DIABETES AND ILLNESS WILLIAM B. ZIPF, MD, FAAP PEDIATRIC DIABETES PROGRAM NOTE: The following guidelines are for SHORT-TERM illnesses (flu, colds, or diarrhea) that do not last much more that 24 hours. With severe or long-term illnesses, emergency room treatment or hospitalization is often necessary.
INTRODUCTION: When your child has even a mild illness, such as a cold, flu, or fever, it is difficult to maintain god diabetes control. If your child is sick, we’re not concerned with “tight” control, but we want to avoid extreme high and low blood sugars and maintain the glucose level within an acceptable range. Many problems associated with illness are related to dehydration---your child may not want to drink and illness increases the body’s need for fluid. Dehydration can occur quickly if there is fever, vomiting, diarrhea, and the high urine production that happens when the blood sugar is high. Illness of a child with diabetes should be treated as if diabetic acidosis may occur. Vomiting and/or diarrhea can make a child lose valuable body fluids, minerals, and electrolytes and leads to acidosis. Therefore, if your child has any illness involving diarrhea and/or vomiting that is severe or prolonged (more than 24 hours), you should call your doctor. HOME MONITORING:
• Measure your child’s blood sugar every four (4) hours. • Check for urine ketones every 4 to 6 hours. • Every four (4) hours beginning at the time you see ketones spilled into the urine, measure
and record your child’s: 1. Weight (body weight is a good indicator of whether the child is dehydrated) 2. Temperature
• Take Tylenol (acetaminophen) every four to six hours to reduce the fever that will help to
reduce the release of extra stress hormones and fluid loss.
• NEVER omit insulin. Illness (especially if associated with a fever) usually causes a
greater than normal requirement for insulin because the stress triggers the release of hormones that raise blood sugar. This is true even if there is a decrease in appetite and/or vomiting.
GENERAL GUIDELINES FOR ADJUSTING YOUR INSULIN:
1. If there is vomiting and if blood glucose is low or showing fairly good control (less
than 150 mg/dl) and there are no urine ketones present, take ½ the usual NPH insulin dose. (The short-acting insulin (R or H) should be omitted)
2. If the blood glucose is normal or high and urine ketones are present, take the usual
insulin dose whether there is vomiting or not.
Your doctor may advise you to give your child more short-acting insulin according to his/her blood glucose level and urine ketones. Be sure your child drinks plenty of fluids during illness since dehydration is more likely to occur at this time. GENERAL GUIDELINES FOR FLUID INTAKE:
• If your child is feeling nauseated or is vomiting, encourage your child to take small sips of
fluids of 1 to 1 ½ ounces every 20 minutes;
• If blood sugar is greater than 200, drink diet beverages.
• If blood glucose is less than 200, drink regular sweetened beverages. • If your child cannot eat regular foods, replace them with carbohydrates in the form of
liquids or soft foods (see attached list). Eat at least 50 gm of carbohydrates (about 3 slices of regular sliced bread) every three to four hours. Sherbert, fruit juices, pop-sickles, regular pop, regular jello, etc. may be used on sick days to make intake of calories easier. Alternate sugar-containing fluids with non-sugar containing ones in order to get in the needed fluids, but not too many carbohydrates. To replace sodium (a mineral), drink salty broth, bouillon, or clear soup. To replace other minerals, drink uncarbonated beverages and / or fruit juices. This will provide some readily available sugar so the body won’t have to burn fat for energy that produces ketones. When illness subsides, return to the usual meal plan.
CONTACT YOUR PEDIATRICIAN OR FAMILY PHYSICIAN if your child’s temperature is elevated to be sure no ear, nose, urinary, or other types of infections is present to cause the fever. Most illnesses are viral, but we don’t want to overlook a bacterial infection that requires treatment with an antibiotic. CALL YOUR ENDOCRINOLOGIST IF YOUR CHILD IS:** 1. Unable to eat regular foods for more than one day 2. Vomiting 3. Having diarrhea 4. Positive for urine ketones 5. Having repeat high blood sugars (usually 300 or greater) ** You may want to call the doctor as soon as your child is sick to alert him/her to the problem. HAVE THE FOLLOWING INFORMATION READY FOR THE DOCTOR: 1. Age 2. Current weight (the day you are calling) 3. Approximate date of last visit 4. Current insulin dose 5. Blood glucose readings 6. Urine ketones 7. Temperature 8. Information on any other close family member who may have experienced this illness SICK DAY CUPBOARD:
Copy of “Sick Day Guidelines” Ketone Strips Thermometer Broth or bouillon Can of soup Cans of pop (sugar and sugar-free) Jell-O (sugar and sugar-free) Kool-Aid canister (sugar and sugar-free) Pedialyte liquid or popsicles (for younger children) Medications (see below) Body weight scale
MEDICATIONS: Several medications may be useful in the sick day management of your child with diabetes. These should be available in your Sick Day Cupboard. These medications are described below.
1. TYLENOL or IBUPROFEN (available over the counter=OTC)
This should be given as directed on the package label for treatment of fever and generalized discomfort.
2. EMETROL (OTC) This medication can be given to relieve nausea and vomiting. It should be given as directed on the package label. In addition to relieving the nausea and vomiting, it contains carbohydrate so it will aid in raising the blood sugar. 3. GLUCAGON (available by Prescription only=Rx) a. For Severe low blood sugar:
Given if your child is unresponsive or having a seizure due to hypoglycemia. Glucagon vial is mixed and a dose of 0.5 (1/2 vial) or 1.0 mg. (entire vial) is given.
b. For low blood sugar and nausea and vomiting: Mini Dose Glucagon
Glucagon can be mixed and given just like insulin—using an insulin syringe if the blood sugar is low (< 70) and your child cannot keep any food down or is
· The dose is 1 unit per year of age (one unit corresponds to 10 mcg. of Glucagon). · Dose: 2 units for children 2 years and under
1 unit/year of age for children 2-14 years
· If the blood sugar is not higher in 20 to 30 minutes, repeat the dose.
4. PHENERGAN SUPPOSITORY (Rx) a. Phenergan should be given with caution to someone with diabetes and only after
consulting a medical professional. If phenergan is used when there is vomiting due to impending ketoacidosis or an underlying bowel problem such as appendicitis, inappropriate use may mask the problem and delay the child getting appropriate treatment. Delayed treatment could have serious consequences.
1. Contact your medical professional to determine if an exam is needed before or
2. Continue to monitor glucoses, ketones, fluid intake, weight, and your child’s
3. Have your child examined if indicated by health professional or if condition
4. If your child is ill and experiencing nausea and vomiting, a phenergan suppository
may be given if urine ketones are not present. Further instructions can be given by your child’s endocrinologist to determine if it is appropriate to give this medication.
5. ZOFRAN ODT (Rx) a. This oral dissolvable tablet is available by prescription and can be given for nausea with the same precautions as for phenergan. b. Dose: <11 yr of age – 4 mg. tablet
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