We are now 8 months into the search for consistent blood glucose for Emerson and while we have made some gains across most times of the day, the after breakfast period still remains a huge challenge for us. We have seen readings all over the board at mid-morning checks, but mostly they are above the target range (100 – 200) and quite often, substantially higher than the upper threshold, evidence of some serious postprandial spikes. We have tried some different approaches but are dealing with a few factors that are increasing the level of difficulty. The first of course, and one we suspect many of you experience, is the type of foods that Emerson likes to eat for breakfast. While we have made great strides to incorporate foods that are better for her, she still likes her Cocoa Krispies, Fruit Loops, and other sugar-laden cereals on occasion. Our second challenge is associated with the timing of many of her mid-morning glucose checks. During the week, when she is at pre-school, the kids are given their morning snack at 9:00am, or soon after. Emerson usually doesn’t finish eating breakfast until close to 7:30am. So her mid-morning glucose check occurs only an hour and a half after breakfast, which we don’t believe is enough time to really see the full effects of her breakfast bolus. We have recently begun to slowly adjust the timing of breakfast to create a bigger window between these two. While this will likely have some benefit, we don’t expect it to be the full solution given our experiences. On the weekends we usually have a snack closer to 10am. This has some impact (avg mid-morning weekday reading = 258, avg mid-morning weekend reading = 196) but doesn’t result in readings that are consistently where we would like them.
So how do we currently manage this period of the day? It should be mentioned up front that Emerson does not have a CGM, so in order to get a true sense for what her glucose is doing, we have to perform more frequent finger sticks, which we obviously try not to do very often. She has however been a pumper since June, when we chose the OmniPod as her lifeline. This introduced some flexibility in what we could do with her basal and gave us the ability to more aggressively attempt to eliminate the morning glucose spike and overall inconsistency. After considering some things others were doing we decided to try the super bolus approach. So we added a couple hours of basal to her breakfast bolus and cut her basal down as low as possible for the hours following breakfast – which on the OmniPod meant a .05 basal rate. At the beginning we were generally pleased, as we saw less lows at lunch due to the lower spike and subsequent late morning crash and improved overall consistency. We made some minor adjustments over time but just weren’t finding the consistency that we would like. Recently, however, we reached a point where we noticed some difference in her readings depending on what she ate (e.g. high sugar cereal vs. oatmeal). So we planned to more closely track this for a period of time to see if we didn’t need to create different formulas to figure breakfast boluses depending on foods consumed. Soon after, Emerson had a quarterly appointment with her Endocrinologist. Her A1c had improved significantly, much to the delight of Dr. Hannon. However, the improvements that we have made across the day now made the mid-morning readings look like a flashing red light. We discussed the challenges and some things to try. She suggested we try to include more protein at breakfast to slow the digestion of carbs, thus reducing the spike in glucose and hopefully improving consistency throughout the morning. We were willing to give it a try, although didn’t have high expectations. On the first day we did everything the same – except gave her a banana and peanut butter instead of the normal fresh strawberries and blueberries. At the time of Emerson’s mid-morning snack I got a call from her pre-school…she was at 95 when they tested her. Per our agreement with them, they treated her. However, when they tested her again she was at 75?. This was the first time they had experienced this so were understandably a bit worried. We were shocked – it appeared the addition of the protein – via the peanut butter – worked much better than we assumed it would. We figured the use of a super bolus with the added protein meant she now got way too much insulin. We would need to obviously make a change to her breakfast dose tomorrow but were very encouraged by this. Since that time we have constantly made adjustments to her breakfast I/C ratio and the super bolus amount. We are now back to the same parameters as the day she went low at her mid-morning check but have not had that repeat itself. On the majority of days we have experience the same mid-morning spike that we thought for a moment we had conquered. Back to square one.
We are hoping somebody has mastered this period of the day and might be able to provide some guidance to us and anyone else that might be having the same struggles.
Has anyone had similar challenges and been able to overcome them in a child of a similar age (4 yrs old)? If so, is there any advice you would be willing to offer?