It has been two months now that Gregory is attending kindergarten.
Current equipment
Insulin pump: Medtronic 640G
CGM: Guardian 3
Remote BG monitoring: Nightscout and xDrip+. Also 600 Series Uploader Android app that would take the BG values from Gregory’s pump via Contour Next Link 2.4 BG meter.
BG Meter: Contour Next Link 2.4
In general we are happy with how we (including Gregory) manage his diabetes but there is plenty of space to improve. Let’s see which are the things that make us happy and which ones not.
Cooperation with nurse and teacher
It couldn’t be better. His teacher is very switched on and she treats his lows very successfully using glucotabs. She is of course stressed because she has the responsibility of the primary diabetes management, but she seems to be more confident day by day taking initiatives and giving glucotabs earlier on in order to avoid an obvious upcoming low.
The nurse too. She has Gregory’s Nightscout page open in her office and frequently checks his status and BG trends. She goes after each snack/meal at his class to give the necessary bolus according to what he has eaten. She uses the pump easily and even takes the initiative to give a dual square bolus in order to fight a slow carb or fatty meal.
Meal Management
Gregory school meal schedule is approximately the following:
07:15: Breakfast at home
10:00: Snack at school
12:20: Lunch at school
There was an option for hot meal provided from school but we opted it out as it would be extremely difficult to count the carbs consumed. We therefore chose to prepare snack and meal for him, count the carbs and write them on his personal diary that he takes with him every day. That way we make the nurse’s life easier as she could see the leftovers after he ate and she could easier count the carbs, thus giving the correct bolus.
How could she compare the initial portion with the leftovers? We took a photo of every meal with his Nightscout phone every morning, therefore she could see how much he has finally eaten.
Blood Glucose Management
The fact that Gregory is only 3.5 years old makes it vert difficult to predict if he would finally eat the full portion of his meal. Therefore pre-bolusing is not an option as we could end up giving an insulin overdose in case he would not eat all his food.
This results into having persistent highs. Moreover, the time between breakfast and snack was only 2h45m, while time between snack and lunch was 2h20m. The time-frame was very short for BG to return to normal levels. The next snack/meal had to be given again without prebolus and in the end the high BG ended up on an even higher BG.
Then insulin resistance built up and eventually ended up with overtreating high BGs and a nice low after a few hours.
CGM performance
Medtronic 640g is a great pump with an excellent feature of insulin suspension when CGM sensor along with the pump’s algorithm predict an upcoming low. But unfortunately the 7 day duration Guardian link sensor barely durated 4 days. “Sensor updating, please wait 3 hours” errors caused extra stress to the teacher who was “blind” without BG updates. Stress that we could also feel as parents as we were continously monitoring Gregory’s BGs from home or office using his Nightscout page.
If an error ended up into a “Sensor failed” error then me or my wife had to go to school in order to pick up Gregory and change the sensor at home. There was no option to change it at school as sensor warming up was also part of the procedure and leaving him without a CGM for 2-4h that could be dangerous.
Blood Glucose Statistics
Hyperglycemia
The absence of pre-bolusing caused inevitably a lot and persistent highs. The short time between the meals as already mentioned made the problem even worse as Gregory had to eat mostly with already high BGs. Trending over 350 was a daily habit.
Hypoglycemia
Overtreating the persistent highs was something common. This was causing most of the times hypoglycemia. On average Gregory had 2 hypos during his school day.
Technical Issues with phone
I am using a Xiaomi Mi6 Android phone for Gregory. Every phone has different energy saving features which tend sometimes to kill active apps in order to save battery.
Many times, if for example xDrip+ app was dead (or mistakenly closed by the teacher), then BGs where not uploaded to the internet (Nightscout) therefore nurse and we as parents were actually blind not being able to intervene in case needed.
Gregory was going to school which was very important but we as his parents were not really satisfied about his Time In Range (TIR) statistics.
We had to find a way to:
- prebolus in order to avoid BG spikes,
- give corrections early enough to avoid insulin resistance built up
- be careful not to overtreat a persistent high which would inevitably end into a low
