Fall-ing Blood Sugars

During my daughter's first autumn with diabetes, almost a year after her diagnosis,  something weird began to happen. She started to experience low blood sugars.  Lots of them.  At all different times of day.  She wasn't eating less.  She wasn't more active. This new pattern seemed to have come out of nowhere. 

Stumped and worried, I called our Certified Diabetes Educator.  She instructed me to cut back the dose of long-acting insulin.  I agreed to do so, but asked if she had any idea why this might be happening.  She made a couple of guesses.  Maybe her pancreas was giving insulin production one last effort in what clinicians call the 'honeymoon period' of diabetes.  Maybe she'd been growing for a time and had stopped.  More likely, though, we'd never know.

We still don't know, but what's really curious is that it's happened every fall since then.  It makes very little sense. In fact logic would lead one to assume the opposite would happen.

Fall is the season of slowing down.  She's settled into a chair at school all day, and homework takes up a good chunk of every afternoon.  School leads to more moments of stress. Apple desserts, heavy dinners and in our family, birthday cakes should be leading to high blood sugars.  Yet usually around the first of October, this bizarre pattern begins.

Yesterday's mid-morning low blood sugar call from the nurse's office after a bowl of cereal and an apple for breakfast was unprecedented.  Monday's post-gym low was less surprising, but that she didn't crest over 100 again until evening was unsettling.  Eating a brownie covered in m&m's at noon on Sunday with a blood sugar of 110 an hour afterwards was pretty awesome, but disconcerting at the same time.  Last night's blood sugars of 65 at 1:30 a.m., 80 at 2:30 a.m. and 90 at 3:30 a.m. and their related juicing and basal rate tweaking were exhausting. 

Needless to say, her fall A1C is always the best of the year.  Disappointment inevitably follows when the inexplicable cloud of pixie dust has passed and the high blood sugars creep back in. 

A quick internet search revealed no documented evidence of this phenomenon.  Sharing of similar stories and amateur speculation as to the root causes are welcome of course!

When Is Enough Enough?

After our last endocrinologist appointment at the end of the school year, we decided it was time to look into a continuous glucose monitoring system.  We also decided that we'd wait until fall.  This decision honored my daughter's concerns about having things stuck all over her during bathing suit season as well as my concerns about keeping things adhered to her during the season of water and sand. 

At the end of the summer we visited the orthodontist.  The idea of some kind of braces sometime in the future transformed into definite braces this January.  These won't be just run of the mill braces.  We left the appointment understanding that she will be chewing with only her four back teeth for between eighteen  months and two years, and that she will be wearing head gear, thankfully only at night.

So here she is...about to turn twelve.  She's growing quickly, and at that adorable-only-to-parents awkward, gangly stage. She already has an insulin pump toggled to her at all times.  She already has to carry around a bag full of accouterments everywhere she goes.  Now we're going to fill her mouth with metal, make eating anything coarser than applesauce a challenge and attach head gear to her at night.

Can you see why her enthusiasm about the CGM is waning?  Tacking on another bionic piece and adding another item to her already overloaded purse doesn't sound so appealing, no matter the benefits.  Lets add that it will probably beep at the most humiliating times.

Can you see why, if she knew anything about 70's television, she would be asking why we want to turn her into the bionic woman? 

We'll still proceed with the CGM.  Once those crazy braces go on, it will probably be even more important to keep a closer eye on those blood sugar numbers, at least until she gets used to eating with them. 

But from a psychosocial perspective, I'm reluctant.  Everyone's awkward at 12.  How much equipment can we adhere to her before the balance tips from awkward to crazy robot girl?  When is enough enough?

Logbook?

I discovered something quite by accident the other day.

We haven't kept a logbook all summer.

It seems like this should have been a conscious decision.  It might have followed a period of diabetes contemplation and culminated in a dinner table conversation with the family.  "What if we took a break from the logbook this summer," I might have said, sounding very wise.  "The meter has a history, and even some charts and graphs we can use.  But maybe a break from writing down every number would be good for our mental health."

That's not what happened.  Instead we finished a packet of stapled together log sheets (our version of a 'book') and I recycled it.  Maybe we were headed on a trip.  Maybe I was quickly cleaning up for company. Whatever the circumstances, it simply disappeared.  And apparently that's the last I thought of it...until today.

I spent some time last week tidying the little area in our kitchen where we keep the calendar, the grocery lists, scrap paper and the most urgent of mail and school notices.  I got to the bottom of the back-to-school fliers and recycled a bunch of old notes and receipts. The area looked oddly empty, like there was more space than usual, but I didn't give it much thought.

It was when my daughter got home from school that it hit me.  As she checked her blood sugar for snack, I asked what her lunch number was. I felt an urge to write it down. Suddenly it clicked. That empty spot was where my eyes looked for that familiar chart.

Did I run right to the the computer to print a dozen more log book pages, happily stapling them together and scanning the meter's memory to catch up for the week?

Um...no.

We may ultimately end up returning to that little packet of paper on the ledge, but if it fell so quickly from our collective memory, perhaps it wasn't as useful as we thought it was. First, there are things to consider.

Do we really need to document every number in the first place? Or is a quick glance at the meter's averages by time of day enough to help me spot a trend?  Did this summer's lack of focus on individual numbers allow us to see the forest instead of analyzing every tree? Looking back, I know that I've made insulin adjustments despite the lack of handwritten data.

If we do resume a formal system, maybe it's time to consider some tech-based tracking options, like downloading software or an app. Maybe we'll even give the equipment that came with the pump another go. 

There are surely benefits to documenting numbers. There are 3 of us living here, all interested in my daughter's blood sugars, so it's a communication tool.  I can know the lunch number at school. My daughter can know what she was at 2 a.m.  My husband can check the dinner number before making a late night correction.  It also provides a historical picture, helping us spot changes in blood sugar trends and make needed adjustments.  It encourages smart choices when, for instance, a glance at the post-cider donut 300 provides a reminder to think twice before indulging again. 

While I realize these may turn out to be a rhetorical (ridiculous?) questions, I'll throw them out there anyway:  Do you love your logging system?  Do you have one you couldn't live without?  Should we just go back to our messy, easily forgotten log sheets?  Doing nothing but relying on the meter's memory seems like not enough, but I'm not sure where we go next.

Should I Be More Worried?

It's the first day of school in our neck of the woods.  And I'm not terribly worried about it.

My daughter is off to the same school.  She'll have the same nurse.  While her academic teachers will be new to her, the rest of the staff and administration is familiar with her.

Don't get me wrong. The baseline anxiety is a constant.  Anything can happen during the 7+ hours my child is out of my sight.  A low blood sugar could go unnoticed and untreated for too long.  A pump site could fail.  A student or teacher could give her a hard time about needing to detour to the nurse's office.

There's also the added first day of school anxiety.  How will the nurse's office visits fit into the new schedule?  Will she have lunch with the same understanding group of friends who always save her a seat?  Will she be so distracted by the newness of her classes and teachers that a diabetes issue will go unrecognized?  Will her teachers understand her needs and be supportive if necessary?

Last year's school start involved a new school and a boatload of anxiety for both of us.  I have to believe this year's challenges, should there be some, will pale in comparison. 

I have my phone at hand, well prepared for 'school' to pop up on the caller i.d.

I am planning a special first day of school dinner complete with a bolus-worthy dessert intended to smooth out any wrinkles of the day.

Yet I'm not that worried.  If I'm proven wrong, I guess I'll deal with it then.