# Is it a no win situation...



## Gemma444 (Jan 25, 2010)

Since J's DSN went into the school to sort out the food situation, J's b/s have been a little better. Since then the school have been keeling a record and when J tests it seems J's blood sugars were dropping too low at 10:30am. If the insulin is reduced then J's b/s are too high later on and the doctor does not want to reduce the insulin anymore for that reason.

We can't change breakfast time as me and J's dad both work full-time and Ive been told that if he has rice crispys to have 1 piece of toast with the cereal and if he was to have 2 pieces of toast to have a cereal bar just before going to school. The bread he has is grainery (sp) and is says low gi on the wrapper and has 11.9g carbs and im not sure how to work out the rice crispys as it says carb 32g of which is sugars 9g, starch 23g this includes 125ml of milk. he sometimes has porridge but doesn't like it much or weetabix. If he has 2 rounds of toast that are 11.9g each then he has a cereal bar just before school which is 15.5g or 16.6g of carb. Depending which bar he chooses. J says he can't each much more than this. Any help trying to stop the hypo before 10:30am will be greatfully received.

Gem xx


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## Adrienne (Jan 25, 2010)

Hiya

I'll try and help here.   If I remember rightly J is on twice daily mixes.   Unfortunately this is already a no win situation.   The highs and lows on mixes will get worse and J will swing up and down.  

The normal pattern with mixes is you go high mid morning and then hypo by 12 noon.    I guess that as the morning insulin is quite high to stop the mid morning high and instead is having the reverse effect and causing hypos which are then treated and therefore high at lunch time.

The mid morning spike is horrendous to deal with but you have this sussed with the high morning injection so all you need to deal with now is stopping the hypo at 10.30 so as not to cause J to go high by lunch after hypo treatment.

Does J have midmorning snacks.

On mixes you feed the insulin.   On all other regimes, MDI and pumping you give insulin to cover the food so a totally different way of doing it which is much easier.

Chasing insulin, like you are doing is damned hard work so you are doing ok.

The normal way to deal with mixes is the following regime with food :

breakfast
Midmorning snack
lunch
midafternoon snack
tea
bedtime snack


The snacks are so very very important.

The breakfast you are giving is fine.    When you look at the carbs on a packet of cereals you look where you are looking ie 30g (or whatever it is) with 125 ml milk is 32 carbs.   Do not bother looking at the 'of which are sugars' or the starch, just look at the whole carbs.

Whatever you are giving him is obviously not seeing him through to lunch time and that's ok which is why the snacks are so very very important and you need to get the right amount.    If he is going hypo at 10.30 then he probably needs his snack at 9.45 to 10 am.    I am presuming breakfast is quite early and the snack should be about 2 hours after breakfast.   However maybe he needs two snack breaks as breakie is so early, it will just be trial and error.  

Start with say 20 carbs for a snack.   I used to go up and down the biscuit aisle adding up combinations.   A digestive is 9 cho but I think a chocolate one is 11 or something like that.    May a choc digestive or two is the way to go.   In this instance you have the chocolate which whilst it is not quick enough to hypo treatment it is pretty quick so will take him up and then the biscuit bit will keep him up.

Allsorts of ways to work these snacks but they are very very important.  Don't be fobbed off by fruit.   When on mixes fruit generally won't be good enough to keep the levels up unless you give grapes which won't work as they will shoot his levels right up and plummet down again !

I hope that has helped a bit.   Let me know if you want anything more.


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## Gemma444 (Jan 26, 2010)

Hya Adrienne

Jack does sometimes have fruit for a snack at school. They have said it is his choice. I try to tell him to have a cereal bar instead, he does when hes a home. They are 16.6g of carbs per bar. He was having his snack at 10:30 a school but i think he now has it at play time which is a be a bit later as they didn't want him coming out of class alot, don't see why they can't have the snacks in the class room then he could eat at the desk. I agree that I think he needs his snack before 10am rather than later than 10:30am. thanks for the biscuit idea I will try it and while i'm off this week i will go into the school to have a word with J's teacher. 

Thanks again.
Gem x


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## Kei (Jan 26, 2010)

Great advice from Adrienne.  This bit is especially important ...



Adrienne said:


> Does J have midmorning snacks.
> 
> On mixes you feed the insulin.   On all other regimes, MDI and pumping you give insulin to cover the food so a totally different way of doing it which is much easier.
> 
> ...



If F doesn't get her midmorning snack, she goes hypo almost instantly.  Her teacher knows she MUST have it at 10:00 and no later.  Because she has milk at school (10 carbs), she has a digestive with it at 10:00, which takes it up to 19 grams of carbohydrate.  In the afternoon she has 20g of carbs at her desk at 3:00 - usually a cereal bar or something similar.


Here is F's current carb-counting regime, which should probably be about the same for J, as she's eating a similar amount to what an average adult female requires daily (still trying to regain weight after the DKA).

Aim for 200g - 240g per day of carbohydrate.

Breakfast - 50g
7:50 - 20 minutes after insulin

Mid-Morning - 20g
10:00

Lunch - 60g - 70g
12:00

Mid-Afternoon - 20g
3:00

Evening Meal - 60g - 70g
5:30 - 20 minutes after insulin

Supper - 20g - 30g
7:00

As Adrienne says, you ignore the breakdown of the carbs and just read the total on the packet.  F usually has cornflakes and raisins for breakfast.  I weigh it all out every time, and her numbers stay fairly steady if I do that.

Here is the information sheet I typed out for F's grandparents when we were staying with them...

_The following list of mealtimes and carbohydrate requirements needs to be stuck to fairly strictly in order to keep F’s glucose levels stable.

She MUST have her breakfast and dinner about 20 minutes after her insulin, because that’s the optimum time for it to work at its best. She MUST have her insulin at pretty much the same time each day.

If she has too many carbohydrates or too few, her insulin will not deal with it effectively and her sugar levels will be too high or too low.

When checking packets for carbohydrate content, do NOT look at the “sugars” section, but at the section that is the total carbohydrates. Remember to check whether the portion size you’re reading on the pack is for 100g of the product or a specific serving, or your calculations could be wrong.

Each meal and snack must include a starchy carbohydrate (bread, potatoes, pasta, rice, etc…). There is a list of these on an information sheet which I will copy for you.

She can drink lots of sugar-free squash, but not fruit juice.

F now has semi-skimmed milk. She likes low-sugar hot chocolate as part of her supper. Cadbury’s highlights do one which has very few carbohydrates and she likes it.

Supper is generally toast and low-sugar jam with hot chocolate. The quantity depends on which bread you use and how thick or thin the slices are. I’ll photocopy the carbohydrate counting guide we have here.

She only has chocolate or cake rarely, and usually at the end of a low-carb dinner. If it is eaten after a dinner, it absorbs more slowly, which is better for her. For example, if I make dinner and it turns out to only contain 50g of carbohydrate, she might be allowed a single-finger Twix, which works out at 14g carbohydrate. This doesn’t happen often though, as the slow-release carbohydrates are better for her than the fast-release carbohydrates in sugary foods._

I also scanned this document for my mum, which the hospital gave us.  "Children With Diabetes"  It's very useful and the explanations in it are easy to understand.  There are some good snack suggestions too.  If you think it would help I could also scan in the carb-counting leaflet they gave us.  I use that, alongside the Collins Gem Carb Counter and we get along very well.

It is VERY hard to keep good control on mixes, but we've just got F's insulin dose about right, and had two weeks of numbers between 4 and 8, with only 2 hypos!  This weekend ruined it slightly as she ate iced cake at her brother's birthday and went quite high for a while, but we're getting it under control again.

It's a pity that the hospital didn't take the time to teach you all this.  I think it's essential for anyone dealing with type 1 diabetes.

The school will need to let J eat where and when he needs to.  Explain the dangers of low blood sugars to them (I don't think most teachers "get" hypos unless you frighten them with worst-case-scenarios!), and if they are still reluctant to let him eat in class, ask to see their special needs policy.


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## Adrienne (Jan 26, 2010)

Gemma444 said:


> Hya Adrienne
> 
> Jack does sometimes have fruit for a snack at school. They have said it is his choice. I try to tell him to have a cereal bar instead, he does when hes a home. They are 16.6g of carbs per bar. He was having his snack at 10:30 a school but i think he now has it at play time which is a be a bit later as they didn't want him coming out of class alot, don't see why they can't have the snacks in the class room then he could eat at the desk. I agree that I think he needs his snack before 10am rather than later than 10:30am. thanks for the biscuit idea I will try it and while i'm off this week i will go into the school to have a word with J's teacher.
> 
> ...



Hi

The school HAVE to make reasonable adjustments under the Disability Discrimination Act for J and if that means J eating his snack during class then sobeit.   A few years back in the London Borough of Bromley a school was pulled about a girl with type 1 not being able to eat her crisps in class which were her snack.  The school were taken to court I believe over this and the parents won.

You should have a full care plan at school which should include all eventualitys ie PE, wet play, fire drill (who will take J's emergency kit outside with them) etc etc.   It should also include a daily plan and emergency plans on how to treat hypos and hypers.   The DSN and the school SENCO should have sorted this out along with you as you know what is best for your child.

If you look at www.childrenwithdiabetesuk.org there are examples of care plans that are used by other children.

I hope that helps.


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## grahams mum (Jan 26, 2010)

as adrienne said they have to have snack in class when they need to  grahams school  never had any problem they even check that is having his lunch before is allowed to go out to play   the teachers explained this to the other children so in case graham is having a snack not everybody is going to  ask for one every time that graham needs one


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## Gemma444 (Jan 27, 2010)

Hya all 

Thanks you have all been very helpful. I know most of the above and the problems at school are due to his not having is snack at 10am and it seems hes having it later. The hypos at 10 at school are not happening on the wekend at home due to the fact that he has breakfast at 8:30 and snack at 10am. On a work and school day he has breakfast at 7am and not haivng a snack till 11am at play time. 

Herea a typical school day.

7am - breakfast rice crispys - toast - glass of milk 32g+ 11.9g + 10g (think ive added right)

11am Snack - Cereal bar 16.6g. dietician said he can have fruit but Ive told jack to have a cereal bar instead.

12:45pm - School lunch

3:15pm - Snack Cereral bar 16.6g

Tea - 5:30- 6pm -last night jack had pasta followered by a banana

Supper - 7:30pm - Toast and class of milk or cereal.

On the weekend the times are different. 8:30am for beakkie and 10am for snack, 12:30 for lunch, tea and supper same as a school day. 

I can see the problem easliy myself its the length of time from breakfast and his mid-morning snack. 

Thanks
Gemma


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