Sick day management in children with diabetes mellitus type 1 Dr. Hashemi Pediatric Endocrinologist Isfahan University Of Medical Sciences

What do I do if I am/my child is unwell? How do I work out the insulin dose to give if I am/my child is unwell? What should I/my child eat and/or drink when unwell?

The effects of illness on diabetes ● Increased insulin requirements ● Decreased insulin requirements Up to date 2016

Increased insulin requirements Increase in counter-regulatory hormones Raise peripheral insulin resistance Illnesses associated with fever Up to date 2016

37.8 - often 25% increase of doses 38.9 - up to 50% increase of doses

Decreased insulin requirements Reduced oral intake Decreased appetite Poor absorption illness associated with vomiting and diarrhea Up to date 2016

The effects of illness on diabetes Cont,…. There are increased insulin requirements during the incubation . The increased need for insulin may persist for a few days after the illness . ISPAD 2014

Complications Hypoglycemia Significant hyperglycemia Diabetic ketoacidosis Ketosis, independent of hyperglycemia (starvation ketosis ) Up to date 2016

Case 1 دختر 9 ساله ای دیابتی با وزن 40 کیلوگرم ، دچار تب و گلو درد چرکی شده است . مادر وی نگران است و سوالاتی راجع به " میزان و نحوه تزریق انسولین " ، " نوع تغذیه ، " تعداد دفعات اندازه گیری قند خون " و" مراقبتهای لازم" می پرسد . چه آموزشهایی به مادر ارائه می کنید ؟

Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness ISPAD 2014

More frequent monitoring Glucose BG should be monitored at least every 3 – 4 h including through the night and sometimes every 1–2 h

More frequent monitoring Ketones

Ketone Ketones are produced from the liver when there is a lack of glucose (starvation ketones) and as an alternative energy source when there is a relative insulin deficiency.

A healthy cell Cell Insulin Blood Urine test shows vessel O2 CO2 Water Energy Glucose Ketones 0 0 00;18 CWD, Orlando 2006. R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

Diabetes - lack of insulin Cell Blood vessel Urine test shows in liver Fatty acids Ketones Glucose Ketones +++ +++ 00;18 CWD, Orlando 2006. R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

How patient can measure ketones? Urine strips measure acetoacetate (AcAc) and acetone . Blood strips measure beta-hydroxybutyrate (BOHB).

Relationship between urine and blood ketones

When patient can measure ketones? Checking for urinary ketones with each void.

Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

Never stop insulin The most common mistake is complete omission of insulin ‘the child is ill and not eating,’ Even in the fasting state, some insulin is still required for basal metabolic needs.

Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

Maintaining hydration with salt and water Hyperglycemia Fever Excessive glycosuria Ketonuria Contribute to increased fluid losses.

Maintaining hydration with salt and water • Liquids ( Chicken soup or clear broths )

Maintaining hydration with salt and water If appetite is decreased or the BG is falling below 180 mg/dL , sugar-containing fluids should be considered (e.g. diluted fruit drinks, colas.)

Maintaining hydration with salt and water Intravenous fluids may be required if nausea, vomiting or diarrhea are persistent .

Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

Additional insulin Daily dose of the NPH can be reduced by 30 to 50 % . Glargine can be continued at the usual rate or slightly decreased by 10 to 20 % . ISPAD 2014

Additional insulin 0.05 to 0.1 units/kg (5 to 10 percent of the total daily dose), given every two to four hours as needed based upon blood glucose. ISPAD 2014

Additional insulin When patients in remission phase are ill (during ‘the honeymoon phase’) there may be a need to increase insulin up to 1 U/kg/day very quickly.

Extra carbohydrates & fluid BS> 400 mg/dl 250 < BS < 400 mg/dl 180 < BS < 250 mg/dl 1oo < BS < 180 mg/dl BS < 100 mg/dl Urine ketones 0.1 IU/kg 0.05 IU/kg No need extra insulin Neg / trace 0.1 IU /kg Extra carbohydrates & fluid Small to moderate 0.1 IU/ kg 0.1 IU / kg Moderate to large Up to date 2016

Case 1 دختر 9 ساله ای دیابتی با وزن 40 کیلوگرم ، دچار تب و گلو درد چرکی شده است . مادر وی نگران است و سوالاتی راجع به " میزان و نحوه تزریق انسولین " ، " نوع تغذیه ، " تعداد دفعات اندازه گیری قند خون " و" مراقبتهای لازم" می پرسد . چه آموزشهایی به مادر ارائه می کنید ؟

Case 1 اندازه گیری مکرر قند خون و کتون ادرار مصرف بیشتر مایعات عدم قطع تزریق انسولین تغییر دوز انسولین

Case 1 مادر عنوان می کند با توجه به میزان انسولین دریافتی ، چه تغییری در دوز انسولین بدهد ؟ NPH morning : 10 IU NPH evening : 8 IU Regular morning : 4 IU Regular evening : 2 IU

Case 1 Daily dose of the NPH can be reduced by 30 to 50 % . Our case : NPH morning = 10 IU NPH evening = 8 IU …….. In sick day = 9 IU ( 6 – 3 IU )

Case 1 تزریق انسولین رگولار، بر اساس میزان قند خون و کتون ادرار می باشد .

Case 1 For example : BS = 300 mg /dl ketone = Neg

Extra carbohydrates & fluid BS> 400 mg/dl 250 < BS < 400 mg/dl 180 < BS < 250 mg/dl 1oo < BS < 180 mg/dl BS < 100 mg/dl Urine ketones 0.1 IU/kg 0.05 IU/kg No need extra insulin Neg / trace 0.1 IU /kg Extra carbohydrates & fluid Small to moderate 0.1 IU/ kg 0.1 IU / kg Moderate to large Up to date 2016

Case 1 40 ₓ 0.05 = 2 IU Regular

Case 2 پسر 10 ساله ای به گاستروانتریت مبتلا شده است . وی تحت درمان با انسولین گلارژین 10 واحد و انسولین آسپارت هر وعده 4 واحد می باشد . قند فعلی = 80 و کتون ادرار متوسط می باشد . مادر وی راجع به نیاز به تغییر انسولین با شما مشورت می کند . چه پاسخی می دهید ؟

Case 2 Gelargine = 10 IU ……. In sick day = 8 IU

Case 2 BS = 80 mg/dl Ketone moderate

Extra carbohydrates & fluid BS> 400 mg/dl 250 < BS < 400 mg/dl 180 < BS < 250 mg/dl 1oo < BS < 180 mg/dl BS < 100 mg/dl Urine ketones 0.1 IU/kg 0.05 IU/kg No need extra insulin Neg / trace 0.1 IU /kg Extra carbohydrates & fluid Small to moderate 0.1 IU/ kg 0.1 IU / kg Moderate to large Up to date 2016

Case 2 Extra carbohydrates & fluid Repeat BS 1 – 2h ……

When do your patients need to go to the hospital? - Large or repeated vomiting Increasing levels of ketones Continued high BG level > 270 mg/dl Unable to keep BG > 70 mg/dl The underlying condition is unclear Severe or unusual abdominal pain The child is confused or his/her general well-being is affected Up to date 2016 CWD, Orlando 2006. R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

REMEMBER: " S - I - C - K " S is for blood sugar I is for insulin C is for carbohydrates K is for ketone

REFERENCES : Uptodate 2016 ISPAD 2014

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