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

3. 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?

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

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

6. 37.8 - often 25% increase of doses
up to 50% increase of doses

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

8. 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

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

10. 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 ؟

11. 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

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

13. More frequent monitoring
Ketones

14. 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.

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

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

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

18. Relationship between urine and blood ketones

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

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

21. 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.

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

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

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

25. 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.)

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

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

28. 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

29. 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

30. 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.

31. 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

32. 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 ؟

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

34. 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

35. 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 )

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

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

38. 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

39. Case 1
40 ₓ = 2 IU Regular

40. 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 ؟

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

42. Case 2
BS = 80 mg/dl
Ketone moderate

43. 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

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

45. 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 R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

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

48. REFERENCES :
Uptodate 2016
ISPAD 2014

49. با تشکر