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Re: [IPk] hypos at night

On 12 Jun 2006 at 0:57, Karen Persov wrote:

> I dont know anything about hypopituitary problems, but just a few thoughts
> on what you have said.

Hi Karen, thanks for your reply.

> The lows late at night for the last few nights could be down to the
> weather. Certainly, my daughter Sarah drops more in the heat as the blood
> flow is faster as the body cools itself. 

Sorry, I didn't make it clear in my email but we've been having these 
problems for over a year.

> Normally in children, we raise
> basals early evening to midnight to cope growth hormone released in deep
> sleep. (in children this can be within 2 hours of falling asleep). These
> hot nights make for restless sleep and sleep patterns. See if there is any
> correlation between the time Emily goes to bed and the time until she
> hypos. We delay nighttime basal increases if Sarah goes to bed later than
> usual.

I can usually relax (and go to bed) about 3 1/2 hours after Emily 
goes to bed. Recently she has been going to bed at the same time 
every night so it's a easier to see this pattern. After 3 1/2 hours 
the basal rate needs to be increased to 0.8/0.7 to cope with growth 
hormone presumably. 

> Has your daughter started puberty and menstruation yet? This will make a
> huge difference to insulin needs. Girls grow fastest in the 12 months
> before they start their periods..and levels of growth homorne increase
> leading to insulin resistance and high basals. When the growth spurts
> wane, the insulin requirements, especially during the afternoon and night
> can reduce dramatically too.  

I'm not sure if it's connected. Her growth seemed to stop and she 
dropped below the percentile line she had been following closely at 
about the time her period started (2 years ago). Her growth started 
again after a pause but is following a lower percentile line. It's 
hard to tell but it looks as though she has gone from the 80th to 
just under the 70th centile. But the drop in insulin needs happened 
after she started growing again, about 9 months after her period 

> When in a growth spurt, Sarah's afternoon
> basals are around 0.4 but we can literally have her on zero when she's not
> and she will still hypo. 

I haven't really been able to spot growth spurts that clearly so it's 
hard to say. Earlier in the year BGs at this time of night were more 
variable than they are now with as many nights going high as low at 
this time. The low nights are more common than high now and high 
nights can usually be linked to miscalculations with carbs/exercise. 
If Em has a quite afternoon/evening and doesn't eat after tea, she 
seems to go low most times.

> Insulin needs during teens and puberty can
> increase to 1.5units/kg and should fall down to about 0.8units/kg after
> major growth. 

This seems to have stayed the same at 1unit/kg over the last year and 
a half (1 a year and a half ago, 1.02 now).

> Once menstruation begins, many women notice their insulin
> needs will be quite a bit higher in the few days before they have their
> period and will then drop substantailly during the first couple of days of
> their period, making them at risk of hypo. Insulin needs are also low
> mid-cycle. You mention you are comparing Emily's basals/TDD to last year,
> but a 14 year old girl's body develops so much in a year it is unlikley to
> be relevant. Try looking for any monthly pattern in highs/lows, you may
> find something you haven't noticed before.

I'll check this out tomorrow if I get chance.
> I am a believer in low basal ratios but 21% of TTD seems very low. Sarah
> fluctuates between 30 to 38% depending on growth. If you are using such a
> low basal, what carb ratios are you using? 

Breakfast 4.5, Lunch 7, Tea 6.5, Supper 8.5.

A year and a half ago it was 4.5, 6.2, 6.5, 6.5.

> You don't mention when Emily
> ate dinner, just she had 1.5 units. Was this with food or a correction
> bolus? 

This was the last part of her insulin for tea. She gave 7.5 units in 
all for 56g carbs (her BG was 3.6 so we reduced the bolus). She had 
pizza for tea that day.

> What was the time period between eating and going to bed. My son is
> 14 and now finds he needs to eat quite a good size snack (50carbs) around
> 10.30/11 before going to bed as he is hungry. This is after a huge meal at
> 6.30/7.0pm. He had never previously been a good eater and is very lean,
> but he is eating as a teenager now! A teenager's energy needs in order to
> grow are huge (so even a lazy day could might be a busy day with growth).

If anything Em is off her food. She went to bed at 11pm, so 4 1/2 
hours after eating.

> Could the late night hypos be due to not enough food or eating too ealry?
> When Sarah was very young, she used to hypo at the same times as Emily.
> She wasn't on a pump then, but ice-cream did the trick. A small portion of
> dairy ice-cream before bed, would hold her over until the growth hormone
> release and prevent the late night hypos. A low sugar drink made with milk
> is also beneficial. The milk is slow burning and the calcium a great
> bonus. We use a low calorie/sugar chocolate powder mixed with milk as a
> bed time drink. This is only about 12 carbs but should cover those first
> few hours of sleep when Emily seems to drop. Once deep sleep is acheived
> and the growth hormone releases, the high basal rates from midnight should
> deal with any insulin resistance at this time.
It could just be that Em needs to have a snack before bed despite 
being on the pump and most nights she does but in the form of glucose 
tablets while she's asleep. She doesn't usually get to hypo levels as 
I check hourly. Over the last few nights I've given 12, 15, 30, 33, 
18 and 30g. Until recently, BGs have been more mixed but as the low 
levels seem to predominate now, maybe a snack is the answer, maybe 
about 30g. 

It's just that she has had other symptoms of cortisol deficiency 
(fatigue, malaise, nausea, faintness, loss of appetite, possibly 
weight loss but this was comparing home scales to hospital scales). 
I've read that cortisol deficiency can cause hypos but haven't found 
anything to suggest a pattern. If we find that Em's drop in insulin 
requirements between 2pm to 2am are unlikely to be linked to cortisol 
deficiency we will probably delay the blood tests as see if the 
symptoms develop further. It just seems strange that between 2am and 
2pm the total basal rate has only dropped from 10.8 to 9.4 but 
between 2pm and 2am it's dropped from 8.2 to 1.9.

Thanks again for your thoughts, very helpful.

Best wishes,
Coeliac & hypothyroid Mum to:
Emily (13), dx Oct '99, D-Tron Plus pump Oct '03,
Robert (15), dx Mar '03, Novomix 30 am, Humalog Mix50 pm,
and Matthew (10). All home educated. Married to Tony.
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