So the kids need what they need!

2 Likes
30

Tia, just over the past couple weeks Liam has gone from a TDD of 5 - 7 units, to between 9 - 12 units TDD. It seems that, after 3 years, he may finally be exiting the honeymoon stage.

2 Likes
31

It looks like she needed more insulin for that meal. Maybe 1 unit actually covers less than 12.5 grams of carb. If you see this same thing at lunch for a few days, it may be time to change the insulin to carb ratio to give a stronger dose of insulin.

The right amount is whatever the body actually needs. You make it sound like you have a theoretical idea of what the proper amount of insulin “should have been.” We deal with the practical reality: if the BG is too high we need more insulin. If the BG goes low after a meal we needed less. And it’s a bit like tuning a guitar: whatever is correct for now won’t stay correct in the future. There’s a continual process of watching the response and adjusting the insulin dosing as the body’s requirements change.

1 Like
32

I think my wife being T1 has also clouded my mind a bit. Her insulin requirements are often lower than my 5 year old, which seems shocking, but I guess she’s not growing anymore like the 5 year old.

2 Likes
33

I think one thing that makes it tricky is ( for me), 1 unit may drop my bg 50 pts if current bg is 150, but only 30 pt if 200.

I think of it as insulin is opening the door, but cells are saying, sorry, i’m full! Then that insulin molecule is no longer able to open another cell for glucose uptake.

I was diagnosed at age 5 over 50 years ago. Times have changed!!!

1 Like
34

It turns out that although there are lots of common lessons, we all differ in how we need to treat our BG. We sometimes say YDMV (your diabetes may vary) as an acknowledgement that what works for me may not work the same for someone else.

And I’d like to second MM2’s statement. I find that it takes much more insulin to fix a high BG than it would have taken to prevent it.

3 Likes
35

Hi @CodyA

I am parent of a 3yo girl diagnosed 18months ago. She uses Dexcom G6 and Omnipod/Humalog.

It sounds like you are considering a pump – my daughter uses omnipod w/ Humalog if you have any questions. I would highly recommend a pump – I did consider Medtronic/Loop/tslim.

I think it is important to treat the lows carefully. I usually weigh a spoon and add Dex4 glucose gel to the spoon to make sure I am treating with a good amount to get rid of the low but not go over 150. Its usually 2grams, 3 grams or 4 grams (total weight) depending on how fast the Dexcom is falling.

I also treat lows with small amounts of 2% milk e.g. 1.5oz or 2oz usually if she is hanging annoyingly in the mid nineties.

For the pre-meal insulin timing I divide her Dexcom number by 10 and wait that number of minutes. E.g. 120 divided by 10 = 12mins. 220 divided by 10 is 22mins. It seems to work well for us – bearing in mind I use Humalog through the pump.

I usually have specific dosing for different meals e.g. a McD happy meals I give75% before and 25% of dose 30mins after the meal.

Firstly try get rid of the lows one at a time then try to reduce the highs one at a time.

I have always found the Dexcom clarity tool very useful for pattern recognition– particularly the Data/7 Days/Data Overlay. Even the overview page can be helpful.

Ed

3 Likes
36

Welcome @EdD!

37

Nice process you have figured out for your little girl. Congrats, you are way ahead of the game in my experience. Even have an insulin recipe figured out for the Happy Meal!

1 Like