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Gary Scheiner MS, CDE
A Certified Diabetes Educator and Type-1 diabetic for over 20 years, Gary Scheiner applies the latest and best techniques for achieving optimal diabetes control. After earning a Master of Science in Exercise Physiology, Gary received his diabetes training with the Joslin Diabetes Center. Today, Gary directs a team of Certified Diabetes Educators at his Philadephia-based practice, Integrated Diabetes Services, which specializes in intensive blood glucose control for children and adults with insulin-dependent diabetes. His practice, which includes more than 2000 insulin pump users and hundreds of continuous glucose monitor users, consults clients worldwide via phone and the internet.
In addition to serving on the Executive Board of Directors for the Diabetes Exercise & Sports Association, Gary is an active volunteer for the ADA, JDRF, Children With Diabetes, and Setebaid Camping Services. Gary has authored three books (You Can Control Diabetes
Integrated Diabetes Services is a private consulting practice composed of Certified Diabetes Educators who have Type-1 diabetes. Diabetes management and education services are offered to anyone with diabetes, with special emphasis on children/adolescents with Type-1 diabetes and insulin pump & CGM usage. Services are available in-office or remotely via phone and the internet. Call (877) 735-3648 for more information.
Recent Responses
How is it that one son was diagnosed at 16 months and the other son didn't develop type 1 until he was 20 years old!!?(20 yr old dx 9/27/09)
The likelihood of an autoimmune attack on the pancreas was present in both from birth. The age difference at diagnosis is likely due to when each boy was exposed to the environmental stress (virus, toxin, etc...) that triggered the autoimmune response.
I'm looking to get my 7 yr-old daughter's ears pierced. She is type 1. Any of you aware of any concerns/cautions?
Only major risk is infection. Make sure her blood sugar is well controlled before doing something like this, and watch the skin around the piercing for at least the first couple of weeks. Also, the trauma of the piercing could send her blood sugars temporarily high due to an adrenaline surge.
Where is the best place online to buy insulin pump supplies and accessories?
I’ve had nothing but good experience, and heard nothing but good things from my clients, using Byram Healthcare for ordering diabetes supplies. They have a diabetes specialty division that deals with pumps, continuous monitors, meters, etc., and they have a pharmacy for prescription items as well. They are covered by almost every major insurance plan, and their staff is very knowledgeable. Phone number is 877-902-9726.
Would you please help me understand diabetes and how to deal with ups and downs?
This is one of those "open-ended" questions that are so hard to answer. It would take an entire book to teach them the answer to this. But I would suggest that the consider what their target range is: If they are aiming for too tight a range, they are going to be frustrated. They need a fairly liberal range with a child, and accept that not all readings will be in that range. For example, I try to keep very young kids between 80 and 200 at least 70% of the time, at least pre-meal. If they are concerned about being over 120, they're going to go out of their minds.
Do you think restricting a child's diet in necessary for blood sugar control?
That is an OUTSTANDING question. Having lived with type-1 diabetes for nearly 25 years and worked with thousands of children and adults with type-1, my answer would have to be "no" and "yes". No, I don't think you have to limit the types or quantities of food, as long as you know how to count carb effectively (using insulin-to-carb ratios), time the insulin properly based on the nature of the food (glycemic index), and make appropriate basal insulin adjustments for fat content.
However, "grazing", as many kids (and adults!) have a tendency to do, never seems to work when it comes to controlling blood sugar levels. We all know that blood sugars come up temporarily after we eat. It is necessary to give insulin a chance to bring the blood sugar back down before eating again, or else we run into a situation where the blood sugar stays at a chronically high level.
In other words, eat what you choose, but space out the meals and snacks.
How do you get a 12 year old to give her own shots? We are trying, but she will have no part in it yet!
That's a difficult question to answer, because every kid is different.In some cases, the child has severe anxiety over needle sticks, in which case desensitization therapy with a counselor could be very helpful. Other kids just don't care for sticking themselves so many times a day. An injection port such as the I-Port might be the solution. I've known kids who felt very self-conscious about using syringes in public (due to the image they portray). Use of a pen might alleviate that. But in most cases, kids just like the attention they get from their parents. They figure that as long as they refuse to take the shots, their parents will take care of it for them. When that happens, the parents must take a very firm stance.
"What’s best to use if we want to bring a low BG up quickly? We use glucose tablets and they work well. What other option do you suggest?"
The reason glucose tablets and gels work so well is that they contain DEXTROSE, the same stuff given by IV when somebody is unconscious from a low. Dextrose is glucose in its purest form (2 glucose molecules linked together), and thus raises blood sugar the fastest.
Many candies are made with mostly dextrose, and will also work very quickly. These include Smarties (called Rockets in Canada), Sweet Tarts, Nerds, Runts, Spree, Bottlecaps, and a bunch of others. Many are branded under the name “Wonka” candies. Just check the ingredient list: if dextrose is the first thing listed, it should be a winner!
Is there a difference between Novolog & Humalog?
The scientific answer: Slight difference in the amino acid sequence. In Humalog, lysine and proline are switched. In Novolog, proline is switched for aspartic acid. The changes cause the molecules to repel eachother (avoiding aggregation) and accelerating absorption & action.The practical answer: The insulin action profiles and potency are virtually identical. But there are some differences in the solutions in which the insulins are dissolved. Novolog (aspart) has some extra buffering agents that seem to make it more resistant to deterioration and (at least in my experience) less likely to cause site irritation.
Any advice on school field trips? My 11 yr old son is going to the museum without me for the first time since being dx a year ago August. He is pumping and the school nurse is going. I would really rather go- it's about an hour away and it is fo...r the whole day. But he doesn't want me to - he said he could handle it! I guess it's good for him to feel empowered to manage his diabetes at a young age but it is scary for me. Do you guys pack a seperate backpack with all supplies and how much should I "train" the nurse on pump stuff?
I think it's great that your son is eager to tackle a bit of "life on his own" with diabetes. It's a very controlled situation given that a school nurse will be there, and it's not overnight. Treat it as business as usual, but with a few common-sense precautions: Have him check BG every 2 hours and notify the nurse if he is above or below what you would consider "safe ranges". Have him bring a syringe and vial of insulin (in case his site comes out accidentally) and glucose tablets (or whatever you normally use to treat lows).I would supply the nurse with written instructions on specifically what to do in the event he is out of a "safe" range. Of course, if you can loan your son a cell phone, he can call you if he has questions. Otherwise, let him enjoy himself!
"I would love to know how to stop worrying ALL the time, especially when Alexis isn't with me, at a sleepover for example."
"A little bit of worry can be a good thing. It keeps us on our toes and keeps us from being neglectful. But worrying too much too often just isn't healthy for anyone.
A good way to minimize worry when your child is not with you is through sound planning and open communciation. The planning should include provisions for blood glucose monitoring, insulin dosing, snacks, adjustments for physical activity, and treatment for mild hypoglycemia. The communication is best provided through web messages (if you carry a blackberry or similar e-accessible device), text messages, or calls to & from a cell phone at regular intervals.
How can you convince fairly recently diagnosed teenagers to consider the pump..?? Our kids want NOTHING to do with pumping.. They are 15 and 17.. don't want "something attached".
My answer to this family is this: Expose the kids to other kids their age who are taking a proactive approach to caring for their own diabetes. This certainly doesn't guarantee that they will want to go on a pump, but it will allow them to see how other teens are using them and benefitting from them.There is no place better for doing accomplishing this than at a CWD (Children With Diabetes) conference. CWD conference group kids of similar age/interests together. Although not the primary intention, doing so forces the kids to learn from each other and inquire about some of the newer technologies and techniques that are being used to manage. Regional conferences are held throughout the year in various cities, and a mega-conference is held annually in Orlando. More information is at www.childrenwithdiabetes.com.
How come we can't get more clear cut answers about what kinds of damage (percentages?) can be done to the organs from going very high or low, many times in one year over several years?
It's very difficult to quantify blood glucose exursions over a large population of people for scientific analysis. That's why A1c levels are usually used. It's a nice "tidy" way of assessing overall control. There has been some work on the impact of post-meal blood glucose spikes, and they do appear to negatively affect long-term health (as well as short-term performance).Incidentally, don't panic over individual high readings. Having high blood sugar for 3 hours affects only one tenth of 1 percent of a single A1c measurement.
How do I handle a 12 yr old not testing & bolusing? She almost went DKA last week and just doesn't seem to care. Her latest thing is lying about her number. Saying it isn't as high as it is so I won't get mad.
When your child's life depends on taking insulin, it is your responsibility as a parent to make sure it happens. Any priviledges your child receives (internet access, cell phone, spending money, transportation, etc...) should be contingent on performing certain diabetes self-care behaviors: checking BG regularly, counting carbs, bolusing appropriately, etc... These are NON-NEGOTIABLE behaviors.If the DKA was related to a potential pump/tubing/infusion set malfunction, you may need some additional education on ketone testing and troubleshooting.
I am interested in knowing the pro's/con's of pumping vs. administering insulin with a syringe.
Major "cons" to pumping are: cost (deductibles/copays), inconvenience of having to wear the pump around all the time (albeit this is minimal), minor inconvenience and occasional discomfort of infusion set insertions, and risk of extreme high BGs and DKA in the event of a mechanical problem.The "pros" are extensive: ability to fine-tune basal insulin to meet the body's needs, ability to make temporary adjustments to basal for unique events; ability to deliver mealtime doses over an extended period of time (for slow-digesting foods); bolus calculator built right into the pump; historical record/download-ability might eliminate need for written records; ability to dose in very small increments; convenience of not having to give a shot at every meal/snack, and so on, and so on.
But keep in mind that just "going on a pump" does not automatically mean better control and a more flexible lifestyle. It takes extensive education and a clinician who knows how to help you fine tune all of the settings.
Gary is a Certified Diabetes Educator who has had diabetes for more than 25 years. He and his team of CDEs provide diabetes management "coaching" for children and their families via phone and the internet, with an emphasis on pump therapy, CGM, and intensive insulin management. For information, call 877-735-3648,
What's the deal with Diabetes and feet, my 5 year old was diagnosed 3 months ago, the Dr's didn't mention anything about shoes or feet, but on internet sites about diabetes it seems to be an issue, she hates wearing shoes, does she really need to wear them all the time, or can she go barefoot when at home?
I'm sure I'll get slammed by my colleagues for saying this, but you really don't have to worry about it. Yes, high blood sugar can increase the risk of infection and will slow healing, but as long as your child's blood sugar is reasonably well controlled, there should not be any foot problems. The reason people with diabetes develop foot problems is because of many years of neglectful care, which leads to neuropathy (loss of protective nerve sensation) as well as poor circulation in the feet, Minor injuries tend to become major ones, and the body is unable to heal itself correctly. Again, as long as you focus on controlling your child's blood sugar as well as can reasonably be expected for a five-year-old, they should be able to play barefoot and do all the other things a five year old likes to do.Gary is a Certified Diabetes Educator who has had diabetes for more than 25 years. He and his team of CDEs provide diabetes management "coaching" for children and their families via phone and the internet, with an emphasis on pump therapy, CGM, and intensive insulin management. For information, call 877-735-3648,
Yes...We have been reading about Insulin and Diabetes, different web sites. The one thing that keeps coming up are the side affects of diabetes and the amount of insulin used. We were wondering, with protein, fruits, veggies, minimal fat, and LOW AMOUNT OF CARBS, (to cut down on the insulin given for the day) what is the recommended amounts of carbs for an adolescent to have during the day, the amount of insulin given for the day? Are we doing the right thing? Also, is there a list of free foods they can eat? If so, where can we find it? Looking for a support group here in Southern N.J. can't find one, where can we look?
For adolescents with type-1 diabetes, insulin needs can be quite high due to rapid growth and insulin resistance created by pubertal hormones. It is completely NATURAL for teens to need large amounts of insulin -- sometimes 60, 80, even 100 units or more per day. And if they did not have diabetes, their pancreas would be producing all that insulin for them.Unless you child is significantly overweight, there is not reason to be concerned about how much insulin they are using -- only that their insulin is properly matched to their needs.
Incidentally, my office has a list of "free foods" containing less than 5g carb per serving. It's not the most appetizing list you'll ever see, but if you're interested, call me at 877-735-3648. Being near Philadelphia, I might also have some insight for you regarding support groups.
My daughter, 13 years old, started to go crazy with a nearly carb-free diet. She refuses to eat properly and lost a lot of weight . She is terrified of going hyper and I think she just doesn't wanna eat to avoid high blood sugar. She is on the pump and her basal rates are already very low and she still goes low a lot especially at night. She also started exaggerate exercising . Thank you for any suggestions, we are really worried about her.
This sounds like the makings of an eating disorder and/or body-image problem. I would highly recommend that you take your daughter for counseling before it goes any further.BTW, There is no reason to avoid carbohydrates. In fact, they should be included in the diet of everyone with diabetes. The key is to match the carbs with the right doses of insulin, given at the right times.
Gary is a Certified Diabetes Educator who has had diabetes for more than 25 years. He and his team of CDEs provide diabetes management "coaching" for children and their families via phone and the internet, with an emphasis on pump therapy, CGM, and intensive insulin management. For information, call 877-735-3648,
We are about 19 months into diabetes life, and we see that her insulin requirements are steadily increasing. Just how much insulin is she going to need when her pancreas completely stops making its own. She is currently on about 25 units for morning needle, and about 7 in the evening...this has doubled since last fall. We are just wondering what she may "top out" at...as it already seems like such a lot. I guess I don't understand enough about the progression of this condition....what "changes" can we expect in the next few years even.
Total daily insulin needs can vary considerably for people who make little or no insulin on their own. Pubertal hormones can increase overall insulin requirements, and physical activity will decrease it. For a moderately active school-age child, we typically see total insulin somewhere in the range of .5 to 1.0 units per kg body weight. For teenagers, it is around .75 to 1.5 units per kg body weight.I would not be overly concerned about these numbers. Whatever your daughter needs to properly control her blood sugar is the right amount.
Is there a certain length of time you have to wait to get a pump? What are the long term effects of taking insulin?
Insulin is a substance that the body normally produces on its own, so there are really no long-term "side effects". Since people with diabetes take insulin by injection (or pump), it is delivered into the fatty tissue below the skin. If the insulin is given in the same local area over many months or years, a condition known as "lipodystrophy" can develop. This involves a breakdown or inflammation of the fatty layer, resulting in hardening and poor absorption of the insulin. This can usually be avoided by rotating the injection/infusion sites correctly.In terms of pump usage, there is no set time required before one begins to use one. I have always found it best to wait until the "honeymoon" is over, since blood sugars are usually easy to control on shots during the honeymoon. But this should not prevent someone from using one during the honeymoon phase if they with. Of more importance is the user's SKILL SET. Prior to using a pump, a person (or their caregiver) should be adept at carb counting, record-keeping, self-adjusting insulin doses, and checking blood sugar at least four times daily. It also helps to be on a multiple-daily-injection program prior to starting on the pump, and have an understanding of the "basal/bolus" insulin concept.
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
gary@integrateddiabetes.com
My 11 year old daughter was diagnosed @ 6 & has been successfully wearing a pump for about 3 years. Thankfully we have had very few issues other than a visit to the ER for a low just a few weeks after her diagnoses. In the past 2 months she has been hospitalized & put in ICU overnight twice due to "highs" ! She acts as if she is checking/bolusing...when in fact she doesn't! In short she lies about it in order to eat!! Other than watching her like a hawk...what can we do?!?! Is it normal to be rebellious @ some point?!?!?
Is it normal to be rebellious? It is abnormal to not be rebellious! Almost every kid goes through a phase like this. She needs to understand that food is not her enemy and not off limits, as long as she compensates with appropriate insulin. She also needs to understand that blood sugar values are purely for decision-making; they are not to judge her or the job anyone is doing. Any readings is a good reading because it helps us to learn and fine-tune. If a good heart-to-heart talk doesn't resolve the problem, it would be a good idea to have her talk with a mental health professional at the hospital who specializes at working with kids with diabetes.Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
gary@integrateddiabetes.com
My son awakes on a daily basis at over 300. He seems to be rising steadily after about 3am. Is there anything you can suggest that may help? He is on Novorapid at mealtimes and levimir at breakfast and lunch and lantus at night. If ever I raise the dosage of levemir he hypos at about 2am.
If you are fairly certain that he is rising after 3am (this can easily be verified by using a continuous glucose monitor for a few days; it could also confirm that he is not dropping low soon before the rise), there are potential solutions. The obvious one would be to switch to an insulin pump. The rate of basal insulin delivery on the pump can be increased starting at around 1-2 am to offset the rise that takes place after 3am. Another option would be to add a small dose of NPH insulin at bedtime (10-11pm). The NPH peak could effectively offset the middle-of-the-night rise. We have used this strategy with several of our clients and it has worked quite well.The whole issue of taking 3 injections of long-acting insulin (1 glargine/lantus, 2 levemir/detemir) is another story. I have never seen a need for taking two different long-acting insulin types and cannot fathom why you might be using this approach.
Anyway, let me know if you would like to discuss this further. My e-mail is gary@integrateddiabetes.com or visit my website Integrated Diabetes Services.
My son is Type 1, he is 5 and was diagnosed last June. My endo has been talking a lot about the pump lately. I am considering switching this summer, looking at the Animas ping. Can I really get tighter control on the pump? His first A1C was 7.8 and his most recent was 8.1 and it's hard to not take it personally. How do you know when the honeymoon is over? I have noticed that his numbers have been much more jumpy since December so I assumed that maybe it's over. About the pump- my son is a little afraid to switch to the pump, is it ok to bribe him with a giant Lego prize if he switches? We love technology in our family and he does think it's cool that he will have his own "computer".
You ask some excellent questions. Very few people jump into pump therapy fully convinced that it is the right thing to do. It takes a bit of faith. Given that more than 95% of people who try pumps stay with them long-term speaks volumes. And remember that if you try the pump and don't care for it, you can always go back to injections. The biggest "complaint" I hear from most people is that they didn't try pumping sooner.A pump is little more than a tool for delivering insulin. Ultimately, your skills and motivation are what will drive your son's control. But there are things about pump therapy you just can't get with injections: The schedule flexibility, dosing precision, built-in calculations with adjustment for insulin-on-board, ability to fine-tune basal insulin levels, amazing convenience, fewer needle sticks, and so on. To me, it's worth the initial leap of faith. And a Lego set is reasonable reward for trying something new. It would work for me!
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
gary@integrateddiabetes.com
My son is 7 diagnosed 2yrs ago. He just had his first stomach bug and since hasn't need insulin to cover his meals. Almost 10 days without. He is still getting 11 units of lantus at bedtime but plan to cut it back b/c he is waking up low. Is this unusual after an illness.
Hi Melissa (I should say "neighbor" because I'm right next door in Wynnewood!) -This is very unusual. Typically, an illness will trigger further destruction of any functioning beta cells along with some insulin resistance, so insulin needs tend to increase. Has your son's eating patterns changed since he was sick? If he is eating very few carbs, his mealtime requirements could go down dramatically. Also, if he has lingering effects from the "stomach bug", he may not be absorbing his carbohydrates normally. If it continues, you should probably have your son evaluated by a gastrointenstinal specialist. One other consideration is the possibility of gluten intolerance (celiac disease), which could cause stomach bug symptoms as well as serious digestion problems. If your son has not been screened for gluten intolerance, now is a good time to do so.
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
gary@integrateddiabetes.com
My son has type one and he is ten years old, there is alot of training/information/conferences geared towards parents, but not towards kids.. I would like to see more activities directed towards kids besides Diabetes Camp. What kind of education/group support etc is available for our children? So far everything is for me and how to take care of him, but not directed towards kids learning about the disease themselves?
Probably the best place for your son to learn, interact with other kids with diabetes, and grow in terms of independence is at the CWD (Children With Diabetes) conferences and website. At CWD meetings, the kids are grouped with kids their own age, and the staff (mostly nurses and CDEs who have type-1 themselves) get them involved in learning-type activities that are really a lot of fun. For example, they often take a ride to a local mall, go to the food court, and count carbs together. Or they participate in sports activities and observe how their blood sugars change.The CWD website is packed with age-appropriate resources and networking opportunities for kids of all ages. Just as parentingdiabetickids provides outstanding support and information for parents of kids with diabetes (thus the name!), CWD's website has some terrific material for kids.
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
gary@integrateddiabetes.com
My 11 year old is scheduled for a tonsillectomy soon,does anyone have any experience or advice w/this surgery & Type 1 diabetes? I've not found much information on line.
Minor surgery such as a tonsillectomy usually requires very little adjustment in insulin prior to or during the procedure. However, afterwards, your son will probably need dosage increases to keep his blood sugar near normal. And it is important to keep the blood sugar well controlled to minimize the risk of post-op infection and enhance the healing process.If he uses an insulin pump, temporary basal increases can be used for the first few days as he rests and recovers. If he is taking injections, increases in the long-acting insulin can accomplish the same thing. Of course, check with the doctor who treats your child's diabetes prior to making any adjustments.
I am beginning to question the possibility of getting Kinsey (8) on the pump - I have heard it is just like starting over. Am I ready for that?
Like starting over? Well, yes and no. (don't you just love answers like that!?)Yes... it will require new adjustment/titration of the insulin doses. If your current insuilin program is working fairly well, the initial pump doses will probably not be too far from ideal.
No... assuming that you are properly educated and prepared for pump use (counting carbs, keeping good records, checking BG sufficiently, adjusting doses based on food/activity/BG levels, understand the basal/bolus concept), you should not require much in the way of new education. Of course, there is education pertaining to making optimal use of the pump, but the basic education should already be in place.
Here's a little trivia question for you. The song "Starting Over" was a hit back in the early 80s. Who was the artist? (hint: he had a famous haircut)
Our 5 year old daughter Ava does not have a lot of fat. She is currently on shots. Would a pump be hard for her because she has less fat.
Seems like the whole world is against lean people these days!Being lean will create some challenges when wearing a pump, but it's nothing that can't be overcome with proper infusion set selection and site rotation. Angled sets (opposed to straight-in/perpendicular sets) are usually best for lean individuals, as the angle can be adjusted based on the thickness of the fat pad. The buttocks is an excellent infusion site for lean kids (not to mention lean adults) -- the upper/outer portion of each "cheek". Rotating the sites in an organized way, so that a multitude of spots are used and no area is overused, will help to prevent the buildup of scar tissue, lipodystrophy and irritation.
When giving my 5 year old daughter her injections on her legs it nearly always bleeds is there any way of preventing bleeding when giving injecitons as the bleeding upsets her. thanks
A number of things could cause the bleeding: Too deep an injection, too shallow an injection, pinching too hard at the injection site, injecting into very bony or muscular areas, or chronic use of blood thinners such as aspirin.
The solutions stem from the possible
causes. Use short-needle (5mm) syringes or pen needles, and inject
perpendicular to the skin (no angles). Pinch gently; not too hard. And
use body parts that have a sufficient fat pad: hips, upper buttocks,
lower back, and sides of the abdomen. The TOPS of the thighs should not
be used in lean kids.
When doing the injection, remove the
needle quickly after injecting (pen needles need to be kept in the skin
for at least 5 seconds; syringes may be withdrawn right away). Do not
move the needle around under the skin, as it could cause the breaking of
capillaries.
I hope that helps!
Gary Scheiner MS,
CDE
Owner & Clinical Director
Integrated Diabetes Services
333
E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free:
877-735-3648
Can a specific subcutaneous site not be suitable for use? We have tried my son's stomach (he is thin) over and over and though he used it effectively for shots, it fails frequently for his pump sites.
Yes, some sites are not going to work well for pump infusion sets. These include:1) The area immediately around the belly button
2) Spots that have bone right underneath
3) Places where clothing may pull at or press on the site often (the pants waistband, for example)
4) Places that are prone to being hit or knocking into things (backs of arms for active kids)
5) Anyplace where the fat under the skin has either worn away or has become hard and swollen. Insulin simply will not absorb well at these sites.
The buttocks is a great place for most lean kids to wear their infusion sets. To avoid site overuse (and lipodystrophy), rotate sites in an organized way. Stay on one "cheek" for several site changes before going to the other cheek. Here is an example:
left side right side
1 2 3 12 11 10
4 5 6 15 14 13
7 8 9 18 17 16
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
My daughter was diagnosed at 4years old. She is now 9. She does not take her diabetes serious at all. She sneaks food constantly. We hide her 100 cal. snacks because she will eat them throughout the day. She is always high in the evening, and I mean high. I am worried, I don't feel we are doing enough. We address this with her Dr. every time we go. She says this is normal for her age group. She loves grapes and her snack. 1 point a piece. But I can't really buy them for her, because she sneaks them at other times in the day. Any advice, I am so worried about her. What do we do to make her believe this is serious. Just a little background...she was adopted at birth so counselors say her diabetes just may be one thing she feels like she can control. HELP
Tough love is probably in order here. You (as parents) need to take control of the situation. Your daughter needs to know that there are times to eat and times to not eat. This doesn't just go for kids with diabetes; it's a good policy for all kids.Punishing your child for disobeying the rules is certainly in order. Find something that is "near and dear" to her (computer time, nintendo, tv, etc...) and make it contingent on her following the rules regarding meal & snack times. YOU ARE NOT PUNISHING HER FOR HAVING DIABETES. You are dealing with the fact that she is breaking non-negotiable rules and not taking proper care of her diabetes.
This is actually much more difficult for parents to monitor than it is for kids to follow. But be persistent. Your daughter may expect you to "give up" enforcing the rules. She needs to see that you mean business and will not relent.
Anyway, that's my take on it.
When carb counting, do I subtract the fiber for total carbs OR include the fiber??? I'm coming across more and more food items that have more fiber and if the fiber doesn't change bg why count it!?
Since fiber has no noticable impact on blood sugar levels, I recommend deducting 100% of the fiber from the total carb count, regardless of how many fiber grams there are.How do I protect my sons pump site when he swims?? I have tried every "waterproof" bandage, tegaderm, etc.. Is there an adhesive or skin glue??? Please help..
Who says you have to "protect" the pump site? Infusion sets are water-tight once you disconnect the tubing. Nothing should be able to get in or out. There is really no need to cover it, unless you are trying to provide extra adhesion.If the infusion set is exposed to "dirty" water, it is reasonable to either clean the connection portion of the set with an alcohol wipe, or change the site completely.
What are some things to be aware of when her body is changing?She is a 11.
Because girls tend to hit puberty earlier than boys, their insulin needs usually begin rising significantly around age 11. Both basal/long-acting and bolus/rapid-acting insulin requirements may need to be taken up on a frequent basis due to the production of pubertal hormones which cause insulin resistance. It is not unusual for insulin requirements to double or triple between ages 10 an 15 in girls.Keep good records and stay in touch with your physician frequently during this phase. If your physician is not responsive to your needs, give my office a call. We can work with you by phone/internet to keep things on track.
Can the heat make a child go high? When it's hot, my son tends to go very high and stay high!!
Heat usually makes blood sugars drop, as the body works harder to keep itself cool and increased blood flow to the skin surface makes insulin absorb more rapidly.However, extreme heat can cause insulin to spoil, particularly if it is carried around outdoors, left in a car, or worn in a pump. You may need to protect the insulin in a cooling pouch (the Frio pouch works quite well), and change the insulin more frequently when it is exposed to temps over 90 degrees for several hours at a time.
I have a 16 year old daughter with Type 1. She was dx'd at 10. Her endo Dr. will not sign a medical release for her to get a drivers license because her A1c is an 8.She has never had any hospitalizations or complications. I think they don't understand a teenager living with Type1. Am I being too biased?
I don't think this has anything to do with understanding what it's like to be a teenager with diabetes. It is a serious issue of liability. Any child who is not doing the following should be considered a serious risk behind the wheel:- checking blood sugars frequently
- avoiding extreme highs/lows
- taking insulin in a timely/appropriate manner
- appearing for their scheduled appointments on a regular basis
- generally being responsible for their self-care
If your child is doing all of these things, and your physician does not provide a reasonable explanation for not signing the forms, then you have every reason to complain.
My daughters basal #'s seem to not be doing the job even though we have changed the insulin and the sight 2 times over the last four days. This is her eight month with DM1. We increased her basal by 50% and still not great. She is 17 and had an A1C of 6.2. Is this normal?? Any suggestions?
Basal insulin's one and only job is to hold blood sugar steady when there is no bolus insulin working, food digesting, or exercise taking place. If the readings are elevated within a few hours after a meal, it is more likely the bolus amounts that need to be adjusted.Because there is no long-acting insulin used with pump therapy, it is important to check for ketones whenever unexplained high readings occur. The presence of ketones almost always means that the pump is not delivering insulin properly. An injection (via pen or syringe), lots of water, and a site & cartridge change would be in order.
If you would like some guidance on gettting your daughter's basal and bolus doses set up properly, let me know. This is what I do for a living! (gary@integrateddiabetes.com)
What is considered a safe number at night for a 6 year old? We always test him at 11 pm and his numbers vary from 6 to 15.
Ultimately, what is safe for your child is to have blood sugars that are STABLE though the night, regardless of the bedtime reading. An 8 or 9 at bedtime may not be safe if their basal insulin is causing them to drop 4-5 points while they sleep. And if they are rising overnight, their A1c will probably be higher than desired. The optimal situation would be to have them in the 6-8 range before going to bed, and then stay in that range until morning.If BGs are rising or falling more than 2 mmol through the night, an adjustment to the basal insulin is probably in order. Also, make sure your child does not have any "active" or "unused" insulin from an earlier dose of rapid-acting insulin when going to bed, as this can also cause an overnight drop.
BTW, to convert blood sugars from mmol to mg/dl, multiply by 18.
My 10 year old son has had diabetes for 3 years and has been on a pump for 9 months. Two times while on the pump he has had what I call a growth spurt that has dramatically affected the amount of his basal insulin. It seems to take me a week to 10 days to increase his basal insulin appropriately. I have been told by the Ping representative that I need to have him fast for three mornings; fast for three lunches; and fast for three dinners and evenings to evaluate his basal. I see the logic behind this. I can't imagine implementing this because: 1. His days aren't the same (school days, sport days,less active at home days). 2. He seems to have these growth spurts 2-3 times per year. Once I evaluate his basal he'll grow (or change his sport choice of the season) and we'll start all over again. 3. The number of days involved three breakfasts x three lunches x dinners x three evenings = 12 days. 4. Very busy schedule (Piano, Church, Tae Kwon Do, etc.) How beneficial is this whole process for a child? Is it worth the disruptions to his life? What can I glean that will give me the best information with the least amount of effort and upheaval?
Dear Susan -As is often the case, the best option is a compromise between what is "ideal" and what is "practical". I do agree that basal testing is important for establishing appropriate basal patterns -- when peaks/valleys take place, and how long they last. This can usually be accomplished by fasting just once at each phase of the day, adjusting accordingly, and repeating the test during those phases that were adjusted.
After the initial pattern is set (properly), as your child goes through growth phases and needs increases, the entire basal program is simply shifted upward. The peaks/valleys stay the same, but the magnitude of all the settings increases.
If this doesn't make sense or you would like some assistance with the basal fine-tuning process, please feel free to get in touch with my office. This is something we work on with our clients all the time via phone and the internet: (877) 735-3648.
How does growth spurts or puberty affect insulin absorption or needs?
Growth and puberty don't affect insulin absorption, but insulin needs can increase dramatically. Growth hormone, pubertal hormones, and increases in body size create insulin resistance; the body is not as sensitive to insulin as it was previously. As a result, more basal insulin is needed, more mealtime insulin is needed to cover the same amount of carbs, and more correction insulin is needed to fix highs.Add to this the fact that kids tend to develop some blood-sugar-challenging habits during puberty: erratic sleep patterns, "grazing" type snacking behaviors, emotional swings, and so on.
My advice is to roll with the changes (adjust insulin frequently), but take your expectations down just a bit, or you'll find yourself in a constant state of disappointment.
This is a big one. My daughter was diagnosed 1 year, 10 months, 2 weeks and 6 days ago… Since then it has been a nightmare with a moment of clarity and then back to our nightmare. First part of our night mare is our daughter becomes more stubborn every day; she gags on her food when she doesn’t like it or is done and we already gave her insulin. She isn’t picky by far, she just hates certain things; like mushrooms… okay so maybe not that picky. She takes ages to eat when she does eat, unless she really loves her food. Her I:C is 1unit:10 carbohydrates, but I have notice with some things that ratio leaves her either too high or too low after meals. I feel so lost and confuse on how to please everyone at the dinner table and make everything healthy. Her doctors said after keeping her blood sugars stable (between 100-160) for 60 days she could get put on a pump, testing would be the same but insulin delivery would be easier. My question is with healthier foods such as pure apple juice, apples, strawberries, cucumbers; would her blood sugar rise and fall faster with her bolis? And the same with un-healthy foods like pizza, burgers fries. Would the un healthy foods make her bloods sugars stay elevated longer before coming down? How do I deal with that?
There are many important questions and issues in your message below. To answer them properly would take up an entire book. So let me give you the "reader's digest" version.1. If your child is a picky eater, don't make every meal a family catastrophe. If she won't eat something that you gave insulin for, you can always compensate with a beverage containing carbs, such as milk or juice.
2. Using the same I:C ratio at each meal is probably not going to work. Almost everyone requires different ratios at different meals. If your health care team isn't aware of that (or helping you to adjust), maybe it's time to work with someone else.
3. Having stable blood sugar should NOT be a prerequisite for going on an insulin pump. I don't know any kids whose blood sugars are as stable as you described. The purpose of the pump is to GET the kind of stability and lifestyle flexibility you're looking for. Again, if your health care team doesn't get that, might be best to look elsewhere.
4. Different foods do effect BG differently. The carbs in some foods raise the BG very quickly; others take longer. This is called "glycemic index".
If you are interested in some personalized care for your daughter's diabetes, please give my office a call. We work with families all over the country on issues like these. Our CDEs provide consulting via phone and internet, and all of us live with type-1 personally. My website has details: www.integrateddiabetes.com.
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
> gary@integrateddiabetes.com
Anyone got any info on Humalog 25? My daughter had to start it last Friday, as they've withdrawn Mixtard 30, her sugars have rocketed and I can't get them down, despite increasing the dose each day. She has eaten half the amount she would usually have and its just not going below double figures. She can have Novorapid at teatime...so we can get her down after that, but the next morning when she has Humalog again...the day is spent with highs. She is on a 3 injection system...Humalog 25 morning, Novorapid and carb count teatime and Lantus at bed. Any info would be great. The Hospital have told me to wait a bit longer to see if it starts working...but after 5 days of highs I'd like an alternative! She can't inject herself so extra injections are no good.
The Humalog 25 is a premixed insulin, just like the Mixtard 30. It just contains a bit less rapid insulin and a bit more longer-acting (NPH) than Mixtard 30. Regardless, premixed insulins are major trouble for most kids. They limit carb intake and schedule flexibility, and often lead to both highs and lows. I would recommend doing whatever it takes to get off of the premixed insulin altogether: either lantus once daily with novorapid at mealtimes, or (since you said that she cannot give her own shots) an insulin pump.Are there any tips for getting through puberty without extreme highs from time to time (300 - 400)? What about the ketones that seem to be caused by puberty? Extra insulin and water don't seem to keep them from returning.
During puberty, insulin doses (basal and bolus) need to be ratcheted up on a regular basis. Occasional "super highs" are going to happen, but ketones should not. The presence of ketones indicates a severe lack of insulin. Forgetting (or neglecting) to take insulin is not something to take lightly.My 8 year old daughter was diagnosed this last Memorial Weekend. I know she has Type 1, but still question it at times too. I'm sure that might be normal too, who knows. But her last A1C at her 3 month was 5.7, and the doctor said that's where a "normal" person is supposed to be. Then I get her urine checked at the doctor for an infection, and the doctor seemed surprised that there wasn't any trace of sugar in her urine. Is this normal? I guess I'm just not satisfied yet, even though I'm sure she has it. Thanks!
She is most likely in a "honeymoon" phase of her type-1 diabetes. Soon after diagnosis, when insulin injections are given, the pancreas regains the ability to produce some insulin on its own. This keeps blood glucose levels very close to normal which, in turn, prevents the spilling of sugar into the urine. The honeymoon phase may last anywhere from a few weeks to several months. Once you start noticing elevated readings when she first wakes up, that's a sign that the honeymoon is just about over.I am in a group of 67 other families. One of our new families has a child dxd. with both Type 1 and Type 2. Can you explain this. I can't find any info for a duel dxd. Also what are the care differences. Love to offer advice when asked but we are afraid. Is there a name for this duel Type?
It is possible to have both type-1 and type-2 diabetes. Type-1 is the classic "autoimmune" form of diabetes, whereby the body's immune system destroys the insulin-producing cells of the pancreas. Those with type-1 are susceptible to ketoacidosis and generally produce little-to-no insulin on their own. There are antibody tests that can verify a diagnosis of type-1.Type-2 really means that the body's cells are very resistant to insulin. This often occurs when multiple family members have type-2 (heredity) as well as when a person accumulates excess body fat as the result of unhealthy lifestyle habits. Most ethnic minorities are also at high risk for type-2 / insulin resistance.
When a person with type-1 diabetes is also highly insulin resistant, treatment involves relatively large doses of insulin as well as special efforts to improve insulin sensitivity: reduced caloric intake, regular physical activity, stress management, and potentially oral medications to help overcome the insulin resistance.
My son was diagnosed with diabetes two years ago. We are having trouble with high blood sugar at night. When he falls asleep his blood sugar jumps up. By 1:00 in the morning he is 300 or higher. Has anyone heard of this? It also happens if he takes a nap, he falls asleep and when he wakes up he is over 300.
Hi Rebecca -I see this quite often. But it may be due to two completely different causes.
The highs around 1am are likely due to an increased basal insulin need in the evening. My practice has conducted research in this area, and found that most children and adolescents (during growth years) require increased basal settings in the evening and early part of the night.
The highs after napping or sleeping at times other than the usual bedtime are resulting in highs simply because of the sharply reduced level of activity. Many of our clients set a temp basal increase if they plan to take a nap so that their BG doesn't climb quite so high.
Feel free to get in touch if you would like to discuss further. My e-mail is gary@integrateddiabetes.com.
My son is 7 yrs old. We have been pumping insulin for 3 yrs now. When he goes into heavy activity, or exercise, we usually disconnect from the pump, in conjunction with giving an uncovered 15 carb snack. Why does he not stay stable without the snack and goes low unless we do that? Shouldn't disconnecting be enough,? or is everyone different? Of course if he is 200 we just disconnect and no snack, but if he is 100 he needs the snack. Thank you
Excellent question. Even a young person can burn large amounts of glucose during exercise. The more intense the exercise, the more rapid the glucose-burning. Lowering the basal by a few tenths of a unit per hour (or suspending or disconnecting) does not do nearly enough to compensate for the amount of glucose being utilized, thus the need to consume extra carbohydrate.When do you know if your child is ready for the pump?
Good question. A lot has to do with the age of the child, and the skills/abilities of the parents. Any child can use a pump, no matter how young, if he/she does not pull out the infusion set, either accidentally or intentionally. But the parents must have a good handle on carb counting, using I:C ratios, keeping detailed records, and understanding what basal/bolus concepts are about.Could you give some tips on how to dose for dinner rolls, french bread, etc. heavy breads? When my son eats these for dinner I can almost guarantee a spike about 3 to four hours later. Any help would be great.
Bolus in advance (15-20 minutes) if possible. These types of breads digest very quickly and cause a major post-meal BG spike. Also, if you're unsure of the carb count, weight the food on a gram scale and use its "carb factor" to determine the exact amount of carbohydrate. For example, 48% of French bread's weight is carbohydrate. Weigh the bread in grams and multiply by .48 to get the exact carb count.At what blood sugar level do you suggest giving a correction?
Personally, I like to correct for any reading that is above your target number. With a pump, it's easy because the pump can dose in very small increments, and insulin-on-board (active insulin) will be deducted. By always aiming for your target number, you will spend less time in high/low ranges, and more time within your target range.At what age do you think kids should be able to go on a pump? When our Daughter was first diagnosed at age 3 in 2000 about a year into her diagnosis, a Dr. laughed at me when I asked that question and snottily told me 12! needless to say that was our last appointment at that hospital and then we switched to Yale (yeah!) and our daughter started on the pump 6 mos later in time for kindergarten.
It's not the child's age that counts, it's the parents' skill set and motivation. Parents who are competent at carb counting, dosage adjustment, record keeping and BG data analysis are usually well-prepared to transition their child to a pump.My son has been battling various illnesses the past two weeks, rashes, stomach bug and bronchitis. His blood sugar has been pretty high. Yesterday it was well over 500 and would not come down. The solution was to get new insulin because the insulin had only a week left until it expired. He is doing better today, but the past four days, he has been acting as if he is starving. I don’t know if I should take this as a growth spurt like most parents with two year olds would, or if there is a problem. Does anyone else have experience with this?
It is vitally important to check your child's urine (or blood) for ketones during an illness. The presence of ketones provides an early warning that an infection has developed. The high glucose that would not come down may have been due to dehydration rather than "bad insulin" (although you can't rule that out completely). During illness compounded by high blood glucose, dehydration is very common. When this occurs, insulin given below the skin may not absorb into the bloodstream. It may be necessary to give insulin into muscle or intravenously (at a hospital). Making sure your child consumes large amounts of fluids is critical.As for the hunger, it is probably due to going several days with diminished food intake. His growing body is trying to make up for "lost calories"!
No specific question other than tips for handling the transition to middle school, high school, and then college life.
Things vary so much from person to person and family to family. However, one recommendation that I make to virtually every parent of a child with diabetes is this:STAY INVOLVED. Even though your child is developing the skills necessary to perform day-to-day management tasks, it doesn't mean that they have the ability or motivation to manage their diabetes. Stay involved and continue to oversee their care for as long as possible. Enforce the "rules" (checking BG, taking insulin, etc...) strictly!
My son plays ice hockey and skates a lot. Any suggestions on how to keep meter and pump warm enough so they work when he needs them. We have tried a cooler with a heat pack in it which works some what.
Most BG meters work down to 40-50 degrees, so just keeping the meter and strips in a thermos might be enough.The pump should work fine in cold temperatures. If you have to be disconnected for a prolonged time and the temperature is well below freezing, again, putting it in a thermos should keep the insulin from freezing.
My son is about to be a teenager and has had diabetes for 3 years.He is very responsible and takes good care of himself, with our help. As a middle school, there are more and more opportunities for him to "go out on his own". His sugar checks and insulin shots are not the biggest issue.....it's counting carbs. How do you handle this when your child is out somewhere and you don't know ahead of time what they will be eating? Any tips for making this easier for him and us?
Interestingly, the challenge of counting carbs while out on the go applies to adults as well as teenagers. The first important message to impress upon your son is that every carb must be covered with bolus insulin. Then, I find the best approach to counting carbs when out is to estimate portion sizes (using a 1/2 pint milk carton or a fist as a reference to represent 1 cup) and then converting the portion into grams of carb. It's quick, easy, and accurate enough to keep BGs from going way out of range. For example, potato is around 40g per cup, so having a "fist and a half" of fries equals 60g carb. A hand-sized slice of pizza is about 30g, so a 2-handed slice is also around 60g. There are lists of these types of conversions in my book, "The Ultimate Guide to Accurate Carb Counting", and we also cover them in detail at the www.type1university.com course on Advanced Carb Counting.My 7-year-old daughter was diagnosed 4 months ago and is in a major honeymoon period. She has weeks where she will only need a half unit of insulin all day and her blood sugar stays in the 80s and is often low. When her blood sugar levels start to rise into the high 100s and low 200s...and I can tell another batch of beta cells are gone, it's like she becomes a totally different kid. She refuses to pay attention in school, do her homework, help around the house, do her blood tests and she is mean to her siblings. Then she has a couple of days where she is a complete mess. She has a 3 hour long meltdown... and then on the day after her meltdown, her blood sugar levels are back down in the 80s and 90s and she is often low. She will be in a great mood and catch up in school, help around the house, do her homework without us asking, etc. This will last for a few weeks and then as her blood sugar levels start to rise it starts all over again. Is this normal? I didn't think anything of it until I started to pay attention to the timing of the change in her behavior and in this fourth month it happened like clockwork. Can the honeymoon period cause mood and behavior fluctuations too?
That is very observant of you. In all likelihood, it is not the immune system activity or cell destruction causing these mood changes. It is the upward swing in her blood sugar levels. Even temporary rises in blood sugar can make people tired, lethargic and grouchy, and it can make it very hard to focus mentally and perform physically. My recommendation is to watch for the first signs of higher (and lower) readings, and work with your healthcare team to adjust her insulin quickly.Hi help...my dd was diagnosed t1 6 months ago and we are using shots, aged 4 then....I struggle to keep her bg between 4 and 10 ..they are mainly between 11 and 16.... We are always changing her insulin doses but I just feel that I must be doing something wrong.......also when she Is very high....22+ and its bedtime what/ how do I treat these such high levels.??????
If your child's blood glucose levels are consistently above target, you should discuss increasing insulin doses with your health care team. There is a good chance that the basal/long-acting insulin needs to be increased."Correcting" at bedtime can be a bit tricky, since rapid acting insulin can lower the blood sugar a great deal late at night. Again, work with your health care team to create a correction formula to use at night.
If you are not getting much help from your health care team, please get in touch with my office. My team can work with you via phone or the internet to solve these types of issues.
My son was diagnosed at 5 1/2 and is now 8 1/2. I can see him struggling with having diabetes lately, like sneaking food. In the beginning of diagnosis, I use to feel bad for him and always sorry for him. Just lots of hugs and tears. I still feel the same way but I feel I am a bit confused on how to discipline him. Do I do the tough love and tell him.... "this is how it is and always will be so lets move on and deal with it" You always hear the stories of " My mom was tough ... never let me give up . Made me keep going forward" I feel I should be that way. Maybe it will make him strong and gain control more when he is older, BUT he is only 8. I know he wants to be independent. I know he is struggling not being "normal" like his friends. I feel that approach my be too tough at this age. On the other hand I do not want to coddle him. So confused and was wondering how everyone else treats their children with the disease.
As a parent, it is important that you set guidelines for your child to follow, and build structure into his life. Like it or not, he has a health condition that does not allow for unlimited eating. You might consider hooking up with a family therapist who could help you develop some ground rules that you and your child can live with... hopefully for a long, long time.How do you handle a 20 yr old who is terrified of going low so she keeps her b.s. too high and is afraid to be independent? She was diagnosed at age 10 and has never had a severe low where she needed assistance. Everything she learned years ago is being ignored, it's as if she needs are-booting. Are there any programs for college students to address this issue?
One of my colleagues in the psychology field has done research on this issue. It comes up quite often. He believes that it is a form of post-traumatic stress, and it can indeed get in the way of managing one's diabetes properly.The two things I can recommend are: 1) Work with a mental health counselor who understands diabetes well, and 2) Use a Continuous Glucose Monitor to provide early warnings when BGs are just beginning to head downwards. This may give your daughter the confidence to manage a bit more aggressively.
My son is 12 years old and weighs about 70 lbs. Can he use the new Medtronic mio infusion sets with a 90 degree angle? We have been using the angled infusion sets all this time because of his lean body, but we are really ready to try something different without the "ouch" factor.
You could use the 90-degree sets, but I would recommend staying with the Silhouette/angled set. The angled sets are usually more comfortable, less likely to clog, less likely to irritate below the skin, less likely to come out accidentally, and safer since you can see the exact point of insertion through the "window".Recently I saw this family talking about having reversed Type 1. What they seem to be saying is a very strict low carb/plant based diet. What is your view of this and what does Laura think given the efforts she made with her son when diagnosed. Thanks
There is no proven treatment that can reverse type-1 diabetes. Anything you try may produce harmful side effects. DON'T STOP TAKING YOUR INSULIN!!!My 10-year-old son was diagnosed in March of last year. He started pumping in December. Prior to pumping, we started having problems with his sugar after dinner. We always eat at 6. At 8, his BG is great. At 10, he's high. Every. Single. Night. I've checked (and double checked) his evening basal and it is right on. When I lower his dinner ratio, he goes low at the 2 hour mark. Our CDE had a do basal tests with food and without and every time we did the test with food, his sugar went high at the 4 hour point. I guess it's the way his body is processing food at night??? Anyway, the CDE's seem to have not seen this before. They suggested doing an extended bolus at dinner. We have had a bit of success with it, but truthfully, it's exhausting because he has active insulin in him so late. I would LOVE to find a solution that doesn't involve an extended bolus every night. (But of course, if that is necessary, we will do it.) This week, I finally decided to try increasing his basal between 7 and 10 to see if that off-sets the rise. The CDE thinks it's a safe test, since he will always eat dinner. Do you have thoughts? I feel like I'm all alone in this and I want to do right by my son. I just wrote a question...and forgot to give you one other bit of info. Yes, this is the longest question ever...I'm so sorry. But with my son's evening meals....a nutritionist has already looked at the food he's eating and they do not believe that's it. We don't eat high fat food at dinner...in fact, his evening meals are healthier than ever in an effort to fix this problem. Most recently, he went high on a tuna sandwich, baked ruffles, strawberries and 2% milk. All the meals are meals that he eats at other times of the day and is fine. It's something about dinner. And it's a complete mystery to me! Thank you for any help.
I would not rule out the need for an extended bolus, but I'd bet my hard-earned money on the basal being too low in the evening. It is very common for pre-adolescent boys to require large amounts of basal insulin in the evening as their growth hormone starts to kick in at this time. I'll bet that if you were to run a true basal test, his BG would rise dramatically in the evening.There are other possible solutions, but this seems like the most likely. If you would like to problem-solve together, please get in touch with me. My e-mail is gary@integrateddiabetes.com.
How do you determine how much insulin to give if you know you are going to be exercising within a couple of hours?
Not a simple solution. Some exercises (very high-intensity, competitive, quick bursts of activity) can make blood sugar rise; more insulin than usual is needed. Most exercises (aerobic, daily activities) make blood sugar drop. If the activity takes place within a few hours of a meal, the bolus given prior to the meal will need to be reduced. I usually recommend starting out with a 25% reduction for mild activity, 33% for moderate activity, and 50% for longer/more intense activity.You might consider taking the course on "Blood Sugar Control with Sports & Fitness Activities" at www.type1university.com. It should answer most of your questions.
You can check out type1university in our resource section.
My 3 1/2 was recently diagnosed with T1 and we are struggling with a possible growth spurt causing him to constantly be hungry. We are still on35g/25g/25g meals and 15/15/15g snacks. After a meal he's full (sometimes a struggle to get him to finish) but then within 1/2 hour -he wants more food. We have maxed his carb allowance for that meal/snack so we turn to 'free foods' that don't have carbs. Cheese sticks, turkey roll ups, chicken strips, salami - he's tired of it all. Any other options you can give me?
I'd recommend including "filling foods" at his meals and snacks -- foods that digest slowly and provide a more prolonged sense of fullness. These include most low-glycemic-index foods, as well as protein and moderate amounts of fat.If you would like to discuss with our dietitian over the phone or via e-mail or skype, please give my office a call: 877-735-3648.
My son age 17 only eats one meal a day and he all ways says his not hungry?
Your son should meet with a nutritionist or dietitian who can explain the effects of this type of diet... things like malnutrition, weight control problems, hindered sports performance, difficulty concentrating, challenging glucose control, etc... If you don't have access to a dietitian, feel free to contact my office. I could work with you and your son via the internet.Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
www.type1university.com
gary@integrateddiabetes.com
I'm researching insulin pumps right now. Dawson will be able to get one in August. My husband & I are having such a hard time deciding which one to go with. He wants tubeless, but I'm not convinced with the reviews I've read on the Omnipod. He plays a lot of sports. Any suggestions?
Depends on the sport. Personally, I've found that the pod can get knocked around quite a bit during contact sports. But if there is not a lot of hitting or impact in Dawson's activities, the pod could work very well for him.
We have a 15 y/o son that is having a lot of highs (300-500)and a few lows. He is on the pump and was diagnosed 2 years ago. He started out really good and responsible but is now not checking himself on a regular basis and has to be told repeatedly to check himself, dose, change his pod, etc. He also has open lunch at school and eats a lot of snacks after school. He refuses to eat most healthy food. We are stumped on how to handle this especially since he will only get more independent from here on out and we will have less monitoring. Any suggestions would be appreciated.
Sounds like your teenager is like just about every other when it comes to "taking responsibility" for the diabetes. It is not usually realistic to expect a teenager to take sole responsibility for his/her diabetes; they need structured supervision until the point at which they are living independently. That said, I would recommend that you establish a set of policies that he must follow in terms of checking BG, bolusing, etc... When policy is not followed, there should be ramifications that are enforced strictly. Performing diabetes self-management tasks is not unlike his other responsibilities (chores, schoolwork, etc...). There should be consequences for his actions. The harder job is yours -- overseeing him and enforcing the rules in a matter-of-fact, non-judgmental way is not easy!
Our Endo is really pushing us to try the pump. My son is 15 - soon to be 16. He is type 1 with Addison's Disease. He is a competitive swimmer / triathlete. He spends at least 2 hours a day ( sometimes 4 ) in a swim work-out. I am concerned about having the pump off for 2 hours 15 minutes at a time on a regular basis. I am also concerned about site infections - he swims open water from June - Oct. Any input you could give me would be great .
Hi Melanie-
You have every right to be concerned. While site infections are a relatively rare occurrence, disconnecting from a pump for long stretches of time can wreak havoc on blood sugar control. But there some good options.
Some pumps are completely waterproof, such as the Animas. They can be worn while swimming. Another, the OmniPod, is tubeless and waterproof. The "basal" insulin level can be reduced prior to and during swim sessions to help prevent hypoglycemia.
Another option is to use an "untethered" approach: Wear the pump most days, but on days when lengthy water time is expected, temporarily switch back to injections (taking lantus or levemir in the morning instead of wearing the pump all day).
Feel free to get in touch if you would like to discuss further. I'm a big fan of pumping, especially for athletes, but there are always a few hurdles to overcome. My e-mail is gary@integrateddiabetes.com
I know you can restart an insulin pump 24 hours after a lantus shot, but can't remember when to give a lantus shot after being removed from a insulin pump?
Best to give the lantus shot IMMEDIATELY upon stopping use of the pump. It takes a few hours for Lantus to "ramp up" to a steady state in the bloodstream, and the pump basal will take a few hours to wear off. Delaying the lantus may result in a lapse in basal insulin coverage.
I have a 9 1/2 yr old boy, been 5 years to the month now. He is now wanting to have pancakes or a waffle. I bought the Cary's syrup (sugar free). Should I carb him for the Carb Count only. Or do I add in the Sugar Alcohol level to? I don't want to over correct. He is on syringes. Not a good eater, getting better. First time, I ever really used a syrup? Thank You for any suggestions,except adding fruit, tried it :( .
Bolus for the TOTAL carbs minus 50 percent of the sugar alcohol.
What's it like traveling with a pump for a month? We will be flying to California then driving to South Carolina.
There's a great deal involved with traveling when you have diabetes and wear a pump, but it is very doable. Pay attention to the temperature -- hot weather can spoil the insulin in the pump. Keep it in a frio pouch as much as possible. Also, when flying, have duplicate sets of all your supplies in case something happens to one of them.
My son is 8, he was diagnosed with type 1 on Feb.10th, 2011. He went to diabetes camp a couple weeks ago and had a great time. Although, I was told when we picked him up that he asked to have his sugar checked 20 - 25 times a day, he became very paranoid about going low. Since he has beenn home, he's been acting the same way, telling me he feels "weak," and thinks he's low. He wasn't like this before camp AT ALL, he played soccer and finished his basketball season no problem...after he was diagnosed. He had fun and never went low. Now, he's saying he doesn't want to play football ( his favorite sport ) or any sport, for that matter. Is this a normal phase for a child his age ? Do I make him play a sport for exercise ? I honestly think the only reason he doesn't want to do anything is for fear of going too low... I don't know what to do.
Sounds like your son could use the calming influence of a CDE who has diabetes and is active in sports. If you don't have anyone near you, feel free to give my office a call. I would be more than happy to work with you personally.
If you think this goes much deeper, perhaps your son saw another child experience a severe low at camp, and this has him very anxious. You might consider having him meet with a counselor who has expertise in dealing with chronic illness and post-tramautic stress disorders.
My son just turned six and has been on the pump for the last 2 1/2 years. He continues to struggle with changing his pump site. He has a ton of anxiety and sometimes a site change can last 45 minutes. As soon as it is done he is playing and smiling 20 seconds later. Any suggestions on how to make site changes easier?
Have you considered changing it while he's asleep? That sometimes works well. Also, when he gets a little older, send him to a diabetes camp. He'll see all the other kids changing out their sets without much to-do, and he'll get more comfortable with it in a hurry!
My daughter is almost 13. She was diagnosed with Type 1 diabetes at the age of 9. She has been wearing a pump since age 10. Just tonight, I realized that for the past week or two she has barely been checking her blood sugar during the day, if at ALL! She pretends and tells me a fake blood sugar and pretends to boulous. I am devastated and I have taken away her privileges. I do not know what to do with her...help!
I think you're on the right track by taking away priviledges. No adolescent wants to do things like checking blood sugar; they have to do it because it is necessary for their well-being (like going to school, studying for tests, brushing teeth, etc...). I like the idea of linking certain priviledges such as cell phone, internet, tv, transportation, etc. to performance of diabetes management tasks. Work up a very specific contract, and enforce it closely.
I have a 20 year old daughter with type 1, She has had diabetes since she was 12. She was in ok control. Her A1c's was about 8.6 or around. She is living away from hm, for the first time. We got a terrible result of an 11.1 .She is planning a mission trip to India for two weeks in Sept. What advice do you have for me. As a concerned mother I want to say she cant go .She is not in good enough control.Am I crazy ?
Before assuming that the trip would be dangerous for her, there are a few questions to ask. Specifically, why is the A1c up so much? Is she neglecting to take insulin? Are there weight/body image issues? Is she not monitoring her blood sugar? These types of things should be addressed before she goes on a trip outside the country. If she's just been sloppy about bolusing, not counting carbs right, etc, then the trip should not pose any major threat. She just needs to focus a bit more attention on taking care of herself.
What's the significance of having room temp inslin when loading a new catridge into an insulin pump?
The advantage of using room temp insulin is that it is less likely to form bubbles in the reservoir, and the insulin delivered the first couple of hours will be more comfortable than if the insulin is cold.
My 9 year old got up the other day and gave herself 10 units of insulin via her pump. When I asked her why she said she didnt know why she just did I dont know if she is just acting out or if this is something more?
That's pretty serious stuff. Sounds like she needs both some diabetes education and an evaluation by an expert in childeren's mental health. I'd lock the pump buttons and do all programming yourself until that happens.
I have a 13 year old daughter, diagnosed 6 years ago with T1. The past 2 years had several episodes of very high BM & Ketones, occasionally gone into DKA and has had 8 hospital admissions this year! Intially this was put down to puberty/hormones, so tried an insulin pump for 18 months, with little imrovement and now our consultant has put her back onto mutiple injections, again little improvement. I also have another diabetic child and myself which are all on insulin. Any help/advise, greatly appreciated.
Probably not what you want to hear, but there is a good chance that your daughter is suffering from an eating disorder and is omitting insulin intentionally. This is quite common with girls her age; it is referred to in healthcare circles as "diabulimia". I would recommend a thorough evaluation with a mental health counselor.
My daughter is in her honeymoon period and her bgs remain near normal. She has not had any low blood sugars under 60. What will happen to her levels once the honeymoon is over? Will she experience more lows?
Her blood glucose will become much more varied once she is out of the honeymoon. Now, she is taking less insulin than she truly needs, since her pancreas is able to supplement with insulin on its own. When she is on larger doses and her pancreas cannot "buffer" rises and falls by chaning its level of insulin secretion, she will be susceptible to more highs and lows.
Having the worst trouble with my sons #s starting this past summer... We've been pumping for over 4 years... He's up he's down, he is all over.... He is turning 11 Oct 10... we pump with medtronic mini med. I can't come up with much of a pattern but I'm noticing his #'s are just higher in general and he is higher in the morning. I recently changed his 3:30 am basil up from .55 to .65 and sensitivity to 90 from 100... and insulin on board from 4 hours to 3... he has gone as high as almost 600 a few weeks ago... to as low as 44 today!! Ok any suggestions would be greatly appriciated.. ps .... Camren missed over 30 days of school last year not counting latenesses or picked up early... this year he has missed 3 half days and 2 full days already for being high sick or pump malfunctioning.
It would be inappropriate for me (or any clinician) to give specific advice without knowing the full details of your son's diabetes care. So forgive me if I speak in generalities. A few things to consider:
1. In children your son's age, basal insulin needs tend to be highest in the early part of the night, not in the morning. That said, I always prefer to conduct a series of short fasting basal tests to get the doses set correctly.
2. Using the same I:C ratio at each meal rarely works. Almost everyone needs different settings at different meals. Most people need higher doses to cover their breakfast.
3. Your son's insulin sensitivity seems abnormally high given the amount of insulin he is using.
4. Excessive highs and lows are usually due to miscounted carbs, uncovered snacks, infusion site issues, and over-aggressive correction bolusing.
If you're interested in a "tune up", please give my office a call (877-735-3648). We work with families like yours via phone and the internet all the time. We may not be able to achieve perfect control, but we should be able to improve things considerably.
My son is now 19 and was diagnosed fours years ago. For the first 18 months he managed the blood testing and administraion of his medication very well. For the last few years he has really found managing his diabetes very difficult culminationg in a crisis in the last month. Fortunately he seems to have turned a corner and is very motivated at the moment to lower his blood average from the mid 20's upwards mmol/L it has been. However as a result he is now having far more hypos which is the main reason he cites for actively keeping his mmol/l high. This afternoon he has a reading of 1.6mmol/L so then had to take a significant amount of sugar to raise this. My question is what should he now do for the sugar he has eating to a.) prevent his bloods from rising and b.) to as far as possible prevent another hypo? Grrrrr sometimes I feel I know nothing at all about this which leaves me feeling inadequately placed to support my son so my heart felt thanks in advance for any guidance in this.
Thanks for writing and expressing your concerns. I have seen many cases where young adults keep their blood sugar dangerously high in order to prevent hypoglycemia. This is absolutely not necessary. With an appropriate insulin program -- complete with doses matched to your son's food and activity, and use of the latest tools/technologies -- there is no reason he needs to keep his blood sugar high in order to prevent lows.
If your son does not have access to a qualified diabetes educator, please have him get in touch with me directly. I can work with him remotely via phone and the internet to help him get on the right track.
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
I have a 13 year old son that was diagnosed at age 9. He has been wearing a pump for 3 years and does a really good job of taking care of things on his own. He does not like to wear the pump when he is playing sports and he seems to have highs after practice and games. Is it possible to use lantis and wear a pump? Maybe just put his basal at a really low amount?
Hi Amy -
Sounds all too familiar! Disconnecting from the pump for more than an hour can cause problems with elevated BG at the end of games/practices and for several hours afterwards. There are many options for dealing with this. Perhaps the simplest is to have him bolus a portion of his hourly basal rate before disconnecting, and then reconnect hourly and repeat the bolus. That way, he's only connected for a few moments, and he won't go for too long without insulin.
It is possible to set up an "untethered" program whereby his daytime basal would be replaced with injected insulin such as lantus or levemir, but I would need to have a close look at his current basal pattern to figure that out. Feel free to get in touch if you'd like to discuss further. My e-mail is gary@integrateddiabetes.com.
My daughter is 11 and was just diagnosed in August 2010. She wears the Omni Pod and she is VERY independent with her management,but she gets VERY angry when I ask her if she remembered to cover. Although I am proud of her independence, I feel it's my responsibility as her mom to confirm that she is taking care of her insulin doses. Her BG runs high on most days and I can't get her to check very often. I know this is a terrible disease for her to have to deal with and I don't want to "punish" her for not checking or covering,but, at the same time, I think, if she's responsible for doing the dishes and she doesn't, then there'd be a consequence for that. I don't want her "consequence" for not checking and covering or not allowing me to help her to be long term damage to her body! Any suggestions???
Dear Dawn -
Congratulations on getting your daughter on a pump and moving her towards greater self-responsibility.
At 11 years old, it is extremely unlikely that she can self-manage her diabetes. At that age, kids don't properly comprehend long-term ramifications or justification for daily self-management activities. It requires a well thought-out balance between parental oversight/guidance and the child's performances of essential tasks to make things work right.
In most cases, kids are not ready to truly self-manage until they are well into their teens, and in some cases, their 20s. Until then, I'd recommend deciding on appropriate roles/responsibilities as well as expected behaviors and immediate consequences when behaviors are not appropriate.
Our daughter has both type 1 and type 2 diabetes. She controls her blood glucose levels well with Novolog in an insulin pump, but we wonder if she wouldn't benefit from taking an insulin resistance drug, as well? What medication would be appropriate?
Excellent question. Ultimately, the decision is yours and your daughter's physician's.
For those with type-1 diabetes and insulin resistance, a number of medications (other than insulin) may be helpful. A few of the key ones:
Metformin is an oral medication that reduces insulin resistance in the liver. It can help reduce basal insulin requirements and improve fasting blood sugar levels.
Pramlintide (Symlin) is an injectable agent that slows digestion, blunts appetite and reduces glucagon production by the pancreas. It is particularly helpful in controlling after-meal blood sugar spikes, and has been shown to facilitate weight loss.
Liraglutide (Victoza) is another injectable that facilitates weight loss and helps improve the pancreas' ability to secrete insulin (assuming your daughter still has some beta cell function).
There are also insulin-sensitizing oral medications called thizoladinediones. However, these medications have been implicated in causing fluid retention and congestive heart failure, so the side effects can make them prohibitive.
In all likelihood, THE BEST SUPPLEMENTAL TREATMENT for your daughter is EXERCISE. Physical activity lowers blood glucose acutely and helps to overcome insulin resistance. There is no pill (or pills) that does as much as exercise for people with diabetes.
When counting carbs do I subtract the fiber and sugar and sugar alcohol from the carbs?
Do not subtract the sugar. You may deduct 50% of the sugar alcohol from the total carbs (as they do not break down completely), and I recommend deducting 100% of the fiber grams from the total carbs (as fiber has no noticeable effect on blood sugar).
My daughter is 20 and has had diabetes now for 14years.In the last 7 days she has hypoed 17 times!!! She has always been unstable not due to her inability to look after herself though. When she has been low these last few days she has become quite verbally aggressive and teary. She complains if I ask her how her readings are all the time but also complains when i dont ask "because that must mean that I dont care" It is so hard to know when and how to make her responsible for her behaviour when she is hypoing. How much control do they have over heir behaviour in these instances? She is paranoid about her weight which also makes it hard for her during hypos.
Hi Mandy -
That many lows is no good for anyone. She's putting herself and those around her at risk. She should not be permitted to drive a car until her diabetes is under better control. It may motivate your daughter to know that she will be able to manage her weight much more easily without all the hypos. Let me know if I can be of assistance. Even though I'm located in the States, my practice works with many people in Australia who have type-1 diabetes, focusing on improving blood sugar control. BTW, I'll be in Melbourne next month doing a couple of presentations on pump therapy (at a Medtronic meeting) as well as exercise (at the HypoActive conference). Perhaps we could connect.
Gary Scheiner MS, CDE
Owner & Clinical Director
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
toll free: 877-735-3648
(610) 642-6055
fax (610) 642-8046
www.integrateddiabetes.com
www.type1university.com
gary@integrateddiabetes.com
My 14 year old son has had diabetes since just before his 2nd birthday and lately we've been dealing with burn-out... ALL of us but most importantly our son. Over the past 3 years he has taken some of the responsibility for his d-care; testing and giving shots with reminders from us. He lately has been lying about testing (what his numbers are) and even lying about giving injections. I have taken back his responsibilities because he is clearly stressed out... our family has had a rough year personally and financially... we lost his granfather (who he was very close to), lost our home/everything we worked hard for for years (cars, savings, etc.) and had to move to another state. We also don't have medical insurance because if the step back my huisband has had to take in his career after being unemployed for 2 years. I try to keep this stress from him but kids sense/know when things are tight especially trying to afford diabetes insulin and testinf supplies. All of this stress... How can we get him through this rough patch? His diabetes has to be his/our priority and I don't know how to get through to him whille being sensitive to what he's going through? Any ideas?
When everything seems to be falling apart, I find it helpful to "regroup" and start from scratch. Pick just one thing to work on and focus on that one thing. In a few weeks, regroup again and add something else, and so on. Trying to do everything all at once, especially in times of stress, can be overwhelming.
