Why the pump isn't working?

[kraysmom]

My daughter is 16 years old and is back on the pump for the 2nd time in 4 years.  We are trying everything from talking to her doctors every day and making changes in her dosages to watching everything she eats.  My question is this, why does her blood sugars do well one day and then do the opposite the next?  We haven't had two good days in a row yet.  She is doing nothing different.  There has got to be some tests that would reveal what her body is doing and why it isn't using the insulin correctly.  Everyone blames her age and hormones, but her body can't change this drastically in one day.  She can feel great today and tomorrow be turned totally around for some reason.  I know it takes time to get all the dosages right but why the drastic changes in blood sugars?  I would understand if there were just SOME fluctuations in blood sugars but not what's happening to her.  Can someone help us with this? This is getting really old, fast.  Thanks>

[JDRF-VOL-RL]

Hello.  I'm not a medical professional, just the parent of a kid with diabetes, and a kid who is also on a pump.  If I knew of an accurate way to predict blood sugars and what causes blood sugar changes, I'd make a billion dollars.  Just about anything can cause a fluctuation, from stress to excitement to sleep changes.  Food is a big part of it, but not the only part.  Hormones are a possibility.  

If you're not seeing any changes with stress or exercise or sleep or anything like that, then I'd dig into 2 areas.  First is whether you are getting accurate carb counts, as well as understanding how different types of food affect her.  Things with a high fat content really mess up my daughter's blood sugars.  She's on the MiniMed pump, and for high fat foods we often do either a dual wave bolus or a higher temporary basal for an hour or two.  Different types of cereals do the same thing.  It's all trial and error for figuring out what the effects of everything are.  The other part of this is to ensure that you are figuring out the portion sizes properly in order to dose for the right amount of carbs.  I have no idea how you're doing it, but we thought we were eyeballing things pretty well, using the fist size cup portion measure and other eyeball things like that.  We bought a Salter 1450 electronic scale, which gives very accurate measurements for things like cereal and can also tell you the entire nutrient content including carbs for a food, you just tell it what kind of food and based upon the weight it figures out the carbs and fat.  What we learned was that we were underestimating the carbs we were bolusing for.  Even counting out 17 Pringles, which is the serving size, didn't actually match the grams of chips that are what the nutrition content is based upon.  Always go by the grams of a serving and not the count suggested.  Getting more accurate on that has helped us from bouncing around on blood sugar scores to getting really consistent numbers.

Second is about validating your pump settings.  I don't know what pump you're on, but every pump has software that you can use to analyze your info.  Look at whether or not you're getting a 40%/60% ratio for basal to bolus.  That's the target ratio that is most recommended, some endos want 50/50, but I know a lot of people on the pump and very few people have 50/50.  My guess is that her basals aren't high enough, and on the days you're seeing decent numbers it's because she's bolusing for way too much and not enough through basals.  If you see trends through the day where she's high in the mornings, for example, and is ok for the rest of the day, you can increase the insulin to carb ratio for that time frame, which will prevent the highs.  This is called post prandial highs, and there is a ton written about how to deal with it.  There are other things with the pump like understanding the insulin duration, which is used to determine the insulin on board when you are bolusing or trying to correct from a high.  We lowered our daughter's from the 4 hour duration that the endo set to 3 hours, and may even drop that a little lower.  The reason we did that was because we were seeing extended highs, even after a correction.  That meant the pump thought there was still insulin in her system, and wouldn't dose her any more even though she needed it.  By shortening that, it allowed us to get the corrections to actually occur instead of dealing with extended highs.

But really dig into and understand the data from the pump.  There is an organization called Children With Diabetes (http://www.childrenwithdiabetes.com) that has a ton of info on understanding the pump and insulin.  Everything I noted is really important, but if I had to guess as to where to look first, it would be with the pump settings, and specifically with the basal rates.

Good luck!

[JDRF-VOL-RL]

"My guess is that her basals aren't high enough, and on the days you're seeing decent numbers it's because she's bolusing for way too much and not enough through basals."

I need to clarify that.  What that really should say is:

My guess is that her basals aren't high enough, and on the days you're seeing decent numbers it's because she's bolusing for way too much *through corrections* and not enough through basals.

[JDRF-VOL-SG]

You received some great suggestions from JDRF-VOL-RL. I would like to add that allergies, and any kind of physical activity can make big changes in blood sugar levels for longer than one day. Healthy people have fluctuating glucose levels, too, so don't get discouraged. Hers may be fluctuating too much, but they always will fluctuate, and hormones, stresses, excitement, activity, allergies, etc. can all play a huge role. It is a tough job, but it does get a little bit easier when we grow up and our bodies stabilize a little bit from those growth and development years.