Crisis! (Averted)

'AAAAH CRISIS'

That text arrived around 11:30 the other morning.

Having a 16 year old girl, lots of possibilities came to mind. Forgotten clarinet on a band day, wardrobe malfunction, unexpected test? Turns out it was a diabetes crisis.

'I bolused 10.8 for lunch then 2 more for muffins so then I looked at Dexi and I was skyrocketing and then I looked at history to see if I had bolused and I only saw the 2 units so then I bolused 8.8 more ahhhhh'

So, I confirmed with her via text, she had bolused 8.8 units of insulin with no matching food? She had forgotten that she had bolused for the main part of her lunch, panicked at the rapidly rising blood sugar, and therefore given insulin for it twice?

'YES I RLY SCREWED UP'

While she freaked out, knowing that an overdose of insulin had the potential to be catastrophic, I trusted that her friends would take care of her mental health while I focused on how to fix the problem.

'What's the current insulin to carb ratio?'

'1:8.'

If 1 unit of insulin covers 8 carbs, I reasoned, then 8 units covers 64 carbs, 9 units covers 72 carbs- essentially reverse-engineering of the math to figure out a game plan. She would need to consume some serious carbs to balance out the equation.

'I'm currently eating a tootsie roll pop which is 15 carbs.' (There's a teacher who sells these, essentially at cost, in his classroom...a little mysterious but very helpful at that particular moment.)
'And then I need how many more? Math for me.'

I'll spare you some details, but because to it turned out she was, indeed, skyrocketing we decided that the tootsie pop, one juice box and the pretzels which were to be her snack after school before play rehearsal would be a sufficient start as long as she kept a close eye on the Dexcom. It was a total of about 50 carbs.

It worked out pretty well. At the two hour mark from the error, she was about 150 and continued a slow downward trajectory during play rehearsal but was over 100 when she got home- hungry because she'd eaten her afternoon snack at 11:30 a.m.

Back to School Year #13

My daughter went back to school this month- for the 13th time if we include the preschool years. It's still never easy.

Back to school is a challenge for most kids. There are difficult teachers, tough social situations, and strict schedules to keep.  But for my kid and many like her, fall's biggest stumbling block is diabetes.

The back-to-school diabetes problems are ever-present, but not always the same. Some years there's a new nurse who we have to meet and coordinate with. Some years there's a new activity which coincides with the start of school, adding another diabetes thing to think about. Some years the time of lunch has changed (like the 'year of brunch,' linked for you here though I'm going to choose not to reread and relive the horror). Some years gym proves to be a seemingly insurmountable obstacle (like last year, when at some points it was simultaneously terrifying and ridiculous). Some years there's a teacher who just doesn't quite get it. Or one who's extra nervous. This year we've added a daily walk to school, just a couple of blocks but most of it straight uphill.

There's one back-to-school diabetes challenge that's constant from year to year: the overall change in the daily schedule. August is lazy- featuring vacation, the backyard, books, friends and the pool. For the past couple of years August has also included sleeping late at least a few days a week, and alternate sedentary stretches of binge-watching Netflix and power-finishing summer homework. Going from a slow, sedentary start to 6:30 a.m. breakfast followed by a brisk walk to school would be a jolt to anyone's system. Adding diabetes requires an annual investment in juice boxes and a lot of dosage tweaking.

By the fourth day of school this year we'd already changed the breakfast bolus ratio and several basal rates. Twice.  And she was still eating glucose tabs every day half an hour before lunch. We've gotten that to the point where she's usually just barely 80 at lunchtime but then shooting way up into the high 200's late in the day- except when she has marching band in which case she's staying steady and then tanking overnight. We will not discuss what the weekend numbers look like with an ever-changing band/homework/fun/sleep schedule.

Every year kids face challenges going back to school, diabetes-related or otherwise. They come home and tell their parents, who provide any number of phrases to soothe them: This too shall pass. What doesn't kill you makes you stronger. Life's too short to worry about that. Just do your best. And so we'll continue to apply these same pithy phrases to our approach to managing the back-to-school diabetes adjustment. We'll do our best, making tweaks every couple of days, trying not to worry, knowing that we will get through this, stronger in the end, as we always do.

Muffin Chronicles Part 4: Applesauce Theme Week Edition

 



Applesauce Mini Muffins

Since too much applesauce is never enough, here's the latest batch of muffins for the lunchbox:

1 c. whole wheat flour
3/4 c. white flour
1 tsp. baking soda
1/2 tsp. salt
1 tsp. cinnamon
1/4 tsp. nutmeg
(you could also add 1/4 tsp. clove if you like it but we don't)

1/2 c. shortening or softened butter
1/2 c. sugar
1 egg

1 c. applesauce

Mix flour, soda, salt and spices in a small bowl or in a glass measuring cup with spout. If you use a spouted measuring cup (which makes a later step easier) it's still best to measure your flour first with a standard measure for dry ingredients (you know- a metal or plastic one that'll let you level the flour off across the top). Set this mixture aside.

In a large bowl, cream the shortening and then add the sugar gradually until the mixture is light and fluffy. Then add the egg.



The shortening/sugar/egg mixture will look like this.
Also of note, these single-serve applesauce packs are
1/2 cup each which is convenient.

Add the dry ingredients, alternating with the applesauce, to the bowl containing the shortening mixture. Stir between each addition. I usually add about a quarter of each at a time. This is the part my daughter has always loved to help with!




 

How much dough? I just used a teaspoon from my silverware drawer-
one heaping spoonful per muffin cup.

Spoon into mini-muffin tins and bake at 350° for about 18 minutes until a toothpick inserted in the center comes out clean. I made 33 mini muffins for about 8.5 g. each.


The recipe is adapted from my husband's Nana's applesauce cake recipe. To adapt it back for a great dessert, use all white flour and a full cup of sugar. Bake it in a standard sized loaf pan for an hour (which sounds like it would be too long but trust me, it isn't).

We love this recipe because - yum - but also because we almost always have the ingredients we need for them in the pantry.
 
Hope you'll enjoy it too.




Every Day is Healthy Lunch Day

Yesterday was National Healthy Lunch Day, a diabetes awareness month event sponsored by the American Diabetes Association.  I spent yesterday morning largely off-line, so by the time I saw the e-mail inviting me to participate I was halfway through my lunch and my daughter's had been at the high school for hours.

Fortunately, almost every day is healthy lunch day in our house, so I bring you today's school lunch:



 

 

A variation on this theme goes to school with my daughter every day in our ragtag collection of reusable containers.  Today's sandwich is PB&J with natural peanut butter and low-sugar spiced pear jam. Grapes are today's fruit choice, and she'll have salt and pepper popped rice crisps for the crunchy course. The muffin of the day is apple and pear. 



All packed up and ready to go, with a note reading, "68 g." 

 

 

The Muffin Chronicles Part 3: Apple (& Pear?) Muffins

We started out making these with no fruit at all, as a fall spice muffin.  Then my daughter had her baking-loving friend sleep over one night.  She's is my favorite sleepover guest since the evening always involves making something great either for dessert or for breakfast the next morning.  This friend suggested the addition of diced apples, and we've never gone back.

Start by preheating the oven to 350°.

Then mince up some apple, and maybe pear if it happens to be around. I had parts of two apples left from chopping the rest into salads during the week, and a sad pear.  I was only able to salvage a small chunk of the pear, but I wouldn't want to use too much anyway since they're so much moister and mushier than apples.  In total I used somewhere between 1/2 and 2/3 cup of finely chopped fruit. 

Next, combine in a large bowl (to which you'll eventually add the dry ingredients):
1/2 c. sugar
1/2 c. milk
1/3 c. vegetable oil and
1 egg

 

 

Then add:
1 c. whole wheat flour
1/2 c. white flour
1 1/2 tsp. baking powder
1/2 tsp. salt
1/4 tsp. nutmeg and
1/4 tsp. cinnamon
.

Stir just enough to combine. 

Then fold in the fruit.

The first few times we made these, we went back and double checked that we'd measured correctly.  The batter is extremely dense- more like bread, or even cookie dough.  The thickness does make it easier to get it into the muffin cups, which should be about 2/3 full.  Sprinkle lightly with cinnamon sugar. 

 

Bake for 15 minutes.

 

 

 

The whole recipe has approximately 285 g. carbs if you use the equivalent of one average apple and depending on how heavy-handed you are with the cinnamon sugar.   I ended up with 35 mini muffins which mathed out to approximately 8 carbs each. 

 

They're even more fun if you're fortunate, as I was, to find holiday themed baking wrappers in your pantry!

 



The Muffin Chronicles: Episode 1

My daughter has taken the same basic lunch to school since first grade:

A sandwich (usually sunflower seed butter and jelly)

Fruit (grapes, berries, a clementine, apple slices)

A salty snack (pretzels, goldfish crackers, sunchips)

This year, she needed a lunchbox addition.  With a 7 a.m. start to her school day because of a period 0 choir class, breakfast and lunch are a long time apart.  The previous lunch wasn't filling her up anymore, even with a larger serving of fruit and a heartier sandwich.

She needed something else nutritious which could be eaten quickly, wouldn't spike her blood sugar, and wouldn't rip out her braces.  The braces part eliminated the obvious granola bar choice, especially when paired with eating quickly.  We tried a couple of brands of soft cereal bars, but there was a definite blood sugar spike just in time for important classes like biology and geometry.  Her lactose issue eliminated cheese or yogurt options.  So we went with:

Corn muffins are her favorite but they're even better with blueberries.

Homemade mini muffins.  It sounds ambitious but hear me out.  If once every couple of weeks I make a batch of mini muffins and freeze them, I can take two out every morning, put them in a little container in her lunch box and she has a decent 20-ish gram snack.  Some recipes are good 'as is,' and for others I substitute whole wheat flour or decrease the sugar to make them a little easier on the blood sugar. 

Corn muffin recipes are plentiful so I won't bore you with that one, but I do plan to share a couple of (hopefully successful) muffin experiments in future editions of 'The Muffin Chronicles' this fall!

First Days of High School

So far high school is overwhelming and scary. Not as much so as we'd conjured up in our imaginations, but it's a big new building with a whole new cast of characters and a whole new set of expectations.

If we make it through tonight's first football game, we might be able to breathe again.

Diabetes has, thus far, not thrown any major curveballs.  A couple of borderline (70ish) lows were treated with glucose tabs in the classroom.  The Dexcom has been alternating between impressive accuracy and short bouts of '???' for a couple of days.  Extreme hunger has been reported at lunchtime and we're searching to find a lunchbox addition which doesn't lead to a major blood sugar spike an hour later, but which isn't 'boring.' 

Most significantly, we've already switched up the school nurse game plan.  When we met in June, we decided my daughter would handle her diabetes independently at school unless she was low or otherwise decided she needed assistance. When I dropped off the supplies before Labor Day, the nurse had qualms about being completely out of the diabetes loop. She wasn't asking for my daughter to visit daily or check her blood sugar in the nurse's office. She just wanted to be able to track how things were going.

I had no objection to her being in the know. Ideally she's part of our diabetes success team. If she notices something we don't (like my daughter is crashing half an hour after every time she has gym) we'd welcome the help.  I just didn't know what the best plan was.  Maybe turning in a log sheet at the end of the week, or downloading the school meter for her? We left it that we'd pass along data in some form by the first Friday of school. 

Leave it to the teenager to come up with the most logical game plan.  'Why don't I just text her every time I check or bolus?'  Of course.  Quick and easy.  No writing things down or remembering to stop by every Friday to hand in a log.  My daughter stopped by the office on the first day of school to say hello and to run this idea past the nurse, who enthusiastically agreed to give it a try.

Much of this week has been about finding the easiest and most efficient way to get through the day: planning the right times to go to the locker, finishing homework (already!) before band practice, the best routes through the hallways. Texting the nurse is another variation on the theme.

Time Suck

A sampling of annoying events from the past few summer days:

I received a lunchtime phone call from the beloved nurse-free music program.  "I'm 72.  How should I bolus?"  The question took several minutes to sort out.

While at the pool, she had to stop to disconnect or reconnect her pump while her friends were already running for the diving boards/ping-pong table/snack bar.  This scene repeats several times daily.

She had to leave her friends in the pool to treat a low blood sugar.

We delayed leaving for the pool to replace the tape on the Dexcom.

We delayed leaving for music to add tape to the Dexcom.

I spent half an hour online searching for tips to keep the Dexcom stuck when frequently submerged in a swimming pool, lake or ocean.  (Suggestions are still welcome...).

We expected to do a quick site change, only to find that the pump battery needed to be replaced and the supply of wipes needed to be replenished from the downstairs closet.

A desire for a summer peach turned into an ordeal involving the food scale and the calorie king app since it was the first peach of the season and we couldn't remember the carbs.

A group of friends descended on the kitchen for a snack break.  She was the last to eat, as usual, since she had to stop to check her blood sugar, read the nutrition label, and bolus for her food.

A cure and/or a bionic pancreas will some day dramatically improve my daughter's health.  That, in the big picture, is the reason we want these things.

The other benefits are indisputable though.  When the day comes, we'll go through every day without any of these kinds of stops and detours.  She'll stop being the one lagging behind at the pool.  She'll dive into her friend's pantry right along with everyone else.  Diabetes won't delay the fun.  We can't wait.

Hungry

The phone rang at 10:45 a.m., flashing the school's number on the caller i.d.  It's always with a sense of dread that I answer calls from school.  But, of course, I do.

"Mommy?"

"Yes...hi."  (Who else would be answering?)

"I finished my whole lunch."  (Brunch?)

"O.k.  Good?"  (I was struggling to get the tone.  Was this good news or bad?)

"I'm still hungry.  And the nurse has some pretzels I can have.  But I'm not sure I can finish the whole bag.  And I don't know whether to eat the sticks or the twists. But I'm really hungry.  And I have art club after school that I want to stay for. And then I'll be really, really hungry."

I cut her off before she got too worked up, "O.k.  Look at the label for the twists...they're probably easier to count than the sticks.  How many carbs in a bag?"

"23."

"How many pretzels are in there...open it up and count as best as you can."

"Looks like about 20."

"Ok...well take them and eat what you can and come back and bolus 1 for every pretzel. That should be close enough."

"Ok."

"I'm glad you're hungry!  And make sure you say thank you for the pretzels."

"Ok."

At 11:20, the phone rang again.  School.  "Mrs. Osborne, everything's ok. In fact, I thought I'd call with good news for a change...she finished the pretzels.  I'm so glad she's getting her appetite back."

Me too.  And thankful for the nurse's support, and for how nice her friends have been keeping her company on her many treks to the nurse's office during these first weeks of school.

My wish to provide a balanced brunch snack-like meal which can fill her up is complicated by her aversion to 'cold cheese,' and her wanting to lunch with three friends who are allergic to peanuts. This week we're trying yogurt tube + grapes + crackers or pretzels.  I still contend the cafeteria should serve eggs and toast. 

 

Brunch?

The fifth grade eats lunch at 10:17 a.m. 

"Most of my friends don't seem to mind," was the report.
 
My daughter minds.  A lot.  Because she's a normal person. 

Her response to the problem is our challenge.

The first day, she ate most of her lunch.  The second day she ended up in the nurse's office chugging a juice box since she'd bolused the carbs and then decided she couldn't finish. 

Over the weekend, the lunch issue became an all-consuming, awful problem in the way problems do best when you're in middle school.  All of the anxiety about every aspect of this new school experience was funneled into the lunch predicament and there was no possible solution.

By day three, she had herself so worked up about it that she was sick to her stomach.

Thankfully she's pumping, so we have some flexibility in eating patterns.  But from a regular-people perspective, she has to eat something between 7:40 a.m. and 2:52 p.m., and keep it down.

While she's got flexibility, she's used to eating regular meals on a regular schedule.  It's likely that while the pump allows for different mealtimes, a regular eating pattern makes it easier to keep her blood sugar more stable. Perhaps most significantly, it's her preference (which isn't really odd at all) to eat lunch at noon-ish and small snacks between meals.

Yes, she has her 504 plan which would allow her to eat anytime.  But she can't eat while practicing  the keyboard during music class.  Or while trying to do weather experiments in science.  And, along with every other middle school child, she doesn't want to be 'different' any more than she has to be.  So we seek a way to make this schedule work. 

Our next experiment is two snacks.  One at 10:17, and one at 2, when all 5th graders are allowed to snack if they need to.  A generous policy to make up for the ridiculous lunchtime.  She can then have another substantial 'snack' when she returns home.

Today the anxiety seemed to be dissipating a bit.  Yesterday she ate her two snacks and spent the whole lunch period with friends instead of the nurse.

Perhaps an omlette station in the cafeteria would help.