mid morning highs vs lunchtime lows.

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ruthelliot

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Ben has always struggled with being way too high mid morning (2 and 1/2hrs after breakfast insulin) but hypos at lunchtime or even a bit before. This was much worse on mdi - we never managed to get nearer single figures mid morning. Since pumping he gets breakfast bolus at 7.20am and now at snacktime at nursery (10am) we usually have near perfect results however he still freq hypos between 11.20 and 12.20pm. I have reduced the basal down to the lowest poss between 10-12 (short of having it at zero at this time) and his carb ratio at snacktime is now 1:70g (compared to 1:13g at breakfast) I'm reluctant to allow higher readings at snacktime to compensate as he does feel it when he runs a bit high and anway then I'd need to start messing with correction ratios again as he seems to respons quite variably to correction doses at this time - its an all or nothing effect!
Ive heard it said that hypos breed hypos and at the moment we seem to have that problem as he will often then have a few more on those days (compared to prev when we got huge rebounds) Im also finding the hypos at half 11 seem to be taking a lot to get him back up. Any suggestions? I think the lovely nursery staff have gained a few more grey hairs this week.
 
It's a bit variable, can go either way though i suspect more often ok than hypo.At weekends he will have a later breakfast and no snack and is usually ok but then everything about weekends is different so not the best example. I've always felt the insulin seems to really hang about with ben, so was wondering if reducing the basal from 9 rather than ten might help without making him too high at snacktime. I can't figure out if it's a basal problem or stacking insulin from breakfast and snack? I've reduced the snack bolus further for nursery tomorrow but if that doesnt help I thought I might need to do some basal testing ( I assume I could give him a little cold meat at snack time without affecting this)
 
"I've always felt the insulin seems to really hang about with ben, so was wondering if reducing the basal from 9 rather than ten might help without making him too high at snacktime. I can't figure out if it's a basal problem or stacking insulin from breakfast and snack?"


Hi, it is difficult with post breakfast spike and then bolussing because of a snack - the pump will want to correct that high alongside the snack bolus. Could well be your correction factor that is a bit out.


Do you give his breakfast bolus before he eats, and how long before ? We found waiting 10-15 mins before Millie eating helped with the spiking somewhat, we have learnt to just avoid some breakfast cereals with her too as just not worth the spike.

How long is the active insulin on your sons pump programmed for? Could that be something that needs lookin at? pump taking this into account is supposed to prevent stacking. 🙂
 
ruthelliot said:
It's a bit variable, can go either way though i suspect more often ok than hypo.At weekends he will have a later breakfast and no snack and is usually ok but then everything about weekends is different so not the best example. I've always felt the insulin seems to really hang about with ben, so was wondering if reducing the basal from 9 rather than ten might help without making him too high at snacktime. I can't figure out if it's a basal problem or stacking insulin from breakfast and snack? I've reduced the snack bolus further for nursery tomorrow but if that doesnt help I thought I might need to do some basal testing ( I assume I could give him a little cold meat at snack time without affecting this)
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Hi Ruth how long before his breakfast do you bolus?
It's just a suggestion for you to think about but when you bolus in the moring test Ben 15 mins later and see what he blood sugar is. If it hasn't gone down with the bolus or risen then you know you have a basal problem that needs sorting to counteract his high mid morning reading.
His hypo between 11.20 and 12.20 do you think this is a case of insulin stacking due to his breakfast bolus and snack bolus collideing? Some of the rapid insulin's do have a real kick in them towards the end of their duration.
What happens if Ben has a carb free snack? Pehaps a sugar free jelly or something else to his choice.
If it's not a stacking problem then his basal needs looking at, at least 2 hours if not longer before 11.20 🙂
 
Yeah I bolus about 15 mins before breakfast and I have to say the mid morning highs are rare now except when we do anything to try and tackle the hypo later - it seems to be one at the expense of the other. I will try checking at breakfast Sue. So if it stacking that's a problem which I'm inclined to think it is do I just reduce the snack bolus even more? On mdi we had both the high and the low so I guess the problem is half sorted at least! I agree I also the correction mud morning needs to reduce as the odd time he is high at snack the hypo can be worse. Just wish things were a bit more consistent as everything I do seems to work for a day or so - are things always this unpredictable, I guess I'm just getting a bit weary at the moment!
 
Hi Ruth,
Sorry to hear about the tough week with your little guy. I've been thinking about your late morning hypo problem. I have a couple of ideas - please confirm with others to see if this is crazy talk.

I do think you're into a stacking problem with 10am snack bolus. In today's regimen, it would be interesting to know the 1hr, 90 min and 2 hr bg's from first bite. Would also help to know how much and type of carbs going-in. Short of this info, these are my thoughts.

Stretch Peak / Flatten the Drop / Reduce Low
Assuming you have the morning high under control (with Novo?) and your basals are correct, perhaps you can consider going to this kind of scheme by 1) stretching the bg peak with reduced breakfast bolus and 2) reduce low by incorporating "square bolus" (30 minute) somewhere between breakfast bolus and morning snack.

Put another way.............
1) 7:20am????....Stretch peak: reduce breakfast bolus by X % (Perhaps only take 75% of usual amount).

2) 8:40am???......Flatten the drop: Move the 25% from brkfst into mid-morning square. Mid-morning square bolus would also be accounting for 10 am snack (or a fraction thereof until you have confidence and work into real numbers).

3) 10am.......Ideally, mid-morning snack wouldn't require bolus with this technique. You may not require 10am basal reduction either.
 
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