The following advice relates to days when you are unwell

• Insulin is essential in the body all the time. You can never stop insulin. 
• Insulin doses may need to be changed when you are unwell 
• Monitoring of glucose and ketones will increase
  
• Always check ketone levels when your child is unwell, regardless of what their glucose level is 
• If vomiting and ketones are present and you are unsure of appropriate treatment, call your diabetes treating team early for support with insulin dose adjustments
• You need to bring your child into your closest emergency department for urgent assessment if they have signs of diabetic ketoacidosis (DKA). DKA is a medical emergency and the signs include vomiting, abdominal pain, rapid breathing, drowsiness and ketones 3.0 mmol/L or higher  
  

Sick day management falls broadly into two different categories:

1) Illnesses that cause Hyperglycaemia (High BGL’s)

Illness can trigger stress hormones that cause insulin resistance. This can lead to high BGLs  

• Insulin doses may need to be increased
• Check BGL’s every 2 hours
• Check blood ketones every 4 hours
• See your GP to treat underlying the illness / infection
• Give analgesics to relieve headaches or sore throat
• Encourage sugar free fluids to maintain hydration

2) Illnesses that cause Hypoglycaemia (Low BGL’s)

• Vomiting, diarrhoea, nausea and reduced appetite can all lead to Hypoglycaemia.
  
• Insulin doses may need to be decreased. Insulin can never be stopped but doses can be reduced to minimise the frequency of hypo with decreased appetite.
• Check BGL’s every hour
• Check blood ketones every 4 hours 
  Ketones can be produced during illness even with normal or low BGL’s
• Sip on sugar containing fluids 

Mini doses of glucagon may be used to treat hypoglycaemia if unable to tolerate food or fluids.

What should I do if ketone levels are 1.0mmol/L or higher when using injected insulin?

1. If BGL 15mmol/L or higher 

• Give 10% of total daily insulin dose using rapid acting insulin (NovoRapid or Humalog) immediately
• Check ketones in 2 hours and seek medical advice if ketones remain > 1.0 mmol/L
• Extra insulin may be required if BGL remains >15mmol/L & ketones remain > 1.0 mmol/L after 2 hours
• Seek medical advice if ketones continue to rise, there is persistent vomiting or any change in conscious state

2. If BGL is between 8.0mmol/L - 15mmol/L

• Consider giving 5 -10% of total daily insulin dose using rapid acting insulin.
• Encourage extra carbohydrate to maintain BGL
• Check ketones in 2 hours and seek medical advice if ketones remain 1.0 mmol/L or higher 

3. If BGL is between 4.0mmol/L – 7.9mmol/L

• Encourage extra carbohydrate to maintain BGL
• Give normal insulin dose
• Check ketones in 2 hours and seek medical advice if ketones remain 1.0 mmol/L or higher 

4. If BGL is less than 4.0mmol/L

• Treat hypoglycaemia and encourage sweetened fluids e.g. lemonade icy poles or diluted juice 
• Seek medical advice if insulin is due – a reduction in the insulin doses may be needed 
• Check ketones in 2 hours and seek medical advice if ketones remain 1.0 mmol/L or higher 

If at any stage, ketones are 3.0 mmol/L or higher and your child is vomiting, you should give an 'urgent dose' of injected insulin and present to hospital for urgent medical assessment.

This situation has a high risk of diabetic ketoacidosis (DKA) which is a medical emergency.  

When to contact the hospital:

It is important to follow the above sick day management and then contact the hospital if you are needing more support 

• You are unsure about how to change the insulin doses for the sick day 
• Your child has had 3 vomits or diarrhoea or has unrelieved abdominal pain, particularly if associated with high BGLs
• Your child is drowsy or lethargic  
• After following the above advice, you are unsure how to manage blood ketones of 1.0 mmol/L or higher

RCH Sick day service phone number 9345 5522 ask for the “Diabetes sick day call” (for RCH patients) 

Last updated September 2024