Overview of carbohydrate and insulin management during illness in a child with type 1 diabetes using an insulin pump

	Increasing blood glucose →→→→→
		BG <70 mg/dL (3.9 mmol/L) Check BG every hour	BG 70 to 180 mg/dL (3.9 to 10 mmol/L) Check BG every 2 hours	BG ≥180 mg/dL (10 mmol/L) Check BG every 2 hours
Increasing ketones ↓ ↓ ↓ ↓ ↓	BOHB <0.6 mmol/L	Decrease basal insulin infusion rate by 20% Oral fluids with sugar and electrolytes^* Extra CHO to maintain BG in the normal range^¶ No prandial insulin until BG rises to ≥90 mg/dL Check BG every hour until BG is ≥90 mg/dL Minidose glucagon for persistent hypoglycemia	Continue basal insulin infusion (at usual pre-illness rate) Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL (5 mmol/L) For meals/snacks, give calculated rapid-acting insulin boluses based on ICR and ISF (after BG rises to ≥90 mg/dL)	Increase basal insulin infusion rate by 20 to 30%, particularly if illness is expected to last several days^Δ Oral fluids (with sugar if BG 180 to 250 mg/dL or without sugar if BG ≥250 mg/dL)^*; give at least 4 to 6 mL/kg/hour For meals/snacks, give rapid-acting insulin boluses based on ICR and ISF (if BG ≥400 mg/dL, increase to 110% of calculated dose) For persistent postprandial hyperglycemia, give additional correction boluses of rapid-acting insulin every 2 hours^◊: BG 180 to 250 – Insulin dose based on ISF + 10% or 0.1 units/kg or 10% of TDD^§ BG ≥250 – Insulin dose based on ISF + 10 to 20% or 0.1 to 0.15 units/kg or 10 to 20% of TDD^§
	BOHB 0.6 to 0.9 mmol/L	Decrease basal insulin infusion by 10 to 20% Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL For meals/snacks, give calculated rapid-acting insulin boluses based on ICR and ISF	Continue basal insulin infusion Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL For meals/snacks, give calculated rapid-acting insulin boluses based on ICR and ISF
	BOHB 1 to 1.4 mmol/L	Continue basal insulin infusion (at usual pre-illness rate) Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL For meals/snacks, give calculated rapid-acting insulin boluses based upon ICR and ISF	Continue basal insulin infusion (at usual pre-illness rate) Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL For meals/snacks, give calculated rapid-acting insulin boluses based upon ICR and ISF When BG has risen to ≥90 mg/dL, give correction boluses of insulin every 2 hours based on ISF
	BOHB 1.5 to 2.9 mmol/L	Continue basal insulin infusion (at usual pre-illness rate) Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL For meals/snacks, give calculated rapid-acting insulin boluses based on ICR and ISF If child is young, vomiting, and/or unable to take oral glucose, refer to emergency department for IV glucose	Continue basal insulin infusion (at usual pre-illness rate) Oral fluids with sugar and electrolytes^* Extra CHO^¶ Check BG every hour until BG is ≥90 mg/dL For meals/snacks, give calculated rapid-acting insulin boluses based on ICR and ISF When BG has risen to ≥90 mg/dL, give correction boluses of rapid-acting insulin every 2 hours: Insulin dose based on ISF + 5% or 0.05 units/kg or 5% of TDD	Check insulin pump and adjust basal insulin as above Oral fluids (with sugar if BG 180 to 250 or without sugar if BG ≥250)^*; give at least 4 to 6 mL/kg/hour For meals/snacks, give rapid-acting insulin boluses based on ICR and ISF (if BG ≥400 mg/dL, increase to 110% of calculated dose) Give correction boluses of rapid-acting insulin every 2 hours: Insulin dose based on ISF + 20% or 0.15 units/kg or 20% of TDD^§ Refer patient to emergency department if BG continues to rise and/or BOHB remains >1.5 mmol/L despite extra insulin^¥
	BOHB >3 mmol/L	As above	As above Risk of ketoacidosis	Risk of ketoacidosis Refer patient to emergency department for evaluation for ketoacidosis and further management^¥

This table describes a general approach to sick-day management in a child with type 1 diabetes using an insulin pump. Before using the pump for correction of glycemia and ketosis, check for malfunction or failure of the infusion set and give the initial correction bolus of insulin using an insulin pen or syringe^‡. For children who do not use an insulin pump, general principles of management are similar, but adjustments in insulin dosing depend on whether the child has received the usual daily dose of long-acting insulin^†.

The approach to management varies among clinicians, and details of insulin dosing should be adjusted based on the child's individual characteristics, including age, usual insulin requirement, ability to take and retain oral fluids and carbohydrates, and trends in blood glucose and ketosis. The guidance in this table is mostly based on an ISPAD guideline*. Be alert to changes in concentrations of blood glucose and ketones and clinical status of the patient, which may require further changes in management. Suggested corrections in this table are estimates and should not be considered prescriptive.

BG: blood glucose (or sensor glucose if using a continuous glucose monitor); BOHB: beta-hydroxybutyrate; CHO: carbohydrates; ICR: insulin:carbohydrate ratio; ISF: insulin sensitivity factor (also known as "correction factor"); ISPAD: International Society for Pediatric and Adolescent Diabetes; IV: intravenous; TDD: total daily dose.

* Oral fluids administered for rehydration should contain electrolytes; plain water is not optimal in this scenario. Some options include:

Flat soda or electrolyte replacement solutions such as Gatorade or Pedialyte.
Flat soda or sugary water drinks alternating with an electrolyte-containing solution (soup or bouillon) or taken with saltine crackers to provide salt.
For patients with hyperglycemia (eg, BG >180 mg/dL), oral rehydration solutions such as Pedialyte are optimal for maintaining hydration because they have electrolytes and relatively low carbohydrate content. Other options include water or flat sugar-free soda taken with a few saltine crackers to provide salt.

¶ Oral fluids with sugar and electrolytes generally meet the immediate needs for carbohydrates, but children with BG in the low or normal range generally need extra carbohydrates during illness, which should be supplied if tolerated (eg, crackers or other carbohydrate-containing foods).

Δ During illness, the basal insulin requirement is often increased because of illness-associated insulin resistance.

◊ For children with hyperglycemia but without ketosis, we typically give supplemental rapid-acting insulin every 3 hours (rather than every 2 hours) to avoid an "insulin stacking" effect.

§ For children whose usual TDD is low (<0.7 units/kg/day) or high (>1 unit/kg/day), it may be more appropriate to use a percentage to calculate the bolus (eg, either ISF + 10 to 20% or 10 to 20% of TDD).

¥ Ketosis caused by poor oral intake (starvation ketosis) is usually mild, though it can sometimes be severe. Severe ketosis (BOHB ≥3 mmol/L) in a child with diabetes strongly suggests diabetic ketoacidosis; the child should be urgently evaluated in an emergency department.

‡ Many episodes of hyperglycemia and associated ketosis are related to a problem with the insulin pump or infusion system. It is imperative to give insulin by pen or syringe initially until the function of the pump and infusion set has been fully accessed.

† For children using multiple daily injections rather than an insulin pump (ie, who are receiving long-acting subcutaneous insulin with premeal rapid- or short-acting insulin), adjustment of basal infusion rate will not be possible. Because it is not always clear that a child has received the recommended dose of long-acting insulin, initial treatment should be given as outlined in the table, followed by further correction doses and/or carbohydrates as needed. Rapid-acting insulin should be administered every 2 hours (or short-acting insulin every 3 to 4 hours) until ketones are cleared and the child is in the euglycemic range. Subcutaneous long-acting insulin should be given at the usual time of day, under direct parental supervision.

Adapted from: Phelan H, Hanas R, Hofer SE, et al. Sick day management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:912.

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Overview of carbohydrate and insulin management during illness in a child with type 1 diabetes using an insulin pump