Is it possible to cover breakfast, which is around 7:00 a.m., and a morning snack around 9:00 a.m. with a dual wave bolus? My six-year-old son recently started on a Medtronic pump and we’ve been trying to get his pre-snack and pre-lunch numbers in better control while at school. We have been adjusting his basal rates and his insulin to carbohydrate ratio. We’ve recently learned about the square wave and dual wave bolus and thought maybe this might be a good solution. Any insights you have would be greatly appreciated.

As a new pumper, the first thing that needs to be addressed is that your child should not have to snack anymore. If this is part of the school’s routine, the safest thing to do is send a no or low carbohydrate snack and not have to take the risk of giving the insulin, missing or delaying the snack. Explain that there are limitations and the snack time is one of them. He gets to eat what he wants before and after school and on weekends and holidays.

There are lots of ways to “trick” your pump to give your child insulin for food when you can’t be there to do so. Giving a dual wave or combination bolus starting at 7 a.m. and ending at 9 a.m. could work, but there are several red flags that are raised in doing so. First, if he missed or delayed the snack time, hypoglycemia will result. Second, the combination may be starting too early and hypoglycemia will result as the first part of the extended bolus is peaking. Third, the child must eat all of whatever is decided on as the dual/combination bolus that is set at 7 a.m., so picky eaters will not fair well.

Other families have set a basal, for example, from 9 to 9:30 a.m. to cover the insulin dose for the carbohydrates equal to the total carbohydrates of the snack (which will have to be a fixed amount daily) that is given at 9 a.m. PLUS the basal for that 30 minutes. This actually gives a little room for a few minute delay at school. Again, if the snack is delayed much, your child will become hypoglycemic. You will also need to remember to reset the basal or switch to the weekend pattern on Fridays or your child will end up with his/her “school snack bolus” basal rate on Saturday and Sunday mornings as well and become hypoglycemic.

NB