Pediatric Type 1 Diabetes Sick-Day Guidelines

Stay on track.

Keep your child’s usual routine, including mealtime insulin to carbohydrate ratio (ICR), to prevent ketones from being made. In fact, your child may need extra insulin when sick. If your child lacks an appetite, let them eat and drink as much as they can and give insulin immediately after mealtime. See our sick-day food and drink guide for more tolerable choices on sick days.

Test urine or blood for ketones every 2 to 3 hours.

Ketones may appear with normal, low or high glucose levels when your child is sick.

• If tests show your child has ketones, they’ll need extra insulin to clear their ketones and minimize their risk of diabetic ketoacidosis (DKA). Follow the insulin dosing guidelines.
• Pump users should have a low threshold for changing pump sites anytime a child has ketones.

Keep a close eye on glucose levels.

With the body’s increased need for insulin during illness, check your child’s glucose every 2 to 3 hours.

Stay extra hydrated.

Beverages, such as water or other sugar-free fluids, will help prevent dehydration and flush out the ketones. Avoid drinks with caffeine. Follow the fluid intake guidelines.

Pay attention to nausea and vomiting.

If your child is vomiting, even small amounts of fluids can help. Start by giving 1 tablespoon of fluid every 5 to 10 minutes (about 3 ounces per hour).

• Emetrol is an over-the-counter medication that can settle the stomach.
• A prescription medication, such as Zofran (ondansetron), is a helpful treatment for nausea and vomiting. This medication can be prescribed by your child’s doctor.

Check resources.

• Use the sick-day dosing guidance on fluids and insulin and monitoring glucose and ketones.
• You can also text “diabetes” to 77444 to download the Diabetes Advisor iOS app by Children’s Health for 24/7 help with dosing decisions. (An Android version is in development.)
  • Register for the ketone manager feature using your one-time access code provided by your care team or email diabetesapp@childrens.com to receive a code. Ketone manager access codes are unavailable after clinic hours.

Call the diabetes team at Children’s Health if:

• Your child is showing the following signs of diabetic ketoacidosis (DKA):
  • Moderate or large ketones
  • Deep, rapid respirations
  • Unable to drink or tolerate fluids
  • Vomiting many times or if vomiting doesn’t stop
• Ketones don’t clear after 2 correction doses
• You are concerned at any time

We offer round-the-clock care with our diabetes emergency lines open 24/7.

• Dallas: 214-456-5959

When you call us we will ask for the following information first to help us understand your child’s diabetes needs.

• Your child’s name and age
• How long your child has had diabetes
• Your child’s daily insulin regimen

Extra fluids help eliminate the ketones that have already been made.

• When your child has positive ketones, aim to drink 1 ounce per year of age, every hour until ketones are negative.
  • The maximum fluid intake is 16 ounces per hour for children 16 years old or older.
• Fluids should be water or other sugar-free drinks, unless your child is experiencing low blood sugar readings.

Extra rapid-acting insulin stops ketones from being made. This dose can be calculated as a percentage of your child’s total daily dose (TDD) of insulin.

• If ketones occur at a mealtime, and your child wants to eat, add the calculated units from the sick-day dosing table to the meal dose. Do NOT add the usual correction scale insulin.

Remember, always wait at least 2 hours between doses of rapid-acting insulin.

Add all of the insulin your child takes in 1 day of both long-acting and rapid-acting insulin.

What should I keep in mind when using the sick-day dosing guidelines?

• If your child’s ketone levels are 0.1-0.5 mmol/L (trace on urine testing), it is OK to give the correction bolus through the pump.
• Test your child’s glucose and ketones 2 hours after treating using the pump to see if values are improving. If you don’t see improvement, give the next correction bolus through a pen or syringe and consider a pump site change.
• If ketone levels are 0.6 mmol/L or higher, give sick-day bolus through a pen or syringe using the sick-day dosing guidelines, and change your pump site.
• For glucose readings greater than 200 mg/dL with moderate to large ketones (1.0 mmol/L or greater on blood testing) you may set a temporary basal rate of 120% of the normal rate (increase of 20%) for 2 hours in addition to the advised sick-day bolus.