Managing illness
Managing illness (multiple daily injections)
Children whose diabetes is well controlled should not experience more illness or infections than their siblings or peers without diabetes.
However, it is likely that any illness will have an impact on the diabetes control. In general, illnesses associated with a temperature will cause the blood glucose levels to rise. Many families notice that insulin requirements increase a few days before their child has symptoms of an illness, and that this increased requirement persists several days after the illness has stopped. Alternatively, illnesses where there is diarrhoea or vomiting are likely to cause the blood glucose level to drop and there is often difficulty in maintaining adequate carbohydrate intake. These problems may lead to a need for a reduction in the insulin dosage.
General principles:
- Never stop the insulin
- The insulin dose may need to be increased or decreased depending on the glucose and ketone level.
- Encourage fluids to prevent dehydration
- Increase the frequency of monitoring of both the glucose and ketone levels.
- The preference is to test blood ketone levels. Any rise in the ketone levels will be detected in your blood before it is possible to detect in your urine and normalise faster.
Insulin requirements for ketosis
A high blood glucose level and ketones are an indication that more insulin is needed. We would normally recommend using your Insulin Sensitivity Factor (or correction ratio) to calculate correction dosages of insulin. However, if you have ketones you might need to be more aggressive with your insulin dosages.
We recommend you give a percentage of your Total Daily Dose (TDD). To calculate your TDD, add up all the insulin given on a usual day (i.e. rapid acting injections for meals and long acting insulin injections). Depending on both the blood glucose level and the ketone level, we advise you give an injection of quick acting insulin (either NovoRapid or Humalog Lispro) equivalent to between 5 and 20% of this TDD. See the tables below to calculate how much insulin to give.
Dietary management
Children and young people may not feel like eating when they are unwell. This does not matter – continue to give quick acting boluses of insulin for any carbohydrate eaten/drunk if their blood glucose level are within or above their target range and/or to correct high blood glucose levels.
It is important however, to encourage your child to drink more. A combination of having high blood glucose levels, a high temperature and possibly both glucose and ketones in the urine will increase the risk of your child becoming dehydrated. Drink glucose (sugar) free fluids when the blood glucose is within or above the target range.
If the blood glucose levels are dropping or are low, encourage your child to have drinks containing glucose (approximately 20 grams CHO). This will help prevent starvation ketones.
Blood glucose < 5.5 mmol/l AND:
< = less than; > = greater than
|
Ketone level |
Blood ketones <0.6 mmol/l or urine ketones negative /trace |
Blood ketones 0.6-0.9 mmol/l or urine ketones trace/small |
Blood ketones 1.0-1.4 mmol/l or urine ketones small/moderate |
Blood ketones 1.5-2.9 mmol/l or urine ketones moderate/large |
Blood ketones >3.0 mmol/l or urine ketones large |
|---|---|---|---|---|---|
|
Action |
Treat low blood glucose if hypoglycaemic |
Recheck blood glucose and ketones in 2 hours. Take 20g carbohydrate and clear fluids containing sugar |
Take 20g carbohydrate and clear fluids containing sugar |
Take 20g carbohydrate and clear fluids containing sugar. Check blood glucose and ketones after 2 hours. Repeat above steps again. If remains unchanged after 4 hours, then seek urgent advice/ go to A&E |
Take 20g carbohydrate and clear fluids containing sugar. Check blood glucose and ketones after 2 hours. If remains unchanged after 2 hours, then go to A&E |
Blood glucose 5.5 – 9.9 mmol/l AND
< = less than; > = greater than
|
Ketone level |
Blood ketones <0.6 mmol/l or urine ketones negative /trace |
Blood ketones 0.6-0.9 mmol/l or urine ketones trace/small |
Blood ketones 1.0-1.4 mmol/l or urine ketones small/moderate |
Blood ketones 1.5-2.9 mmol/l or urine ketones moderate/large |
Blood ketones >3.0 mmol/l or urine ketones large |
|---|---|---|---|---|---|
|
Action |
None |
Recheck blood glucose and ketones in 2 hours. Take 20g carbohydrate and clear sugar free fluids Give insulin bolus for half this carbohydrate (i.e. insulin for 10g) |
Take 20g carbohydrate and clear sugar free fluids. Give insulin bolus to match 20g carbohydrate |
Take 20g carbohydrate and clear sugar free fluids. Give insulin bolus – calculated by 5% of TDD Check blood glucose and ketones after 2 hours. Repeat above steps again. If remains unchanged after 4 hours seek urgent medical advice/ go to A&E |
Take 20g carbohydrate and clear sugar free fluids. Give insulin bolus – calculated by 5% of TDD Check blood glucose and ketones after 2 hours. If remains unchanged go A&E as high risk of ketoacidosis If ketones are less than 3 mmol/l then repeat steps above |
Blood glucose 10.0 – 13.9 mmol/l AND
< = less than; > = greater than
|
Ketone level |
Blood ketones <0.6 mmol/l or urine ketones negative /trace |
Blood ketones 0.6-0.9 mmol/l or urine ketones trace/small |
Blood ketones 1.0-1.4 mmol/l or urine ketones small/moderate |
Blood ketones 1.5-2.9 mmol/l or urine ketones moderate/large |
Blood ketones >3.0 mmol/l or urine ketones large |
|---|---|---|---|---|---|
|
Action |
Increase dose of insulin for next meal if blood glucose is still elevated pre meal No further action required |
Give clear sugar free fluids. Give 5% of TDD as correction dose. No further action required |
Give clear sugar free fluids. Give 5-10% of TDD as correction dose. Recheck Blood glucose and ketones in 2 hours. Repeat above steps again. If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give clear sugar free fluids. Give 10% of TDD as correction dose Check blood glucose and ketones after 2 hours. Repeat above steps again If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give clear sugar free fluids. Give 10% of TDD as correction dose Check blood glucose and ketones after 2 hours. If remains unchanged then go to A&E as high risk of ketoacidosis If ketones are less than 3 mmol/l then repeat steps again. |
Blood glucose 14.0 – 22.0 mmol/l AND
< = less than; > = greater than
|
Ketone level |
Blood ketones <0.6 mmol/l or urine ketones negative /trace |
Blood ketones 0.6-0.9 mmol/l or urine ketones trace/small |
Blood ketones 1.0-1.4 mmol/l or urine ketones small/moderate |
Blood ketones 1.5-2.9 mmol/l or urine ketones moderate/large |
Blood ketones >3.0 mmol/l or urine ketones large |
|---|---|---|---|---|---|
|
Action |
Use your ISF to calculate a correction ratio Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. Recheck in 2 hours. |
Give 5-10% of TDD as correction dose. Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give 10% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give 10-20% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give 10-20% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. If remains unchanged go to A&E as high risk of ketoacidosis If ketones are less than 3 mmol/l then repeats steps and recheck in 2 hours |
Blood glucose > 22.0 mmol/l AND
< = less than; > = greater than
|
Ketone level |
Blood Ketones <0.6 mmol/l or urine ketones negative /trace |
Blood Ketones 0.6-0.9 mmol/l or urine ketones trace/small |
Blood Ketones 1.0-1.4 mmol/l or urine ketones small/moderate |
Blood Ketones 1.5-2.9 mmol/l or urine ketones moderate/large |
Blood Ketones > 3.0 mmol/l or urine ketones large |
|---|---|---|---|---|---|
|
Action |
Give 10% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. Recheck in 2 hours. |
Give 10% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. Recheck in 2 hours. |
Give 10% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again. If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give 10-20% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. Repeat above steps again if ketones do not decrease. If remains unchanged after 4 hours, seek urgent medical advice/ go to A&E |
Give 10-20% of TDD as correction dose Give clear sugar free fluids. Recheck blood glucose and ketones after 2 hours. If remains unchanged then review in A&E as high risk of ketoacidosis If ketones are less than 3 mmol/l then repeats steps and recheck in 2 hours |
This guide is also available to download (see related files).