After using an insulin pump for seven years, my teenage son is bolusing too frequently, according to the nurse at the endocrinologist’s office. She maintains that too frequent boluses interfere with the insulin absorption and that’s why my son has been having such huge swings in his blood sugar numbers. I have never heard of this and wonder if that is indeed accurate. One of the things we like about the pump is the freedom it has given our son. If he decides to have a second helping at dinner, we thought it was okay to do a second bolus. The nurse said he should not be bolusing more than once during a two hour period. This also concerns us when he needs a correction bolus and eats sometime after that. The nurse wants him to figure in the correction bolus and the meal bolus to do it at the same time. Although that may be ideal, that does not seem practical to us. How often is too often regarding boluses?

When working with teens, we typically let them bolus throughout the meal. This allows them to have some control over the amount of food they eat and not have to “commit” before they start eating.

We do find with teens that the wide swings in blood sugar come from several sources. The two most challenging are hormones released by the body for growth and stress response and insulin resistance. Pre-bolusing for the treatment of blood sugar, as well as some of the expected carbohydrate intake, will alleviate some of the postprandial hyperglycemia. The wide fluctuating blood sugars may also come from overtreating the hyperglycemia, thus hypoglycemia follows. Make sure your pump is set for a reasonable “insulin on board” (IOB) duration. We typically see teens set theirs at three to four hours. The insulin-on-board feature will keep track of the insulin you have already given to treat the high blood sugar and will help alleviate “stacking” of insulin.

NB
Additional comments from Dr. Stuart Brink:

There is no specific answer to this dilemma except that there still must be a meal plan and appropriate coverage for extra food/snacks. The pump provides more flexibility, but does not allow complete freedom to eat any amounts at any time. So, perhaps the nurse is saying that the large glucose variability and swings are related to sloppy food intake and then attempts at compensation with extra bolus insulins. Is the problem too many episodes of hypoglycemia, uncovered bursts of hyperglycemia, improper carbohydrate counting, or improper portion control? All these need different responses. I would go back and discuss this in greater deal with your diabetes team so that everyone is discussing the same issues in similar fashion and then decide how to change.

SB