INTRODUCTION — Type 1 diabetes mellitus, one of the most common chronic diseases in childhood, is caused by insulin deficiency resulting from the destruction of insulin-producing pancreatic beta cells. (See "Pathogenesis of type 1 diabetes mellitus".)
In children and adolescents with type 1 diabetes, there are circumstances, such as acute illnesses, when glucose metabolism is significantly altered, requiring additional monitoring of blood glucose and ketones and/or adjustment of the child's daily insulin dose. The school or daycare setting also presents challenges in the management of the insulin-dependent child.
Managing the child or adolescent with type 1 diabetes in settings with altered insulin requirements and at school or daycare is reviewed here. Other aspects of type 1 diabetes mellitus in children and adolescents are discussed in separate topic reviews:
●(See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents".)
●(See "Overview of the management of type 1 diabetes mellitus in children and adolescents".)
●(See "Complications and screening in children and adolescents with type 1 diabetes mellitus".)
●(See "Management of exercise for children and adolescents with type 1 diabetes mellitus".)
●(See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus".)
SICK-DAY MANAGEMENT
Indications for seeking urgent medical advice — The family should seek urgent advice from a specialist for children if any of the following are present before or during home management. Children with these characteristics are at increased risk for complications [1]:
●Age <5 years
●Vomiting >2 hours
●Child appears exhausted or confused
●Child is hyperventilating or has abdominal pain
●Blood glucose persistently low (<70 mg/dL) or continues to rise despite supplemental insulin doses
●Blood ketones remain elevated (>1.5 mmol/L) or urine ketones remain "large" despite extra insulin and hydration
●Child has a comorbid condition that complicates home care
Effects of illness on insulin requirements — In children and adolescents with type 1 diabetes, acute illness complicates diabetes management because of its varying effects upon insulin requirements.
●Increased insulin requirements may be caused by an increase in counterregulatory hormones released in response to stress. These hormones, which include epinephrine and cortisol, raise peripheral insulin resistance, thereby increasing insulin requirements. Increased insulin resistance may persist for a few days after recovery from the acute illness.
●Decreased insulin requirements may be caused by reduced oral intake of carbohydrates because of decreased appetite, nausea, or vomiting.
Thus, a child with type 1 diabetes during an acute illness can develop:
●Hypoglycemia
●Significant hyperglycemia
●Diabetic ketoacidosis due to inadequate insulin supplementation
●Ketosis/ketoacidosis independent of hyperglycemia
Sick-day management is directed towards prevention of the above complications and should not be left solely in the hands of the child or adolescent. Parental involvement is imperative to avoid these diabetic complications. Telephone management with the diabetes care team is helpful in the care of these patients.
Management includes the following, as outlined in guidelines from the International Society for Pediatric and Adolescent Diabetes (ISPAD) on sick-day management [1]:
Monitor blood glucose more frequently — During an illness, blood glucose monitoring should be performed more frequently, eg, every two to three hours including during the night; this may be increased to every one to two hours if necessary. A continuous glucose monitor, if available, can be particularly useful for sick day monitoring and management. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Continuous glucose monitoring'.)
Monitor ketones frequently
●For monitoring ketones, the preferred method is home testing of blood for beta-hydroxybutyrate (BOHB). This method permits earlier detection of ketosis compared with tests for urinary ketones, which measure acetone and acetoacetate. Most families find the BOHB blood testing strips easy to use. Blood testing for BOHB is particularly useful for early detection of ketoacidosis in children managed with a continuous subcutaneous rapid-acting insulin infusion. If blood BOHB testing is available, we suggest performing this test each time blood glucose is tested during sick-day management. Ketone formation and ketoacidosis can occur without hyperglycemia if oral intake is poor.
●If home testing for BOHB is not available, the patient should monitor for urinary ketones with each void, regardless of blood glucose concentration. During recovery, improvement in urine ketones may lag behind improvement in blood ketones. Urine ketone test strips may deteriorate within a few weeks of opening the bottle. For this reason, foil-wrapped ketone strips are preferred.
Adjust the insulin dose — Adjust the insulin dose as needed, based on frequent measurements of blood glucose and blood or urinary ketones. Insulin requirements may be either increased or decreased during an illness. Recommendations for insulin dosing are outlined below and detailed in the ISPAD guideline [1].
Patients with hyperglycemia and/or ketones — If the child has elevated blood glucose (>250 mg/dL [13.9 mmol/L]) or ketones in blood or urine (provided that blood glucose is not low), give supplemental doses of rapid-acting insulin (lispro, aspart, or glulisine) insulin (table 1), in addition to the usual insulin regimen. The use of regular insulin is not preferred in this situation but may be used if rapid-acting insulin is not available.
For children on insulin pump therapy, the initial bolus of additional insulin should be given using an insulin pen or syringe because malfunction of the pump or infusion set is a very common cause of hyperglycemia and ketosis/ketoacidosis in pump users. Then, carefully assess functionality of the pump and infusion set before using it for insulin delivery. It is usually wise to change the infusion set.
●Hyperglycemia with no (or small) ketones – For patients with hyperglycemia and absent or a small amount of urinary ketones (or blood ketones 0.6 to 1 mmol/L), administer rapid-acting insulin subcutaneously at a dose of 0.05 to 0.10 units/kg (5 to 10 percent of the total daily dose) every two to three hours as needed. Alternatively, give 110 percent of the calculated correction dose, repeated every two to three hours based on blood glucose response.
For insulin pump users, the initial dose should always be given by insulin pen or syringe, as noted above. After it is clear that the pump and infusion set are functioning properly, further doses of supplemental insulin can be given as boluses via the pump or by increasing the basal rate by 10 to 30 percent for two to four hours, or longer as needed.
●Hyperglycemia with moderate to large ketones – For patients with hyperglycemia and moderate to large urinary ketones (or blood ketones >1 mmol/L), administer rapid-acting insulin at a dose of 0.1 to 0.2 units/kg (or 10 to 20 percent of total daily dose) subcutaneously every two to three hours as needed. Alternatively, give 120 percent of the calculated correction dose, repeated every two to three hours based on blood glucose response.
For insulin pump users, give the initial dose by insulin pen or syringe, as noted above. After it is clear that the pump and infusion set are functioning properly, the supplemental insulin can be given as boluses via the pump or by increasing the basal rate by 20 to 50 percent for two to four hours, or longer as needed.
●Monitoring – When using a rapid-acting insulin analog, it is prudent to check blood glucose and ketones after three to four hours and administer supplemental insulin again if necessary, rather than waiting longer. These insulins have a duration of peak action of approximately two hours and effective total duration of action of three to five hours.
Patients with insufficient oral intake
●Reducing the insulin dose – For children unable to ingest the required amount of carbohydrates and if blood glucose concentration is not high, it may be necessary to reduce the insulin dose to avoid hypoglycemia. To maintain glucose metabolism, insulin should generally be reduced rather than stopped even if the child is not eating (except perhaps briefly, as noted in the bullets below).
The protocol for reducing the insulin dose depends upon the insulin regimen used by the patient (see "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Insulin preparations'):
•Children using an insulin pump – For children on intensive therapy using an insulin pump, the basal infusion can be continued at the usual rate or decreased by 10 to 20 percent. Further reductions in the basal insulin infusion rate may be necessary if blood glucose levels are persistently low [<80 mg/dL (4.4 mmol/L)] despite the initial dose reduction. There are uncommon circumstances when briefly suspending the insulin infusion may be necessary. For example, if blood glucose is <60 mg/dL (<3.3 mmol/L) and the child is on an insulin pump, basal insulin delivery may be suspended until blood glucose increases to >80 mg/dL (4.4 mmol/L), with the help of oral carbohydrates and/or mini-doses of glucagon.
•Children using long-acting basal insulin – For children receiving a long-acting basal insulin via subcutaneous injection, short-term reduction in the dose of basal insulin is not possible. If they are unable to take sufficient carbohydrate by mouth to maintain blood glucose concentrations in the normal range, low-dose glucagon may be tried, as described under "additional measures" below. However, these children may require supplemental glucose by intravenous infusion if oral supplementation and low-dose glucagon treatment are not successful. If it is anticipated that there will be a 24-hour or longer period of decreased insulin need, the basal insulin dose of glargine or other basal insulins can be reduced in the same amount as described for children on insulin pump therapy.
•Children using intermediate-acting insulin – In instances of children treated with a fixed schedule that includes intermediate-acting insulin (NPH [neutral protamine hagedorn]), the daily dose(s) of the intermediate-acting insulin can be reduced by 30 to 50 percent. This type of insulin is often used for diabetes management in resource-limited settings.
If the child's blood glucose rises above 250 mg/dL (13.9 mmol/L) after the dose reductions described above, short-acting insulin can be used to treat the elevations at appropriate intervals.
●Additional measures – Management of patients with insufficient oral intake also includes:
•For patients with hyperketonemia or ketonuria, treat with an increased intake of carbohydrate-containing fluids and insulin as necessary. If oral intake has been deficient, ketonuria with hypoglycemia is not uncommon, especially in young children.
•Maintain oral hydration, if possible, with fluids that contain both carbohydrates and electrolytes. If adequate oral hydration cannot be maintained, especially if ketosis is present, the patient should be evaluated and treated at an appropriate medical facility. These patients may require intravenous fluids and additional insulin. (See "Diabetic ketoacidosis in children: Treatment and complications".)
•For patients who have hypoglycemia and are unable to eat, give ice-cold, sugar-containing liquids if tolerated and/or glucagon in very low doses (known as "minidose" glucagon). Dosing is as follows, using a standard U100 insulin syringe:
-Children ≤2 years of age – 2 "units" (20 micrograms) of glucagon given subcutaneously
-Children 2 years and older – 1 "unit" of glucagon (10 micrograms)/year of age up to 15 "units" (150 micrograms)
A second dose (at double the initial dose) is given if blood glucose does not increase in 30 minutes [2,3].
If the patient has persistent vomiting or if home therapy cannot correct the hypoglycemia, the child should be evaluated and treated at an appropriate medical facility. (See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus".)
MEDICAL PROCEDURES — In patients with diabetes who require medical, dental, and surgical procedures, glycemic management can be complicated by factors that affect insulin requirements, such as a period of medically mandated fasting (nothing by mouth [NPO]), anesthesia, and stress. Withholding oral intake will decrease insulin requirements, while stress may increase insulin needs because of increased peripheral insulin resistance. (See 'Sick-day management' above.)
If the procedure requires a period of fasting, it is preferable to have the patient scheduled as the first case of the day to minimize the duration of fasting [4].
Blood glucose monitoring should be performed every one to two hours while the patient is fasting. The goals should be to maintain blood glucose levels in the 90 to 180 mg/dL (5 to 10 mmol/L) range and avoid development of both hypoglycemia and ketoacidosis.
For most procedures, an intravenous catheter should be placed in case intravenous dextrose administration becomes necessary to maintain blood glucose levels in the recommended range. The patient will require insulin before, during, and after the procedure to avoid ketoacidosis, even if the child is fasting.
Insulin management — Insulin management depends upon the length of the procedure and the insulin regimen used by the patient (see "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Insulin preparations'):
●Short procedures (<2 hours):
•Children using an insulin pump or basal insulin – In children using an intensive insulin regimen with a basal insulin (eg, insulin pump, or insulin glargine or detemir by injection), the usual basal rate should be maintained. If the child is on a pump with multiple basal rates over a 24-hour period, the lowest basal rate should typically be maintained. This approach is quite effective for minor elective procedures.
During and after the procedure, rapid- or short-acting insulin can be used to cover additional insulin needs as determined by blood glucose concentrations, which should be measured hourly during the procedure (table 1). Intravenous dextrose should be administered if blood glucose decreases.
•Children using intermediate-acting insulin – In children using a conventional insulin regimen with a fixed schedule of an intermediate-acting insulin (eg, NPH [neutral protamine hagedorn]), patients should receive two-thirds of their usual intermediate-acting insulin dose and no rapid- or short-acting insulin before the procedure.
During and after the procedure, rapid- or short-acting insulin can be used to cover additional insulin needs as determined by blood glucose concentrations, which should be measured hourly during the procedure (table 1).
●Long procedures (≥2 hours) – During long procedures, glycemic control can be maintained by switching from the usual conventional regimen to an infusion of intravenous insulin administrated at a rate of 0.02 to 0.03 units/kg per hour and 5% dextrose with electrolytes [5]. Details on insulin dosing and fluid infusions during surgical procedures are included in the International Society for Pediatric and Adolescent Diabetes (ISPAD) guideline on management of children with diabetes requiring surgery [4]. Ongoing blood glucose monitoring every one to two hours permits adjustment of the insulin infusion rate to avoid hypo- or hyperglycemia. Adjustment of insulin dosing for medical procedures is similar to that for sick-day management, as outlined in the section above. (See 'Sick-day management' above.)
Fluid management — Fluid management during procedures depends on the expected duration and intensity of the procedure and the kind of insulin that is being administered:
●Short procedures – For elective procedures lasting <2 hours in children treated with a basal-bolus regimen or continuous subcutaneous insulin infusion, one option is to administer intravenous fluids without dextrose, provided blood glucose levels are in the target range.
●Long procedures – For prolonged procedures, major surgery, or if the child is being treated with NPH and a short-acting insulin, the intravenous fluids should include 5% dextrose in normal saline. The dextrose infusion (and insulin dosing) need to be adjusted to maintain blood glucose in the target range (90 to 180 mg/dL [5 to 10 mmol/L]). In the case of intraoperative hypotension, normal saline may be administered in large volumes. It is important to avoid bolus dosing with fluids that contain potassium.
Postoperative management — Postoperatively, the management is similar to intraoperative management until the child can start oral feeds, following which, the home insulin regimen can be resumed. More frequent blood glucose testing than usual is typically advised for 24 to 48 hours after the procedure, given the risk of hyperglycemia due to pain, stress, and reduced physical activity. (See "Perioperative management of blood glucose in adults with diabetes mellitus".)
AIR TRAVEL — In children who travel large distances and cross multiple time zones, the timing of insulin doses should be adjusted to adapt to the new time zone. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus".)
●Insulin pump – Following arrival at the new location, time settings on the pump should be adjusted to local time such that the patient has the same basal rates for different time points in the new time zone as for the previous time zone. The sensitivity and carbohydrate ratio do not need to be adjusted. Similarly, this needs to be adjusted back to local time after the patient returns.
●Multiple dose injections – The long-acting insulin (eg, insulin glargine) that provides the basal insulin dose should continue to be administered at the time that the child would have received this injection in his/her home time zone. If the child is advancing time zones by more than two hours for an extended time period, the family can adjust the time of insulin glargine injections by two hours each day to a time that is more appropriate for the new time zone. Doses of rapid- and short-acting insulin should be given before meals and snacks, as usual.
Management is more complicated in children on fixed-dose regimens with NPH (neutral protamine hagedorn) insulin, which are more commonly used in resource-limited settings. The child can receive additional doses of rapid- and short-acting insulin if the last dose of NPH insulin does not cover the child's insulin requirements before the next-scheduled administered NPH dose. The next dose of NPH should be given as scheduled before the appropriate meal in the new time zone (usually at the child's next breakfast or dinner), when it should be administered with rapid- and short-acting insulin at the dose the child would have received before the meal in question while at home.
●Storage of insulin and equipment in flight – During air travel, insulin (and other diabetes care) supplies should be transported as carry-on luggage. Insulin should be protected (but not frozen) in a cooler during long trips where heat exposure is likely. After initial use, insulin should be stored at ambient temperature: 59 to 86°F or 15 to 30°C. The newer semisynthetic insulins are particularly heat-sensitive. All medications and syringes should have original pharmacy labels; a letter from the health care facility stating that such equipment is necessary will speed the child through airport screening and customs. Food and carbohydrate-containing preparations like glucose tablets should be carried on the plane to protect against hypoglycemia in case of long delays with unavailability of food or carbohydrate.
SCHOOL AND DAYCARE — Some children spend up to 8 to 10 hours a day at school or extended daycare. The overall goals for children in these settings are to maintain excellent glycemic control, minimize interruptions of daily learning, prevent complications, and prevent or eliminate any stigmatization related to their disease. Daycare facilities should have designated individuals who are educated in diabetes management who can help with such management in younger children. School-aged children must be allowed to check blood glucose levels, give insulin injections under the supervision of a knowledgeable adult, and be treated for hypoglycemia in close proximity to the school classroom [6-8]. In one study of 58 children and their parents, better glycemic control was demonstrated in children who had greater flexibility in performing diabetes care at school and who attended schools where school personnel received diabetes training [9].
A school staff member, preferably a school nurse if available, should be identified and appropriately trained to support and apply the prescribed treatment regimen for the student [7,8]. The adult supervisor is responsible for successful implementation of daily care, based on school orders provided by the child's diabetes clinician, including insulin administration, timing and content of meals, physical education classes, and any additional sport activities. This individualized diabetes management plan should be developed collaboratively and agreed upon by the child's diabetes clinician, family, and school personnel. (See "Overview of the management of type 1 diabetes mellitus in children and adolescents" and "Management of exercise for children and adolescents with type 1 diabetes mellitus".)
Teachers must be able to identify and treat hypoglycemia [7,8]. Oral, rapidly absorbed simple carbohydrates should be available in the classroom setting. A glucagon emergency kit should be kept at the school. Intranasal glucagon is the optimal formulation for this purpose because it can be administered more readily by untrained personnel and is more likely to be administered when needed [10]. Guidance for setting up diabetes care at school is available from the American Diabetes Association (ADA) diabetes care tasks at school campaign. (See "Complications and screening in children and adolescents with type 1 diabetes mellitus", section on 'Hypoglycemia'.)
INFORMATION RESOURCES — Useful resources for patients, families, and school personnel include the following:
●International Society for Pediatric and Adolescent Diabetes (ISPAD) recommendations for sick-day management [1]
●Children with Diabetes – Online community and resource, including guidance for completing 504 plans for school
●Juvenile Diabetes Research Foundation (JDRF) – Online resource for management of many special situations, including school and travel
●American Diabetes Association (ADA) – Online resource for patients, families, and providers, including guidance for diabetes care tasks at school
ADA resources for school personnel include the ADA position statement Diabetes Care in the School and Day Care Setting [11] and Helping the Student with Diabetes Succeed: A Guide for School Personnel [12], as well as sample individualized health care plans (504 plans).
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diabetes mellitus in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: My child has diabetes: How will we manage? (The Basics)" and "Patient education: Controlling blood sugar in children with diabetes (The Basics)" and "Patient education: Carb counting for children with diabetes (The Basics)" and "Patient education: Managing diabetes in school (The Basics)" and "Patient education: Giving your child insulin (The Basics)" and "Patient education: Checking your child's blood sugar level (The Basics)")
SUMMARY — In children and adolescents with type 1 diabetes, there are circumstances when insulin requirements are significantly altered, resulting in a need for additional monitoring of blood glucose and/or adjustment of the child's daily insulin dose. These include:
●Acute illness – Children with diabetes who are acutely ill can develop either hypoglycemia or hyperglycemia and ketosis because of changing insulin requirements. Principles of management are (see 'Sick-day management' above):
•Because of the inability to predict the ill child's insulin requirement, the frequency of blood glucose monitoring should be increased and ketones should be measured frequently in blood (as beta-hydroxybutyrate [BOHB]) or urine.
•Even if the child is not eating, insulin generally should not be stopped, to maintain glucose metabolism.
•Adjustments of insulin therapy and dietary manipulations depend on blood glucose concentrations, presence of ketones, and ability of the child to consume adequate carbohydrates and fluids. Additional doses of rapid- or short-acting insulin should be given for elevated blood glucose and urine or blood ketones.
●Medical procedures – In patients with diabetes requiring medical, dental, and surgical procedures, glycemic management can be complicated by factors that affect insulin requirements, such as the duration for which oral intake is curtailed, use of anesthesia, and presence of stress. Adjustments of insulin therapy depend on the insulin regimen used by the patient (intensive regimen with basal-bolus dosing or insulin pump, versus a fixed insulin schedule) and the duration of the procedure. (See 'Medical procedures' above.)
●Air travel – Travel across multiple time zones can require adjustment of insulin therapy, and the strategy depends on the child's insulin regimen. During air travel, insulin and other diabetes care supplies should be transported as carry-on luggage. After initial use, insulin should be stored at ambient temperature: 59 to 86°F or 15 to 30°C. Insulin should be protected (but not frozen) in a cooler during long trips where heat exposure is likely because insulin preparations are heat-sensitive. (See 'Air travel' above.)
●School and daycare – The care of diabetic children in school or daycare requires the following (see 'School and daycare' above and 'Information resources' above):
•An adult staff person, preferably a nurse, should be identified and trained to provide care and supervision to the diabetic child
•A daily schedule should be established that includes insulin administration, meals, physical education class, and other physical activities
•Teachers and school nurses should be trained to identify and treat hypoglycemia
•Oral, rapidly absorbed simple carbohydrates and glucagon should be readily available to treat a hypoglycemic episode
