mid-morning/lunchtime highs

[CaitlinGibbons]

Hi all, just wanted to get your collective thoughts/advice on this - my 3 yr old tends to go very high after breakfast, regularly going into the mid 20''s. we are carb-counting now so I am obviously dosing accordingly, using a lower ratio to compensate. However she then tends to drop quite dramatically at lunchtime so we have been advised to give less again in the morning. I'm worried about her being this high every day, and also think she feels quite unwell during this time period.
Does anyone else experience anything like this? If so, how do you handle it?
[She is on 4 injections a day, Novorapid and Glargine. Although her daily meter readings are quite frequently out of range, her HbAc is usually good, in the 7-8 range.]
Any thoughts would be much appreciated!
Thanks
Caitlin

 

[leggott]

You might need to do a bit of fasting to check if the background / basal insulin is right. Perhaps give her a non carb breakfast and do some hourly testing to see whether her bg changes. If it starts to go up or down then you know that the Glargine needs adjusting. When you get this right you can then start to make changes to the ratio of novorapid. It might take a few days to get it right. Always make one change at a time as if you do too many it can be hard to work out which change worked and which one didn't.

I'm sure that she won't feel right if her blood is going high. My kids tend to feel a sicky when their blood is in the low teens.

let us know now you get on.

 

[serankine]

My daughter used to go high after breakfast if she ate certain cereals.

But we are now in the pump so we alter it . Especially if it is a slow release like porridge or weatabix.
Its so hard getting the balance right.

 

[emmamadi]

Hi! I could have written this post as my son (who is nearly 3) is exactly the same. No matter what he eats he goes high mid morning, and unless he has a snack, even though he is high, he always drops dramatically into a hypo before lunch. He went from lantus to levemir to try and help this, and it has a bit, he has a split levemir dose 3 units in the morning and 1 unit at night, along with his nova rapid for meal times. When I asked his nurse, she said the little ones are particularly hard to regulate. I will be watching this post in the hopes that we can help them! I know what you mean about them not feeling well, and its hard to see them feeling poorly.
Emma

 

[CaitlinGibbons]

thanks all - I will maybe try some non carb breakfasts to see if the glargine needs to be adjusted. I think I must be confused about that.... doesn't the glargine only last for 12 hours? in which case wouldn't it be out of her system by the morning (I give it at 7pm)?
the only thing is, she LOVES her cereal - I try to stay away from the really sweet ones obviously but currently she wants bran flakes and rice krispies which I'm sure aren't great even if you are carb counting!
So much to factor in!
Will let you know how it goes, thanks again
Cx

 

[leggott]

yes, it's always difficult with young ones. May be you could mix some sliced banana with her cereal to give a bit of slow release carb too. On the days that she has sugary cereal then you could try giving the insulin a little bit before she eats to avoid the spikes.

 

[Jen&Khaleb]

I get this a bit too at times. Generally the long acting is running out by 7am so when we get up in the morning he has his insulin (long and short acting) and then breakfast at least half an hour later. I then give him morning tea around 10am as the long acting is 'kicking in' and he will last until lunch. Bit of an example of Khaleb is a waking bsl of 7.9mmol (Novorapid/Levemir), morning tea 9.9mmol (20gm carbs) and pre-lunch bsl 6.3mmol. On this particular day his post lunch was 5.8mmol and he has a small afternoon tea to get him through to dinner.

If you aren't sure your child would eat breakfast and need to give insulin after the meal it would be hard to avoid the big spike. Khaleb usually has porridge or weetabix but he will have muffins and pancakes occassionally also. If he has woken up a bit high in the morning I will even delay breakfast a bit longer than half an hour, if I can, so he gets some insulin in his system. I did use trial and error for a while and did regular tests to see how this worked for Khaleb and I know it wouldn't work for everyone. Before doing this it was common to see bsl's in the 20's from 9am to 10.30am and then hypo before or around lunch time.

Hope you find something that works. Smoothing out the rough edges really improves overall control. Khaleb's last hba1c was 6.2% and we have very few hypos and I've been doing a fair bit of sleeping through the night this year. I'm not a fan of broken sleep even though it is necessary at times.

 

[CaitlinGibbons]

thanks, same thing happened today, she was 15.8 (7am) this morning so I carb-counted and gave her an additional unit of novorapid to help bring it down. however at lunch she was 17 (11.45), having just had cucumber for her mid morning snack. she then had lunch and had another largish dose of novorapid to try and bring it down some more and was then 3.8 by her tea-time at 4pm. She did have a mid-afternoon snack of 2 cream-crackers, cream cheese and half an apple in between.
Interesting that the timing of the injection with the food can make that much difference, I long for the day that she is more predictable in terms of how much she'll eat.
I'm coming to the conclusion that we need to up her glargine very slightly and try and get her back on the weetabix and porridge for a while.
thanks again everyone, really helpful!

 

[Jen&Khaleb]

Did you test at morning tea time? It would be interesting to know what she was about 10am. I can find Khaleb starts to go a little high in the afternoon and tend to give him his Novorapid for dinner early if this is the case. It is just the Levemir running out again as his dose is split morning and night. If I increase it he hypos so I just make do with what I've got.

 

[CaitlinGibbons]

I quite often test mid-morning and she is normally very high at this point, like in the 20's. she then comes down a bit for lunch and then crashes early afternoon (after lunch). a typical pattern would be:

before breakfast: 12
mid morning: 20
lunch: 10
mid afternoon: hypo

this pattern has emerged since we've been carb counting, I can do this at home but at nursery it's impossible so they are just working on a set dose. I have been giving a high-ish dose at breakfast to try and counteract the morning highs, but don't know if this might have something to do with the hypos later in the day? Can the insulin hang around that long I work on a lower ratio at lunchtime but think this might need to be brought down even more...

 

[Jen&Khaleb]

This is only my guess work but I would think that the Novorapid has done the most after 2-3 hours and your late afternoon hypos maybe because your daughter's body didn't like the 20's at 10am and made some efforts to flush the glucose out and at the same time you have administered more insulin. Do you regularly start the day above 10mmol? If this is often I would be increasing the long acting even just by half a unit (if you have half unit pens). Do you split the long acting or give it all in one dose? This might also explain your low in the afternoon and the lack of morning insulin if you have given one large dose in the morning?

Khaleb did actually wake with a bsl of 12mmol this morning even though when I went to bed at 10pm he was 8mmol and at 3am he was still 8mmol. With breakfast he had 2.5 units of NR and 7 units of Lev (will be 7.5 units tonight and tomorrow morning) and at 10am had a bsl back to 8mmol. I only ever correct back to around 8mmol. His pre-lunch was 9mmol but he tends to help himself to the fruit platter at morning tea (daycare) and I am not there to adjust what other food I sent. His post lunch bsl was 6.6mmol but I know exactly what he had for lunch.

Carb counting is great but if your basal is out or unpredictable it doesn't help much at all. Little kids are even harder as their activity, growth patterns and hunger levels change so much. I know Khaleb is on slightly higher Levemir dose than just his basal rate would require and this means he would be prone to hypo between meals if it wasn't for morning and afternoon tea and the supper he has before bed. Khaleb and I would not be happy about having 8 injections a day and he would be starving if he didn't have snacks so this works for us.

Do you get much support from your clinic or other parents?

 

[CaitlinGibbons]

thanks, that's really useful. Syvie had her lowest ever bsl today - 1.4 - and worryingly wasn't displaying any symptoms. it followed exactly the same pattern, she went high after breakfast and was 17 before lunch (12pm) and then by 1.30 had dropped to 1.4. She came back up OK but then went high (of course) so we will now be starting the day high again tomorrow. I called the dsn today and booked in to see the consultant who hopefully will be able to help. I had been suspecting that the basal might need to go up for a while but they have been resistant to this and said I needed to get the hypos during the day ironed out first. Anyway, tomorrow I will take the lunchtime dose down even further and hope that helps. We have half-unit pens for the Novorapid but not the Glargine... I am nervous about increasing the Glargine as I don't want to cause any night hypos, we've not had one yet and of course I panic as I don't know if she'd wake up or not. Seeing as she can get to 1.4 during the day and only complains of her tummy hurting when prompted, it scares the living daylights out of me with regards to what a night hypo would be like... we have never been advised to test during the night but it seems that most people on this forum do... do you test every night?

 

[Jen&Khaleb]

Khaleb was only 8 months old when diabetes struck and I was advised to test once or twice every night. It was exhausting but necessary when he was so young. I don't test every night now but do test when changing doses, if I've given a correction dose before I go to bed, after active days, if the level at 10pm is a bit low, during any illness or during periods of instability. So, yeah, I get a fair few broken nights of sleep as the above happens a lot. After spending a day at a theme park recently I put Khaleb to bed with a bsl of 20 as I have been caught with some terrible hypos in the wee hours of the morning from the activity. I did check him at 1.30am and he was still 15 but woke in the morning with a bsl of 6.8

Have you thought of not giving insulin with lunch and seeing what happens? At least you will be able to find out what level she is at 2/3 hours after eating (count carbs) and whatever difference between the first level and the second will be how much insulin to give. I know that Khaleb would need 1 unit of insulin for 8mmol. You can then experiment whether it is the morning NR lasting 4-5 hours or if the dose of Glargine is the cause. I know clinics don't recommend correction doses but it could be to your advantage to get up at 2.30am or so, correct a high back to 8mmol so you can start the morning with a level in normal range.

Khaleb is often not symptomatic with hypos. I found him at 1.6 one night and he was quite alert and when asked if he wanted something to eat he just nodded. I've also seen him in the low/mid 2's sweating, shaking, crying and ready to pass out. I sometimes think it depends how fast they are falling that is the issue. Hypos can happen day or night even with the best of management. I often find Khaleb has a sudden unexplainable hypo a few days before he comes down with an illness. I have never found Khaleb's DN or Paediatrician to be very helpful with dosage as they don't see how to fit a lifestyle around diabetes that fits the family. Getting the confidence to adjust things yourself works better in the end. Only ever make small changes, one at a time, over weeks.

 

[CaitlinGibbons]

better day today - we reduced the lunchtime dose down to 2 units and nursery gave her a slice of bread with lunch to beef up the carb intake...she was 12 at lunchtime and 10 by afternoon tea, she went to bed at 10 so I feel it has been a successful day! I was awake half the night last night worrying about it and then dreaming about it too so am relieved to say the least. It's reassuring to know that it is possible to go that low and not keel over, although it is not a risk I would choose to take obviously. The pattern of hypos just after lunch emerged a few weeks ago and talking to the nursery manager (who is a huge support), we realised this was when the menu changed and we think she's just not eating as much as she's not as keen on the food. This doesn't explain the highs in the morning but if we can get the afternoon hypos sorted, I will then have the courage to tackle the glargine if needed.
thank you so much for taking the time to work through this with me, it's been amazingly helpful.

 

[CaitlinGibbons]

Hi,
Just thought I'd update in case anyone is still watching this thread... we have increased Syvlie's glargine to 4 units a night, the consultant thinks she could probably go to 5. This has reduced the highs in the morning, from mid 20's to mid teens. Before doing this though I ran her sugars high for a couple of weeks by taking her lunchtime dose down and making sure she was definitely taking in enough carbs (particularly at nursery). This has helped her hypo-awareness and she has complained of feeling funny when she drops to around 4. Her Hbac has gone up slightly to 8 (from 7.3) but I think that's OK as we can ease it down over the next month or so.
The consultant agreed that the highs in the morning were probably due to the glargine being too low, and the hypos in the afternoon a combination of a yo-yo'ing effect with the highs, which was then compounded on nursery days by a change in the menu and Sylvie not really eating enough.
We are checking her in the night at the moment, which we haven't done before but luckily she doesn't wake up when we do this.
All I have to do now is talk to my not-so-helpful GP who keeps cutting my prescription for test strips - she obviously doesn't have a child with type 1..........!

 

[Jen&Khaleb]

Sounds like your working through all the levels and getting them sorted. We are coming into Summer in Australia and Khaleb has had brilliant levels. It is so different when he is well and we are more active, mainly going swimming when we can. He was having a few hypos in our hot weather but I've got that under control. I've resorted to giving Khaleb a little snack before he goes to daycare as he wasn't lasting until their morning tea time. I hate having to work to other people's timetables but I suppose it is just a part of life.

I can't believe you are restricted on the amount of strips you get. We don't get scripts for them and have to pay something depending on benefit levels but just get them over the counter at the chemist. I only need scripts for insulin and hypo kits. Do you get ketone strips when you want them also? These cost $10 for a box of 10 here (for the Optimum Exceed) and we just buy them from the chemist.

Glad that you popped back with the update

 

[wsmum]

Good to hear things are getting on track. Getting the glargine right does seem to be the key to good control for my son (14). He is gradually coming out of his honeymoon and needing to take more Lantus at night. We're wondering whether he needs a different dose for the weekend too, as he's much more idle :lol: But the trouble with that is it takes a while to kick in, and a while to kick out! Ho hum.
As to your GP :shock:
Good luck with that particular battle