November 16, 2006
Daily Care, Hyperglycemia and DKA
Question from Atlanta, Georgia, USA:
Can the dawn phenomenon happen after you wake up? My daughter gets up for school at 6:30 a.m. and her blood sugar is usually between 80 mg/dl [4.4 mmol/L] to 110 mg/dl [6.1 mmol/L]. I give her breakfast and she gets her first bolus at about 7:00 a.m. with a ratio of 1:15. The school then gives the children breakfast at about 8:30. I asked the school to take my daughter’s blood sugar at this time and, lately, she has been having extremely high blood sugars (over 290 mg/dl [16.1 mmol/L]). They will give her a morning snack bolus with a ratio of 1:20 and add a correction with the pump. They will then check her blood sugar again at 10:30 a.m. and her readings are above the 300 mg/dl [16.7 mmol/L] level and she is showing 0.1 blood ketones. A correction bolus is given again. Another blood sugar reading will be taken at 11:30, just before lunch and her readings are usually in the fine range 100 mg/dl [5.6 mmol/L] to 150 mg/dl [8.3 mmol/L] at this time. By 1:30 p.m., she drops into the 50s mg/dl [2.8 to 3.2 mmol/L]. I have increased her basal starting at 7:30 a.m. to 0.20 until 11:30 a.m. and then the rest of the day she is at 0.150. We have done this the last two mornings, but we are still having a high blood sugar reading until 10:00 a.m. and then by 11:00 a.m., she has dropped to the high 60s mg/dl [3.6 to 3.8 mmol/L]. I will continue to make changes to the basal until we get it right, but I just wanted to know if this is considered the dawn phenomenon or if it is something else.
Answer:
The dawn phenomenon typically happens in the early morning hours, usually 4 a.m. until about 7 a.m. in children that are going through puberty. I’m unaware that this specific phenomenon happens during waking hours typically. If you are struggling with blood sugar control, especially if you are struggling with a specific time of day, your daughter would benefit from a close look at how she is dosing insulin. This usually can best be done by your diabetes physician or the diabetes educator you routinely use. Your diabetes physician may be your best first stop; they typically will provide you with a way to assist with insulin dosing changes between your regular appointments.
MSB
[Editor’s comment: Be sure to discuss insulin stacking with your daughter’s diabetes team. This overlapping of boluses, such as those as 10:30 a.m. and 11:30 a.m., could be contributing to or causing your daughter’s early afternoon hypoglycemia.
BH]
