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[IPp] toes and woes

Date: Thu, 8 Jun 2006 21:15:43 +1200
From: "Jane" <email @ redacted>
Subject: Fw: [IPp] Toes and Woes

Sent: Thursday, June 08, 2006 9:13 PM
Subject: re: [IPp] Toes and Woes

Hi ,

Rachel has asked us very specifically to stay away from her toes. She
want them to be used even at night, though she does like me to change her
infusion set while shes sleeping.

I am interested in why Sarah still needs testing 2 hourly at night? You must
be exhausted - have you not found that she can go any longer than that
Its great that you did get a break while she was at Camp though.


Sarah put up a bit of resistance at first to toes.. then got used to it. She
gets used to sites in her tummy and resists rotation to her bum and vice
versa. Kids don't like change, it doesn't mean its not what's best for them.
Site rotation is of course more important than whether to test with fingers
or toes, but one day when her fingers are too sore, suggest she try testing
a toe herself. When she realises it doesn't hurt any more than a finger, she
might agree to toes testing at night to save her fingers.

As far as night time testing, yes we still have to test through the night
and expect to until post pubery and growth. Growth hormone release through
the night will always adversely affect insulin resistance and is by its
nature unpredictable. During growth spurts her insulin needs during the
night can increase a lot, if we didn't test and give a correction bolus she
would wake up very high. My aim is to start each day with a good BG.

Even when we have a perfectly safe night time basal, where her BGs will
remain steady say from 3am to 6am, this basal can only be temporary. If the
days in between have been good (say bgs around 120), by the 3rd night her
sensitivity to insulin will increase and the "safe" basal will be too high
and she will be at risk of hypo. Or any night following a particulalry
active day or low bg day she as at risk during the night.

The biggest problem with Sarah is her correction factor varies from 1:90
after supper, until about 1am (quite insulin resistant) and goes down to
1:210 around 4am when she is super sensitive. So any remaining insulin from
a bolus around midnight can have quite an unpredctable effect at say 3.30am.
By 5.30/6am her sensitivity reduces with the dawn rise and we need to
correct at 1:120. Of course her basals are programmed to reflect this, but
as little as  0.05hr for 1 hour on her basals, or remaining from a previous
bolus can be enough to cause her to drop. On nights she is high, she wakes
to pee, this breaks the sleep pattern and stops her dawn rise, so her early
morning basal will be unsafe. Similarly, if for any other reason she has had
a disturbed night with broken sleep, it will affect the dawn rise.

If she has a great night of deep sleep and her morning basals do not cope
with an increased dawn rise and her BGs go up, she will be very insulin
resistant by breakfast. If Sarah is high before breakfast through insulin
resistance, she can peak to 400 after breakfast, so obvously we have to
prevent this. she will then crash before lunch and hypo.

Of course it depends on your objectives, safety or good night time control?
I aim to keep Sarah at 120 all through the night. I know if this part of her
life is is well controlled her A1c% will stay around 6.5%. This allows a bit
more freedom during the days.

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