Diabetes and illness

Infections associated with hyperglycemia with or without ketosis

• Recommend additional doses of short or rapid-acting insulins with careful monitoring to reduce BG, prevent ketoacidosis and avoid hospital admission
• The dose and frequency of injection will depend on the age of the child, the level and duration of hyperglycemia, the severity of ketosis and previous experience with alterations of insulin
  Example Sick child, BG 15–20 mmol/l (± ketosis): advise 10–20% of total daily insulin dose (or 0.1 U/kg) as short or rapid-acting insulin every 2–4 h until BG falls to <15 mmol/l. Thereafter any additional doses might be 5–10% of the total daily dose

Infections associated with hypoglycemia

• These infections are often associated with nausea, vomiting ± diarrhea. Advise replacing meals with frequent small volumes of sugary drinks and careful BG monitoring
• Reduction of insulin dose by 20–50% may be required
• If hypoglycemia (and nausea or food refusal) persists, an injection of glucagon may reverse the hypoglycemia and enable oral fluids to be re-established

In a child with intercurrent illness urgent specialist medical or nursing advice must be obtained when The diagnosis is unclear Vomiting is persistent (particularly in young children) BG continues to rise despite increased insulin Hypoglycemia is severe Ketonuria is heavy and persistent The child is becoming exhausted, confused, is hyperventilating, dehydrated or has severe abdominal pain

• When metabolic control is persistently unsatisfactory or if BG monitoring is inadequate or unavailable, intercurrent infections may be more frequent and more severe, it would then seem mandatory to
  • advise more frequent urinary glucose and ketone testing
  • give clear guidance on alterations of insulin dosage to prevent ketoacidosis
• If sudden repeated episodes of hyperglycemia with vomiting occur, it should be recognized that this may be due to omission or inadequate administration of insulin (see recurrent DKA)