Background
Acute illness in a child with type 1 diabetes can disrupt blood glucose control. Blood glucose levels may go up or down, depending upon the nature of the illness (
Brink et al., 2014
). Illnesses, such as gastroenteritis, with vomiting and diarrhea, may decrease blood glucose levels causing hypoglycemia, due to poor food intake and decreased gastrointestinal absorption (Brink et al., 2014
). Many other illnesses, especially those associated with fever, may cause blood glucose levels to rise. Stress hormones increase blood glucose and insulin resistance prior to, and for several days after the illness (Brink et al., 2014
, Rusnak, 2000
, ).Daily insulin requirements often increase during illness and are vital in the prevention of ketones. The most common mistake made by health care providers and caregivers, who are unfamiliar with diabetes, is to omit insulin because the child is ill and not eating. When the body lacks the needed amount of insulin, fat is metabolized as an energy source, instead of glucose, resulting in the production of ketones (
Brink et al., 2014
). Ketones accumulate due to increased lipolysis, increased ketogenesis and decreased ketone body utilization due to insufficient insulin levels (Brink et al., 2014
). Ketone body accumulation can lead to diabetes ketoacidosis (DKA), a life-threatening state in the child with type 1 diabetes (Rusnak, 2000
). Additionally, ketone accumulation without concurrent illness can cause vomiting, nausea, and fatigue. Ketosis due to lack of insulin can often be confused with infection. It is important to discern if the symptoms are caused by ketones due to inadequate insulin, or concurrent acute illness or infection, to determine the best intervention for the situation (). Individualized instructions are recommended for the child with diabetes and depend on the type of diabetes, the insulin regimen and whether infection or lack of insulin is causing the acute illness (Brink et al., 2014
, ).Nursing Implications
It is essential for nurses to deliver instructions to caregivers and primary care providers of children with type 1 diabetes to prevent a decline of the health status of the child. Education and guidance can reassure the caregiver and prevent panic. Consults to the pediatric primary care provider occur when a child with type 1 diabetes has an acute illness. Many caretakers of children with diabetes are unaware of recommended sick-day guidelines (
Lamb et al., 2011
). Many primary care nurses do not feel knowledgeable about sick-day management of type 1 diabetes (Vincent et al., 2016
). They feel more comfortable treating every-day management of type 1 diabetes as opposed to specialized sick-day management (Vincent et al., 2016
). Both healthcare professionals and caretakers of children with type 1 diabetes surveyed reported they lack the education needed to improve the quality of sick-day guidelines for children with type 1 diabetes (Soni et al., 2015
). Primary care nurses reported a preference for concrete educational tools regarding diabetes self-management and sick day guidelines (Jansink et al., 2010
). However, the lack of universally approved guidelines for sick-day management of the child with type 1 diabetes increase caretaker and primary care provider stress and confusion (Lamb et al., 2011
).Purpose
The purpose of this article is to describe common diabetes sick-day situations which may arise in the pediatric primary care setting and provide recommendations for proper and safe interventions.
- Case Study 1. A parent of a 10-year-old child, with type 1 diabetes, calls and says “Johnny has been vomiting since yesterday, his blood glucose is high, and he has high ketones. I have been giving insulin boluses every 3 hours with his insulin pump, and he is not getting better. I tried to call his endocrine provider but can't get through, and I do not know what to do”.
If the blood glucose does not come down after an insulin bolus via an insulin pump, then it is very likely that there is a problem with the infusion site or more rarely, an insulin pump malfunction. Johnny's parent should be instructed to increase his usual correction dose of rapid-acting insulin by 10 to 20% via a pen device or a syringe and change the infusion set immediately (
Ackerman et al., 2010
, Rusnak, 2000
).A correction dose should be given every two to four hours, either via the new infusion set or by injection, until the blood glucose is less than 200 mg/dl and ketones are small or less (
Fowler, 2011
, Morris and Campbell, 2008
, Rusnak, 2000
). Also, it is clinically recommended to monitor serum beta hydroxybutyrate ketones, as opposed to urine acetoacetate, when monitoring ketones and preventing DKA (Klocker et al., 2013
, Kuru et al., 2014
).Also, it is necessary to ascertain the child's hydration status and respiratory status. Ask the parent if Johnny is breathing heavy. The parents should be instructed to take him to the emergency department (ED) if either dehydration or Kussmaul respirations are present (
Brink et al., 2014
).Infusion set catheters can kink especially on insertion and become dislodged. For this reason, anytime the blood glucose does not respond to a correction bolus, the infusion set should be changed, even if it was just put in recently (
Rusnak, 2000
).- Case Study 2. A panicking parent calls the primary care office stating that their five year old boy with type 1 diabetes, on a basal bolus insulin regimen, has been vomiting and the blood glucose reading is 40 mg/dl. The child's usual dose of breakfast insulin had been given 2 h ago. They cannot raise the blood glucose because the child cannot keep anything down.
In this case, mini doses of glucagon can best assist to raise blood glucose. Glucagon is a hormone that is produced by the alpha cells in the pancreas. It promotes glycogenolysis and stimulates gluconeogenesis.
The parents should be instructed to reconstitute the glucagon with the entire vial of diluent. Administration depends on the child's age; withdraw the mixed glucagon up to the two unit marking for children age two or less, using an insulin syringe. Glucagon doses increase by one unit for every year of age to a maximum of 15 units (
Brink et al., 2014
, Haymond and Schreiner, 2001
, Rusnak, 2000
). The blood glucose should be rechecked in thirty minutes. If at this time the blood glucose is unchanged, the glucagon dose should be doubled (Haymond and Schreiner, 2001
). It can be repeated every sixty minutes PRN (Brink et al., 2014
, Haymond and Schreiner, 2001
). The reconstituted glucagon should be stored in the refrigerator and discarded after twenty-four hours.Sometimes anti-emetics such as Promethazine (Phenergan) (0.5 mg/kg every four to six hours) or Ondansetron (Zofran) (4 mg under the age of 12, 8 mg over 12 years old, every eight hours) are recommended (
Ackerman et al., 2010
, Brink et al., 2014
, Dayton and Silverstein, 2016
, Leung et al., 2015
). However, these medications should be used with caution in children with diabetes because they can mask the symptoms of DKA. Antiemetics should not be used in children with vomiting of unknown origin.- Case Study 3. Suzie, a thirteen-year-old female with type 1 diabetes, treated with basal bolus insulin, comes to the office with an asthma attack and is given a prednisone burst. What are the essential teaching points to review with the family?
Steroids cause insulin resistance, therefore, increased doses of insulin are typically required to maintain normal glycemia (
Brink et al., 2014
).Suzie's parents need to be warned that steroids such as prednisone can raise the blood glucose and she may need extra insulin (
Rusnak, 2000
). Parents should call their endocrinologist for insulin dose recommendations.- Case Study 4. A parent calls and reports that their son, Jake, a nine year old with type 1 diabetes, is “not feeling well” and his blood glucose is “reading high” on the meter. You ask about ketones and Mom says they have not been able to check because he has not been able to urinate.
Inability to urinate is a sign of dehydration; it is an ominous sign particularly if it has been more than six hours since he last urinated. It is recommended to send this child to the emergency department (
Rusnak, 2000
).If it has been less than six hours, an attempt can be made to rehydrate at home. Jake needs to drink sugar-free fluids since his blood glucose is high, at least one ounce per year of age every hour (
Ackerman et al., 2010
). To achieve adequate, hourly hydration, sip small amounts frequently (Rusnak, 2000
). If his blood glucose becomes low (less than 200 mg/dl), then he would need sugar-containing fluids such as Gatorade, Pedialyte or sugar-containing soda (Ackerman et al., 2010
). If he is unable to take in fluids or vomits, his parents should bring him to the ED for IV rehydration.In addition to rehydration, Jake should be given correction doses of his fast acting insulin (lispro, aspart or glulisine) according to his routine correction factor every two to four hours (
Fowler, 2011
, Morris and Campbell, 2008
, Rusnak, 2000
). Correction doses are given for blood glucose readings that are above the target range; expression occurs as a range in blood glucose readings and corresponding insulin dose. For example: One unit of insulin per 50 mg/dl >150 mg/dl.- 151–200 = One unit
- 201–250 = Two units
- 251–300 = Three units
- Case Study 5: A parent calls and says Katie, who has type 1 diabetes, has a cold. The parent asks, “Can I give her some over-the-counter cough/cold medication?”
Over the counter medications do not interfere with blood glucose and are safe for use in children with diabetes (
Rusnak, 2000
). Decongestants have a warning on the label to check with the doctor if you have diabetes because they work by constricting the blood vessels. Danger from decongestants occurs in the elderly with circulatory complications but rarely in pediatrics. So, the answer to the parent's question is yes, over-the counter cough/cold medication can be given, as long as Katie doesn't have any cardiovascular concerns.Conclusion
The key takeaway messages for caring for the child with type 1 diabetes and an acute illness are:
- •Never stop insulin during an illness, although the dose may need to be adjusted, as instructed by the endocrine provider.
- •Monitor blood glucose levels more closely during an illness.
- •Always check for ketones if vomiting, fever or blood glucose reading is greater than 300 mg/dl (American Diabetes Association, 2013), or if the child has not eaten for more than eight hours.
- •If a child on an insulin pump does not respond to a correction dose, there is likely a problem with the infusion set or very rarely, the insulin pump. Recommended guidelines include a correction dose of rapid-acting insulin via subcutaneous injection and insulin pump infusion set change.
- •Never miss an opportunity to educate (Crossen et al., 2016,
- Crossen S.S.
- Wilson D.M.
- Saynina O.
- Sanders L.M.
Outpatient care preceding hospitalization for diabetic ketoacidosis.Pediatrics. 2016; 137https://doi.org/10.1542/peds.2015-3497Lamb et al., 2011,Renders et al., 2001)!
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Article info
Publication history
Published online: September 13, 2017
Column Editor: Maureen Dever, MSN, CRNP, PPCNP-BC, CDEFootnotes
☆The Pediatric Endocrinology Nursing Society (PENS) is committed to the development and advancement of nurses in the art and science of pediatric endocrinology nursing and to improve the care of all children with endocrine disorders through the education of the pediatric healthcare community. To aid in achieving that goal, the purpose of the PENS department is to provide up-to-date reviews of topics relevant to the PENS membership and to the general readership of the Journal of Pediatric Nursing.
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