Undetected lows

Okay, what a weekend.  Sophia has been having undetected low blood sugars.  It has been just under 3 months since her diagnosis and we were struggling with high sugars most of the time, and when she was low, she would generally come to us and say that she felt shaky. Lately, she has been getting lows (canadian...1.9,  3.2, 3.4)  What has changed is that she is not aware of these lows and her physical symptoms, shakiness, panic etc. have ceased to be present in the early stages.  We double checked her sugars, esp. with the 1.9 as well as putting the solution in the glucose monitor to be sure of accuracy. I read a small paragraph in "Think Like a Pancreas" that said that some people have been able to reverse this low blood sugar unawareness by avoiding low sugars for a month or so.  I guess in Sophia's case we would have to run high...By the way, she is on multiple daily injections and is still in the honeymoon period.

Is Sophia having more frequent lows, or just not feeling them come on?  We're in the US, so I don't know how low the numbers are you quoted, or what her target range is.  William's target BG is 85-150 (he is 9 yo), and he often does not feel low until he is 60 or lower.  Our endo does not consider anything above 60 to be "truely" low (I think it is considered normal in a non-diabetic), so I don't worry too much if he's on the low side without feeling anything.  And, I generally tweek his Lantus or carb:insulin ratios if he's having more than one low in 24 hours (he's on Humalog for meals and corrections).

Keep in mind that Sophia's "experience" of lows may change over time; William's did.  Just after dx (5/13/09), he would freak out if he was even slightly lower than his target of 85; now he can be 60 and not feel it.  I think he had been running high for long enough pre-dx that he got "used to" being high; dropping down into a more normal range took some getting used to.  

Also, I think William experiences lows differently depending on whether it is a slow decline or a rapid drop.  If he's dropping fast, he is likely to feel it sooner than if he is simply "drifting" lower. 

Some of my strategies for avoiding or heading off lows: If he's been having lows, I don't let him go more than two hours after a meal before I test him again.  If he needs a correction and does not want to eat, I only give him 1/2 a correction.  If he is getting a correction with a meal bolus, I try to be sure he eats some protien and fat with the meal (it seems to slow down the insulin somehow).  And, I try to take into account Insulin On Board (IOB); it takes about three hours for insulin to get through his system, so if he had a correction three hours or less earlier I take that into account in his next insulin dose.

Okay, hope that helped a bit.  It's really tough with the younger kids, because they can burn through glucose so fast.  But, you'll get better at "feeling out" where she is and what works for her.  Hang in there.



It is pretty common for young kids to now know when they are low. Sometimes parents/caregivers can still tell by looking at them (start to get pale or glassy eyed) but I can't tell with my son and he can't tell either. We just test a lot (like 8-10 times per day.) Fortunately, since he started on the pump, he has relatively few lows. It is something we worked pretty hard to reduce.

You don't necessarily have to run high, just have the low end of her target range 'higher'. At dx, my son's range was 100-200. So if he was 99, we gave him 15 g carbs. Since it isn't really a concern until <70, there is quite a bit of cushion there. The thought being that hopefully they will be able to feel something if they are below 70, even if they can't tell between 70-100.

My son also had a couple weeks during his honeymoon, probably about 2-3 mos in where he only got his long acting insulin (and that was only 1-2 units) and didn't get any insulin for meals. We just kind of guessed on doing this because he had been getting multiple lows and was very active (it was during the summer). But his numbers were good and our endo said that was the right thing to do. When he starting being high 3 hours after meals, we slowly started reintroducing fast acting at a high I:C ratio (like 1u:50g).

We still get lows and he can't tell and I can't tell and his teachers can't tell. Just it is time to test and hello 56! I so far can usually figure out 'why' and so don't worry about it too much if it is 1x per week or less. (Usually either too much correction from a prior high BG or from extra activity.) If it happens regularly, then I make some changes in his insulin doses.

Good luck. Lows, especially in the 40s and lower are scary.

Dear Mo, Thank you for your response.  Yes, Sophia is having more lows and not feeling them coming on.  This morning we backed off her fast acting insulin and hope that it will help. Sophia's target range would be 6-12 mmol/L which is 110-220mg/dl. Your son sounds similar to Sophia in her detection of the actual lows. She was detecting them at 4 mmol/L  but has been mostly running high since her diagnosis. What you say about the slow decline and rapid drop makes alot of sense.  At times Sophia would come to me shaking and looking unwell and her reading was 4.9 or so.  That would explain her discomfort with an okay blood glucose reading. There is so much to learn and I am hoping to learn more about her insulin (s)  on her next appointment so I can be more confident making corrections. I will keep your strategies in mind for heading off lows; especially the part about testing at meals and snacks and the addition of protein/fat with meal.

Thank you for taking the time to respond.  We will see what today brings! Hope you are well. Stephanie

I guess that is the part that bothered us. We did not see any of the low blood sugar symptoms that we had seen in previous weeks and her lows were actual LOW's....Sophia was also reduced to only long acting due to strong honeymoon and was even taken off all insulin over Christmas. Our endo suggested continuing to poke her with empty needle so we wouldn't lose the routine. I think that was a good idea, because she was back on insulin fairly quickly.

I want to learn more about the I : C ratio.  Right now she is on a set amount of carbs at  meals and snacks. We try to stick to this and adjust her insulin to match, but sometimes she isn't hungry so we back off the fast acting.   She eats so little...we are playing with 10 and 15 carbs and .5 or 1 unit. Thank you JDVs Mom. 

Oh, so is Sophia on a meal plan with fixed insulin doses?  Or do you calculate doses based on how many carbs she is eating?  When William was first dx'd we were on vacation in FL where he was hospitalized for two days.  The endo there put him on a fixed meal plan with Lantus and fixed Humalog insulin doses with a correction factor for highs (no corrections for lows).  As soon as we got home and took him to our current endo, he put William on a different plan that works much better for us.

Just for comparison purposes, here's what William's meal routine looks like.  Before a meal or snack he tests his BG, then he serves his plate.  I calculate his insulin dose based on how many carbs he is eating (right now is ratio is 1:10 for all meals except bedtime snack which is 1:30).  So if he's having 50 carbs for dinner, he gets 5 u of insulin.  The carb/insulin ratio can be different for each meal depending on how his body is processing the carbs and insulin, and those ratios can change from week to week.

If his BG is not in the target range, I calculate a correction; more insulin if he is high, or reduce the total insulin if he is low.  The correction factor I use for both is (BG - 100)/40 during the day, and (BG - 100)/80 at bedtime (with food; without food I cut that in half).  The meal bolus, plus the correction, is the total insulin given.

Especially if Sophia isn't eating a lot, or has sporatic eating habits (like William), I can see where you could have more lows.  It's so hard to get little ones to eat "what" they are supposed to "when" they are supposed to.  That can make a big difference.  William's current management plan allows us to incorporate "special occasion" eating pretty seamlessly, i.e. eating out with friends, parties, etc. 

You mentioned "Think Like A Pancreas" earlier, and I highly recommend reading it cover-to-cover before your next appointment.  I've found the more information you have going in, the more you can get out of your time with the endo, and you can talk to him about possibly adjusting the way you are managing Sophia's diabetes.

Hang in there, mom.  You're doing great, and asking great questions.




Dear Mo, Yes, Sophia is on a meal plan with fixed insulin doses.  Her Humulin dose doesn't change that often, but we calculate her Humalog based on her pre meal reading.  This is fairly rigid and sometimes limiting as some meals that are naturally filling and lower in carbs have me scrambling to find a good carb fit for the remainder of her meal. If her before snack BG reading is high, I cut out the carbs and steer her toward no carb snack.  Not the greatest results as sometimes I have planned whole fruit for her snack (she needs the fiber and vitamins) and she gets cheese or celery and peanut butter instead.  

Thank you for the illustration of William's meal.  I think I am beginning to understand this.  So the meal bolus is the 1:10 ratio? I can see William's plan being more versatile, the only possible issue would be more frequent injections. So does this mean William is only on a fast acting insulin?  I will ask at our next appointment about alternative plans for Sophia.  Maybe they started us on the fixed meal plan until we become expert carb counters and have a better understanding of how Sophia is using the insulin and carbs! 

I will continue reading "Think Like a Pancreas"...admitedly I put it down when he got into the specifics about dosing etc. because I felt I needed to know more about Sophia's insulin.  I get the fast acting, but I am not sure about The curve of her Humulin N. and I didn't see it listed in his book.

I really appreciate your responses.  I plan to go into your past posts(if that is ok with u) and read your other posts as you explain things very clearly.  I am sure I will benefit from reading about issues others have encountered. 

William was only in the hospital for 2 days! Wow, you must have caught on to things quickly.




I'm so glad my explanation helped! 

Yes, William is on a slow-acting, 24-hour insulin (Lantus).  He takes it every evening at 7:00 pm, and it gives him a "base line" (basal) insulin dose slow-released over a 24-hour period.  One of the ways I can see whether or not his Lantus is at the proper dose is to check what his BG is doing between meals (usually in the middle of the night, unfortunately).  If he is at 130 at 3:00 am, and at 150 at 10:00 am, and at 180 at noon, with no carbs injested, then I know he needs a wee bit more Lantus (I'll bump it up by 1 unit and test for 2-3 nights to be sure he's holding steady overnight).  If he's 200 at 3:00 am, and 150 at 10:00 am and 100 at noon, with no carbs injested, then I know he's processing glucose pretty much normally.  If he's having lows throughout the night, with no extra-ordinary day-time activities, then I know we need to back off on the Lantus.

William's carb:insulin ratio-based meals do require more testing and injections than a fixed meal plan and fixed insulin doses.  But, in my opinion, the additional pokes and pricks are worth it.  And, more importantly, I think William agrees.  I can only imagine the panic he feels when he drops into deep lows, and I think I have a decent understanding of how horrible he feels when he is high, and of the damage that is done when he has those highs  (BTW, please do not underestimate the "behavior" exhibited by your daughter when her BG is out of range...it is beyond her control and needs a particular type of "handling" to keep her safe and get her back into range).  So, for us, the additional testing and doses are worth it for the greater "control" of his BG.  If you want a very clear picture of one day's BG management for William on MDI's, you can read this entry on our blog: http://fivebearsablogging.blogspot.com/2010/04/day-with-diabetes-scfl-camping-saturday.html  (Just keep in mind we were camping at the time, which was a great prep for our month-long cross-country camping trip last summer ;)

Once Sophia is stabalized and you've got a good understanding of the in's and out's of diabetes management, you may want to look into an insulin pump for Sophia.  For may people, it offers much greater (and more subtle) control of BG's, and allows for much smaller doses of insulin that can be really important for younger kids (especially when they are not eating much at each meal/snack).  So, instead of caluclating a meal bolus or correction to the nearest 1/2 unit, you can have the pump deliver doses to the nearest 1/10 unit.  Corrections do not require a separate injection, and you can turn off the basal (long-acting) insulin if you need to.

Please be aware that we tried a  pump last year and it did NOT work our for us.  Our Ped Endo agreed that MDI seems to be best for William.  AND, a pump works fabulously well for many people.  It is a personal decision, but one you really don't need to make right now.  Just keep it in mind.

Oh, and like many parents, we had NO idea William was going into DKA.  There is NO family history of T1 on either side of our families.  William was the first ever, and we were completely blown away when he was diagnosed.  We were incredibly lucky that the nurse at the ER we took him to (while we were on vacation) spotted the symptoms right off and tested him, and he never gotmuch above 500 before he was treated.  Our dx story is here: http://fivebearsablogging.blogspot.com/2010/05/rufus-birthday.html  Ironically, I had started our family blog during that vacattion, and it turned out to be a perfect tool for keeping everyone up-to-date on events as they progressed.

Okay, I know you're probably overwhelmed with information right now.  If you want to continue chatting, please feel free to contact me privately at Hueyhome@msn.com.  I'm no expert, and I've only been at this for less than two years.  But, I feel for you and your family, and will do all I can to help and support you in whatever way you need.  And, feel free to poke around our family blog to your heart's content.  I do blog about D, but also blog about a lot of "normal" stuff, too.  I try to keep a balance in our blog, just as in our family life :)




We are going through same thing. He was really running high after diagnosis (20's) So we  were gining like 10 long lasting in morning and 7 at bed, plus fast acting at a CHO ration of 1:3 to meals. But startrd having crazy lows......so honeymooon period.....we cut the long lasting by 50%, and went to a ratio 0f 1:30 for cards at meals with fast acting......and still low....so now just using long lasting insulin morning and night, but we check b.s like 12 times a day! I'm in Canada too!

I am glad you are in Canada too.  It always takes me a while to convert everyone's BS readings so I can understand them!  How is your son doing? Have you got all of his medicines regulated yet?It must be a huge challenge getting balance for him.  Can I ask where in Canada you are?  We are in Saskatoon, Saskatchewan....When was your son diagnosed?

We are in Winnipeg! J is doing good, it is really hard to regulate everything, he was just diagnosed Feb 12th. He was a 6.2 this morning before school so that was good.....it always gets high after lunch at school, then low-ish around 3 p.m

Winnipeg. Well we aren't too far away. You are doing well.  He is back at school and you have only been at this since Feb 12th.  I feel so green at all this, specially when I read all the blogs.  I can take in little bits at a time! Sophia was playing with playdough this morning and was asking for more toys and checked her BS. She was 2.9! She didn't pick up on it.  This stage is challenging!  do you guys have good weather today? 


It's not bad, not  tooooo cold! Jackson doesn't pick up on his lows or highs, that's why we test soooo much. Although I found he looks a little pale when he's low. He was in I.C.U for 4 nights, then the regular ward for 2 nights, we had 4 days home from hospital, then he went back to school, after we had our URIS intake meeting with nurse from school board and the school team. They had to learn to check b.s and all that, they don't give insulin though so we have to use the long lasting insulin given in morning to cover snacks and lunch, sooooooo there's a bit of adjusting involved there depending on if he has gym etc. What do you guys use to give the insulin? We use the pens, one for evertime he eats (except lunch), and one for morning and night.

We use the syringes. She is currently on 3 units of long acting in the morning and usually .5 of the quick acting.  Lunch and 2 pm snack time we generally give her .5 quick acting and then at supper she gets .5 quick acting and 1.5 units long acting.  We don't use pens yet because they don't measure .5 only 1 unit. All these shots!