Diabetes family education. Sick day management by the Diabetes Education Program at The Hospital
for Sick Children. This resource explains how to manage blood sugar levels during an illness
Please note: The images in this video are for illustrative purposes
only and do not constitute the hospital's endorsement of a specific brand or product.
Diabetes and illness. Children with diabetes do not experience more illnesses than their
friends who do not have diabetes. A healthy person with well-controlled
diabetes has normal resistance to infections and injuries heal normally.
See your family doctor for diagnosis and treatment of the underlying illness. Treatment will help to
improve blood sugar levels. Be sure to give your child any necessary over-the-counter medication
to treat the fever or illness. You do not need to purchase sugar-free versions of medicine.
Children who are more independent will need parental supervision and guidance during illness.
Due to the physical stress during illness, hormone levels are increased. This surge of hormones causes
blood sugar levels to rise and the body to be more resistant to insulin. To bring blood sugar
levels into the target range, larger and more frequent doses of insulin are often needed.
Do blood sugar levels always go high with illness? Most of the time yes! The increased hormone levels
and insulin resistance can cause higher blood sugar levels. This can happen even if your child's
appetite is decreased. But sometimes no. Low blood sugar levels can occur during a gastrointestinal
illness, for example, when there is vomiting or diarrhea, or if your child is not eating well.
During an illness, keeping blood sugar levels within the target range can seem
like a balancing act. Things that can cause blood sugar levels to decrease
during illness include: Eating less and vomiting. Things that can cause
blood sugar levels to increase during illness include: Hormones, insulin resistance and stress.
Do not assume vomiting is due to the gastrointestinal illness as it may be
caused by high blood sugar and ketone levels. If your child vomits twice or more within four
hours, contact your diabetes team for advice. [Music] It is important to check blood sugar
and ketone levels every four hours during illness (including overnight). Always continue
to give daily insulin injections. The amount of insulin may need to be adjusted during illness.
Temporary adjustments during illness.
Temporary insulin dose adjustments are based on what the blood sugar level is.
When adjusting for high blood sugar levels you will also need to check ketone levels.
The doses are adjusted in the moment instead of waiting to see blood sugar patterns
over several days. Most adjustments involve fast-acting insulin. [Music]
This chart outlines when and how to adjust the insulin dose during illness.
Let us go through each of these using the blood sugar readings in the table.
We will start with blood sugar levels between 4 and 14 millimole per liter.
If the blood sugar level is between 4 and 14 millimole per liter during illness, you don't
need to make an insulin dose change. Continue to monitor blood sugar levels every four hours.
Blood sugar levels above 14 millimole per liter. Adjusting for high blood sugar levels.
If the blood sugar is above 14 millimole per liter during illness, adjust the insulin dose
to give more fast-acting insulin. The dose change is based on: the total daily dose
of insulin (TDD) and the ketone levels in blood or urine. Let's look at each of these.
Total daily dose or (TDD) of insulin: First, your total daily dose of insulin
is the total amount of insulin your child receives in one day on average.
This includes all doses of fast- acting insulin and long-acting insulin.
To calculate your child's total daily dose of insulin, add up the long-acting
dose and the average amount of fast-acting insulin your child takes during the day.
For example, if your child's long-acting dose is four units,
adding their breakfast fast-acting dose of 1.5 units, lunch dose of 1.5 units,
and dinner dose of 2 units, will give you the total daily dose of 9 units of insulin for your child.
Measuring ketone levels. Blood ketone levels are measured in millimole per liter.
Urine ketone levels are described as negative, trace or small; moderate; and large.
If your child is experiencing blood sugar levels greater than 14 millimole per liter,
find your child's total daily dose and ketone amounts in this dose adjustment chart to determine
how much insulin your child needs when blood sugar levels are above 14 millimole per liter.
This is given as extra doses of fast-acting insulin every three to four hours.
It is added to your usual fast-acting insulin dose.
Adjusting for highs. Sick day example. Here's an example of dose adjustments over the course of a
day while your child has a fever, headache and sore throat. Their blood sugar level
before lunch is 12.1 millimole per liter and their urine ketone levels are negative.
Based on this chart, what would you do with the insulin dose at this meal?
The answer: You would give them their usual lunchtime insulin dose because
their blood sugar level is between 4 and 14 millimole per liter. No extra insulin is needed.
Recheck their blood sugar and ketone levels in four hours.
It is now four hours later and time for dinner. You check your child's levels again.
Their blood sugar level before dinner is 17.6 millimole per liter and their urine ketone
levels are moderate. Based on this chart, what would you do with the insulin dose at this meal?
Answer: They need extra fast-acting insulin because their blood sugar level before dinner
is 17.6 millimole per liter and their urine ketone levels are moderate. Based on this dose adjustment
chart how many extra units of insulin would you administer? Their total daily dose is 20 units.
Answer: They need an extra three units of fast-acting insulin because their blood
sugar is above 14 millimole per liter and they have moderate urine ketones.
Add the extra three units of fast-acting insulin to their dinner dose. It replaces their usual
correction dose if they have one. Recheck blood sugar and ketone levels in four hours. [Music]
It is now four hours later and time to recheck your child's blood sugar and ketone levels.
Blood sugar level is now 19.4 millimole per liter and it is not a time when your child usually
receives insulin. Their urine ketone levels are small. Their total daily dose is 20 units per day.
Based on this dose adjustment chart what would you do with the insulin dose?
When would you check the blood sugar and ketone levels next?
Answer: As the blood sugar is above 14 millimole per liter and their
urine ketones are small, your child needs an extra two units of fast-acting insulin now.
While your child is sick, continue to check their blood sugar and ketone levels every four hours.
Lastly, we will look at adjustments for blood sugar levels below 4 millimole per liter.
Adjusting for low blood sugar levels. If you are concerned your child will not eat well or
tolerate food, and blood sugars are persistently below four to six millimole per liter, consider
reducing your child's mealtime fast-acting insulin dose. If their blood sugar levels have
been trending low during the day, consider reducing their long-acting insulin dose. If you need advice
on how to reduce your child's insulin doses during an illness, contact your diabetes team. Using mini
dose glucagon. If your child's blood sugar level is below 4 millimole per liter and they are unable or
unwilling to take food or fluids, use mini-dose glucagon to treat their low blood sugar level.
If your child is experiencing severe low blood sugar symptoms, give them the full dose of glucagon.
Use the following four steps to give a mini-dose of glucagon.
Step 1: Mix the glucagon. In this video I'm going to show you how to mix and prepare glucagon.
When you receive your glucagon from the pharmacy, it will either be in a white and red box or in an
orange or red hard case. Regardless of what your package looks like, you will find the same items inside.
Inside the package, you will find instructions on how to use and give this medication,
a vial with a small white glucagon tablet inside, as well as a syringe filled with sterile water.
In order to give the glucagon, we must first mix the syringe of sterile water with the
glucagon tablet to dissolve it. Step one is to remove the gray cap from the vial.
Step two is to remove the protective cap off of the syringe. It pulls straight off.
On the top of the vial, there is a soft gray center. This is where we will insert the needle.
Once the needle is inside the vial, you will push down on the plunger to move all of the water
inside the vial. Once the water is inside, remove the needle and we will gently swirl the vial.
You want to swirl the vial until you see that the liquid inside looks clear.
Step 2: Use an insulin syringe. After mixing the glucagon, use an insulin syringe to draw up the
mini-dose glucagon. The mini-dose glucagon will be injected into the arm, abdomen, thigh or buttocks.
You may store unused glucagon in the fridge up to 24 hours.
Step 3: Determine the dose. If your child is less than two years of age, give two units.
For example, if your child is 18 months of age, give two units. If they are between 2 and 14 years of
age, give one unit per year of age. For example, if your child is 10 years of age, give 10 units.
If they are 15 years or older, give 15 units. For example, if your child is 17 years of age give
15 units. In step 4: Check blood sugar levels. Check your child's blood sugar level 30 minutes
after giving mini-dose glucagon. If the level is still less than five millimole per liter, prepare
and give double the dose of mini-dose glucagon. Do not give more than 30 units in a single dose.
For example, if your child is three years old, the first dose of mini dose glucagon would
be three units and any additional doses would be six units. Or, if your child is 16 years old,
the first dose of mini-dose glucagon would be 15 units and any additional doses would be 30 units.
After giving mini-dose glucagon. Continue to monitor blood sugar levels every 30 to 60
minutes, and give additional doses if needed, up to five doses in 24 hours. Encourage your child to eat.
If your child requires more than five doses of mini-dose glucagon
in a 24-hour period, bring them to the closest emergency room for assessment and treatment.
Remember to get a replacement glucagon kit from your pharmacy.
Quick tips for managing illness. Take vomiting seriously. Vomiting with a high blood sugar level
may be a sign of diabetic ketoacidosis or DKA. Vomiting with a normal or low blood sugar can
cause severe hypoglycemia. If your child vomits twice or more within four hours, contact your
diabetes team for advice. [Music] Give your child lots of fluids. This helps to prevent dehydration.
It is better to offer small amounts of fluid more often than to give a large amount at one time.
Ask your dietitian for guidelines around the amounts to give.
If the blood sugar level is above 10 millimole per liter give sugar-free fluids. If the blood
sugar level is below 10 millimole per liter and your child isn't eating well, give sweetened fluids.
Blood sugar levels can often be managed at home with the support of your diabetes team.
Remember: Take illness seriously. It requires more vigilant monitoring and management.
Check blood sugar and ketone levels as soon as an illness is noticed and
continue to check the blood sugar and ketone levels every four hours around the clock.
Be prepared to temporarily adjust the regular insulin doses and if there is
frequent vomiting or if you need help adjusting insulin doses, call your diabetes team right away.
We are here to help. If you have questions or need further tips, please contact your diabetes team.