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Management of Sick Diabetic Child

Major causes of DKA in childhood and adolescence are viral and bacterial infections. Generally, children and adolescents with well-controlled Type 1 diabetes are not more susceptible to infections than the general population. There are, however, certain rules that should be observed in connection with sick-day management of young patients with Type 1 diabetes.

Different illnesses may have a different impact on the diabetes. Generally, conditions with high temperatures cause insulin resistance and increased need for insulin while conditions with low temperatures and vomiting may call for reduced insulin requirements. The insulin requirements during fever is individual but a rule of thumb is that the insulin requirement increases by 25 % per degree of temperature over 37.5°C.

The basis for sick-day management at home is frequent (every 2-4 hour) blood glucose measurements, frequent urine testing for ketone bodies and close contact with the diabetes team for advice.

Ketone bodies may be demonstrated in conditions both with high and low blood glucose. In the former situation a serious lack of insulin exists in the body and the condition may progress to DKA if extra insulin is not given. In the latter situation the ketone bodies are 'hunger' related and are often associated with low blood glucose values.

In either situation insulin should never be omitted, even if the child is unable to eat.

Conditions with raised temperature, high blood glucose and ketonuria, managed at home:

  • Often caused by bacterial infections and the etiology of the disease should be thus sought and treated. Additional insulin should be given according to blood glucose values and the degree of ketonuria. The supplied insulin should be short acting and should be injected into the abdomen or intramuscularly every 2-4 hours.
  • If the blood glucose is higher than 15 mmol/l and there is a moderate to severe reaction for ketone bodies in the urine, the dose of the additional insulin injections should be approximately 20% of the total daily insulin dose.
  • When the blood glucose values are less than 10 mmol/l and ketone bodies are still present in the urine, the additional insulin should be reduced to 10 % of the daily dose and should be given for as long as there are ketone bodies in the urine.
  • To maintain an acceptable blood glucose value (5-10 mmol/l), supplements with glucose-containing drinks (juice, milk or sweetened soft drink) or food (white bread, yogurt, fruit or sweets) may be necessary.
  • In every case the child should be encouraged to drink plenty of fluids to avoid dehydration in connection with fever and hyperglycaemia.

Conditions with normal temperature (< 38° C), low blood glucose and ketonuria, managed at home:

  • These conditions are frequently seen in the very young child, age 0-6 years, and are associated with anorexia, vomiting and diarrhoea and are often caused by viral infections. It is vital to avoid hypoglycaemia and the daily insulin dose may need to be reduced, but not omitted.
  • If the child is treated with two daily insulin injections, the short-acting insulin should be reduced considerably or even abandoned. Possibly the intermediate-acting insulin dose should also be reduced and the adjustments should be performed according to the actual blood glucose values.
  • If the child/adolescent is treated with a basal bolus regimen, the regular insulin doses may need a 20-50% reduction and the intermediate-acting insulin a 10-20% reduction.
  • At the same time, it may be necessary to supply the child with small amounts of sugar-containing fluid (100-200 ml) every hour.

Most often the diabetic child can be effectively managed at home after advice from the diabetes team.

There are, however, certain situations in which the child should be admitted to the hospital for further observation and treatment:

  • Persistent vomiting
  • Increasing ketone bodies in the urine despite adequate treatment
  • Increasingly sick child
  • Abdominal pain
  • Non-compliance and psychosocial problems in the family
  • Language and cultural difficulties very young age (< 2 years)

It is important that the families are taught to react adequately in case of intercurrent illnesses and the diabetes team should provide the family with written instructions concerning sick-day management at home.

Surgery

Surgery on children with diabetes should be performed in hospitals with paediatric facilities and special knowledge of childhood diabetes. If possible, surgery should be delayed until metabolic control is acceptable - meaning that the child/adolescent is without ketone bodies in the urine and the HbA1c value is within the ideal threshold for the age.

Ideally, the operation should be performed in the early morning and the blood glucose values should be between 8-15 mmol/l. If the blood glucose is above 20 mmol/l, a small dose of short-acting insulin should be given immediately before the surgery

The insulin and fluid regimen during and after surgery depends on the duration of the operation, as illustrated below:

Minor surgery (duration < 3 hours)

On the day prior to the operation the usual insulin dose is given.
In the morning of the operation day the following insulin and fluid should be given:

  • Intermediate-acting insulin (corresponding to 1/2-2/3 of the total daily insulin dose).
  • 5 % glucose solution intravenously (maintenance volume, see below)

The blood glucose values should be monitored every 1-2 hours and the values should be kept in the range 11-14 mmol/l. If the blood glucose level is high (>15 mmol/l) small doses of short-acting insulin should be added during the day.

In the evening of the operation day the following insulin should be given:

  • A subcutaneous injection of intermediate-acting insulin (corresponding to 1/3 of the total daily insulin dose

Major surgery (duration > 3 hours):

On the day before the operation, the usual insulin dose is given.
In the morning of the operation day the following insulin and fluid should be given:

  • Infusion solution containing 5 % glucose, 20 mmol KCl and 25 mmol NaCl per litre solution (maintenance volume, see above).
  • Short-acting insulin (50 units insulin added to 500 ml 0.9 % saline administered by a separate drip infusion). The infusion should then run at 0.5 ml/kg/hour corresponding to 0.05 units/kg/hour.

The blood glucose level should be in the range 6-14 mmol/l. If the level is < 5 mmol/l the infusion rate is reduced-Blood glucose measurements should be performed at least hourly during the operation and every 2-4 hours over the next 24 hours. Continue infusion therapy until oral food intake is re-established and for ˝ hour after the first subcutaneous insulin injection.

In this Topic
Blood Glucose Goals In Children: Difference In Opinion
Diabetes at School: Understanding Legal Rights & Responsibilities
Managing Kids’ Diabetes: Unavoidability Of Family Support
Helping Your Diabetic Child with Diabetes Control
Managing Diabetes In Winter
Can Mom Have a Piece of My Birthday Cake?
Lessons For The Teacher
Guide For Baby-sitting Diabetic Children
Emergency Treatment of Hypoglycemia For Teachers
Type II Diabetes - Kids' Epidemic
Diabetes & Children's Height

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