Pumper with widely fluctiating overnight numbers

[Mom of Em]

Hi, my daughter is 12 years old and has had diabetes for 5 years.  She has been on a pump a little over a year.  I am pobably overly compulsive about checking her sugar but really want to maintain good control.  All of her prior A1C's were below 6.7 however her last A1C was creeping up into the 7 range.  I'm having trouble adjusting her basal rates correctly during the night.  She will go to bed with a 130 but when I check her at around midnight she will be anywhere from 200 to 300.  I do a correction then check her at 4 a.m. and she will be low, treat the low with a small glass of juice and when she gets up at 7 for school she's high again.  One day last week she was 79 at 1 a.m., I gave her juice, she told me the next day that she woke up at 4 a.m. and was low again and ate a bannana then she woke up again at 5 a.m. and was still low and drank more juice.  When she got up at 9 a.m. she was 275.  I've tried adjusting the temporary basal rates, she has several different ones running through the night, going up and down and sideways on all of them but can't seem to get it right.  Her next endo appointment isn't until the end of March and I can't get in any sooner.

Any suggestions from other pumpers would be appreciated.  Thanks.

[Mom of Em]

Thank you for the great advice.  I don't know why I didn't relate it to hormones.  She just started menstrating less than 6 months ago and her cycle did begin this past week so that makes perfect sense.  It would seem almost impossible to maintain consistency if the culprit is hormones but I know there has got to be a way.  This past week was loaded with highs during her period, but then on Saturday, she dropped very low (49) several times, which she very rarely does since she went on the pump.  I guess I just didn't notice that it was right around that time until now but it was right in the the thick of it this past week so that has to be it.  She hasn't been very regular since she started either so hard to predict when it going to start.  Wow, it's hard enough trying to maintain control under regular conditions, now I have to account for hormones?  Will it never end ;|

[JDRF Team SGG]

I, too, am a type 1 female, and I also vote for hormonal shifts being the probable cause of this fluctuation. This may settle down once she is menstruating on a regular monthly cycle, but until then, you are doing exactly what you need to do by checking often and treating when the numbers are off. LRS has a good suggestion... the correction numbers may be changing a little during this time of her life, and it might not be a bad idea to look at this a little more critically with your daughter's doctor to see if the correction factor needs to change.

Once your daughter's hormones settle into a fairly routine pattern, she will notice that there are definite days when her glucose levels will tend to run high (because of the hormones that Dr. Johnson mentioned) at the end of her cycle, and this may be followed by a few days of severe lows. If she knows to watch for this, she can manage it without horrible ups and downs.  It is important that you and your daughter know what to expect when hormone levels shift each month.

[JDRF-Team-LRS]

I'm another volunteer here, and a long-time diabetic dx'd as a teen. You've gotten some good insights as to what's going on from others who've posted.

Given the fluctuations and the potential for overlapping boluses, you might talk to your doctor about also using a different insulin sensitivity factor for overnight bolusing.  For example, if your guideline is something like 1 unit of insulin will drop her BG by 70 points, perhaps for the overnight period, you can consider a sensitivity factor like 1 unit to cover 100 points.  The result would be a more conservative approach to treating a high.

Review your data with the CDE to evaluate whether the basal pattern needs to be changed overnight, too.  In addition to the erratic hormonal releases, you might keep track of exercise patterns adn stress patterns, too.  If she is physically active, especially in activities that are weight-bearing, the BG impact can last for 24 hours or more.  Similarly, pay attention to the animal-fat content in her evening meals.  Fat will slow the digestion of the carbos we eat, and when we finally digest them, our insulin may have dissipated already.

Furthermore, do check on how the pump computes remaining insulin on board.  For most of us, a unit of rapid-acting insulin that's normally used in a pump, will have an impact for about 5 hours.  If the pump "thinks" that unit works for a shorter time, there is significant chance of overlapping boluses and thus lows.

The adolescent years are perhaps the most difficult years to fine tune.  Just as we detect a pattern, hormones shift and stressors change and the results are no longer good.  Good luck and please realize that you & your daughter ARE doing very well at this!

[JDRF-Team-ES]

I can really identify.  Sometimes, it is really very hard to figure out what may be causing the problem, especially when you are dealing with a growing adolescent girl.  Her body is probably changing and this may have an impact on her blood sugar fluctuations.  Hormone levels at that age can be erratic and I know that my blood sugars are especially sensitive to the particular time of the month.  The doctor can probably recommend some adjustments to her basal, but my guess is that he/she won't want you changing things too drastically until you can figure out if there is a pattern.  Does your doctor have a nurse practitioner or a nurse educator that you can speak to before March?  I hesitate to even try to make any recommendations, even though I am a pumper myself,  because I know how different every person is.  I also know how difficult it is to control blood sugars, especially in hormonal teenagers.   Please talk to your octor's office and see if they can recommned someone for you to talk to before March.  If htere are any parents of teens out there who have any suggesstions, please write in.  In the meantime, it sounds like you are doing all that you can do and your daughter's A1C's are still excellent.  You both are to be commended for all the work it takes to accomplish that.
Es