Management of type 1 diabetes mellitus in children during illness, procedures, school, or travel

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 (BG) and ketones and possibly requiring 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 — Sick-day management includes adequate hydration and adjustments to the insulin dose based on frequent monitoring of blood glucose (BG) and ketones. The goal is to maintain BG concentrations between 70 and 180 mg/dL (3.9 to 10 mmol/L) and to maintain or reduce ketones to less than 0.6 mmol/L. The following discussion is consistent with guidelines from the International Society for Pediatric and Adolescent Diabetes (ISPAD) [1].

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

●BG is persistently low (<70 mg/dL [3.9 mmol/L]) 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, or the family does not have the resources to manage the illness at home

In children with nausea and vomiting, the possibility of diabetic ketoacidosis should always be considered. (See "Diabetic ketoacidosis in children: Clinical features and diagnosis".)

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 persists for a few days to weeks after recovery from the acute illness; this has also been observed following coronavirus disease 2019 (COVID-19) infection and COVID-19 vaccination.

●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 toward 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.

Supportive care

Monitor blood glucose more frequently — During an illness, BG monitoring should be performed more frequently, eg, every one to two hours, including during the night. The frequency of testing may be decreased to every two or four hours as the child recovers.

A continuous glucose monitor (CGM) can be particularly useful for sick-day monitoring and management because of the need for frequent monitoring of glucose levels and because the CGM also signals whether glucose levels are rising, falling, or stable. Use of acetaminophen, ascorbic acid, and salicylic acid can interfere with readings on the CGM, with acetaminophen and ascorbic acid falsely raising sensor glucose readings and salicylic acid falsely lowering these readings. Newer models of the CGM perform better in this regard, but higher-than-recommended doses of acetaminophen (eg >1 g every six hours in adults), ascorbic acid (>500 mg/day), and salicylic acid continue to result in inaccurate readings. Further, readings with the CGM may be erroneous when the patient is dehydrated because of poor perfusion. In all such instances, fingerstick glucose testing is advisable. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Continuous glucose monitoring'.)

Monitor ketones frequently — Ketone formation and ketoacidosis can occur even without hyperglycemia if oral intake is poor.

●If home testing of blood beta-hydroxybutyrate (BOHB) concentration is available, we suggest performing this test every two to four hours, in conjunction with the fingerstick glucose test. Home testing of BOHB is the preferred method for monitoring ketones because it 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 an insulin pump.

●If home testing for BOHB is not available, urinary ketones should be checked with every void, regardless of BG concentration. It is important to recognize that improvement in urine ketones may lag behind improvement in blood ketones during recovery. Also, urine ketone test strips may deteriorate within a few weeks of opening the bottle. For this reason, foil-wrapped ketone strips are preferred.

Maintain hydration — For all patients, maintain hydration by encouraging regular oral fluids. If BG is <250 mg/dL (13.9 mmol/L), the fluids should include carbohydrates and electrolytes. If hypoglycemia develops, higher concentrations of carbohydrates may be required. If BG is >250 mg/dL (14 mmol/L), carbohydrate-free fluids should be used. (See 'Insulin and carbohydrate dosing' below.)

For all patients with suspected or confirmed ketosis, rigorous oral hydration is essential, in addition to insulin and carbohydrate therapy. To hydrate, administer oral fluids every one to two hours at the rate of 4 to 6 mL/kg/hour or 100 mL/hour.

If adequate oral hydration cannot be maintained, particularly 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".)

Insulin and carbohydrate dosing — Adjust the insulin dose as needed, based on frequent measurements of BG and blood or urinary ketones. Insulin requirements may be either increased or decreased during an illness.

For children with a poor appetite, options for carbohydrates include easily digestible and tolerated foods (such as soft rice, rice cereal, rice and lentil broth, rice porridge, cooked farina, noodles, crackers, and yogurt) and carbohydrate-containing fluids (such as sports drinks, lemonade with sugar and salt, juice, and sugar-containing sodas). The "fizz" in sodas and soft drinks should be allowed to dissipate before administration to reduce flatulence and improve tolerability, particularly when there is associated nausea and vomiting. Fluids containing both carbohydrates and electrolytes (eg, Pedialyte or soups) are preferred to fluids with carbohydrates alone. For children with vomiting and/or nausea, iced popsicles or very cold sugar-containing liquids may be better tolerated than other drinks or soups.

Administration of both insulin and carbohydrates is necessary to avoid "starvation ketosis." The relative amount of these components depends on the child's BG concentration. Oral fluids with sugar and electrolytes generally meet the immediate needs for carbohydrates, but children with BG concentrations in the low or normal range generally need extra carbohydrates during illness.

Recommendations for insulin and carbohydrate dosing are summarized in the table (table 1) and detailed in the ISPAD guideline [1]. The approach depends on the child's BG concentration and severity of ketosis:

Hyperglycemia — Children with hyperglycemia (BG >180 mg/dL [10 mmol/L]) require additional insulin, as well as fluids (with carbohydrates unless BG is ≥250 mg/dL [14 mmol/L]).

●Basal dosing – For patients with persistent hyperglycemia or illness expected to last three or more days, the dose of long-acting or intermediate-acting insulin may be increased by 20 to 30 percent or the basal rate on a pump by 20 to 50 percent. In these situations, the basal insulin requirement is often increased because of illness-associated insulin resistance.

●Coverage of meals/snacks – Give rapid-acting insulin (lispro, aspart, or glulisine) boluses based on the insulin:carbohydrate ratio and insulin sensitivity factor (if BG ≥400 mg/dL [22.2 mmol/L], increase to 110 percent of the calculated dose). If rapid-acting insulin is not available, short-acting (regular) insulin may be used instead.

●Correction doses – To manage persistent postprandial hyperglycemia (BG >180 mg/dL [10 mmol/L]), give additional correction doses of insulin every two hours, as outlined in the table (table 1), using rapid-acting insulin (lispro, aspart, or glulisine) (table 2). Short-acting (regular) insulin is not preferred in this situation but may be used if rapid-acting insulin is not available (administered at three- to four-hour intervals). Of note, for children who typically have very low insulin needs (eg, during the "honeymoon phase" of diabetes), insulin requirements during sickness may be higher than otherwise expected.

For children on insulin pump therapy with persistent hyperglycemia or hyperglycemia and ketosis, 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. Next, functionality of the pump and infusion set or pod should be assessed before using it for subsequent insulin delivery. It is usually wise to replace the insulin pen cartridge and needle, pump cartridge, infusion set, or pod at this time. For children using a hybrid closed-loop system, the setting should be switched to manual mode during sick-day management.

●Monitoring blood sugar – When using a rapid-acting insulin analog, it is prudent to check BG and ketones after two hours and administer additional doses of supplemental insulin as necessary, rather than waiting longer. These insulins have peak action at one to three hours and effective total duration of action of three to five hours. When BG decreases to the 70 to 180 mg/dL (3.9 to 10 mmol/L) range, checking every three to four hours is usually sufficient. If BG is higher, checking every two hours is advisable.

Normoglycemia — For children with BG between 70 and 180 mg/dL (3.9 to 10 mmol/L), intake of sugar-containing food or liquids should be encouraged to provide extra carbohydrates. For children with vomiting and/or nausea, iced popsicles or very cold sugar-containing liquids may be better tolerated than other drinks or soups. (See 'Insulin and carbohydrate dosing' above.)

●Basal dosing – Administer basal insulin at the usual pre-illness dose.

●Coverage of meals/snacks – Once the BG rises to ≥90 mg/dL (5 mmol/L), give rapid-acting insulin (lispro, aspart, or glulisine) boluses (or short-acting [regular] insulin if rapid-acting insulin is not available), based on the insulin:carbohydrate ratio and insulin sensitivity factor.

●Correction doses – Additional correction doses of rapid- or short-acting insulin may be necessary depending on ketone levels (table 1).

●Monitoring blood sugar – Check BG every hour until BG is ≥90 mg/dL (5 mmol/L), after which the frequency of BG monitoring may be reduced to every two to four hours depending on BG and ketone levels.

Hypoglycemia or borderline hypoglycemia — For children with hypoglycemia (BG <70 mg/dL [3.9 mmol/L]) or borderline hypoglycemia (BG 70 to 90 mg/dL [3.9 to 5 mmol/L]), intake of sugar-containing food or liquids should be encouraged to provide extra carbohydrates and insulin doses may need to be reduced. Oral intake may be insufficient in many of these children because of reduced appetite, nausea, or vomiting. For children with vomiting and/or nausea, iced popsicles or very cold sugar-containing liquids may be better tolerated than other drinks or soups. (See 'Insulin and carbohydrate dosing' above.)

●Reducing the basal insulin dose – Insulin should generally be reduced, rather than stopped, even if the child is not eating. A brief pause in basal insulin may be appropriate, as noted in the bullets below. Complete cessation of insulin administration for a longer period can cause increased ketogenesis, worsening ketosis, and, possibly, ketoacidosis.

The protocol for reducing the basal insulin dose depends on 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 using an insulin pump, the basal infusion can be continued at the usual rate or decreased by up to 20 percent (particularly when ketones are low to absent). Further reductions in the basal insulin infusion rate may be necessary if BG levels are persistently low (<70 mg/dL [3.9 mmol/L]) despite the initial dose reduction. In addition to reducing the basal rate, bolus dosing may be reduced by as much as 50 percent. Caregivers of children using a hybrid closed-loop pump must be aware that these pumps may algorithmically maintain glucose in range during illness. However, if there are concerns, it is safest to return pumps to manual mode and monitor and treat altered glucose and ketones accordingly. (See "Insulin therapy for children and adolescents with type 1 diabetes mellitus", section on 'Automated insulin delivery (hybrid closed-loop insulin pumps)'.)

There are uncommon circumstances when a brief suspension of the insulin infusion may be necessary. For example, if BG persists below 70 mg/dL (<3.9 mmol/L) despite administration of carbohydrates or if the child is unable to consume sufficient oral carbohydrates, basal insulin delivery may be suspended briefly until BG increases to ≥70 mg/dL (3.9 mmol/L). In such situations, intravenous glucose infusion may be necessary to enable insulin administration without incurring hypoglycemia.

•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 BG concentrations in the normal range, lower doses of bolus insulin followed by 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.

●Coverage of meals/snacks – Avoid prandial insulin until the BG is ≥90 mg/dL (5 mmol/L).

●Monitoring blood sugar – Check BG every hour until BG is ≥90 mg/dL (5 mmol/L), after which the frequency of BG monitoring may be reduced to every two to four hours depending on BG and ketone levels.

●Correction of hypoglycemia – When BG <70 mg/dL (3.9 mmol/L), correction of hypoglycemia is necessary. For children who are unable to eat, give ice-cold, sugar-containing liquids if tolerated. If the patient is vomiting and/or oral intake is poor, consider sending to the emergency department for administration of intravenous glucose-containing fluids, particularly if they have severe ketosis (BOHB is ≥3 mmol/L or large urine ketones).

●Other measures:

•Antiemetics such as ondansetron or promethazine are an option in children with gastrointestinal illnesses who have nausea or are vomiting.

•If the patient has persistent vomiting (eg, for more than two hours if the child is younger than five years old) or if home therapy cannot correct the hypoglycemia, the child should be evaluated and treated at an appropriate medical facility. This is particularly important if ketosis is severe. (See "Hypoglycemia in children and adolescents with type 1 diabetes mellitus".)

Ketosis — For patients with ketosis, management depends on the blood sugar concentration, as outlined in the table (table 1). Patients with low or normal blood sugar concentrations typically have "starvation ketosis" and require both carbohydrates and insulin to correct this. Patients with hyperglycemia and severe ketosis (BOHB ≥3 mmol/L or large urinary ketones) may have impending diabetic ketoacidosis and should be referred to the emergency department for evaluation for ketoacidosis and further management [2].

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), 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.

Blood glucose (BG) monitoring should be performed every one to two hours while the patient is fasting. The goals should be to maintain BG levels in the 90 to 180 mg/dL (5 to 10 mmol/L) range and avoid development of both hypoglycemia and ketoacidosis [3].

For most procedures, an intravenous catheter should be placed in case intravenous dextrose administration becomes necessary to maintain BG 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 on 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 provide additional insulin needs as determined by BG concentrations, which should be measured hourly during the procedure (table 2). Intravenous dextrose should be administered if BG 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 but 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 BG concentrations, which should be measured hourly during the procedure (table 2).

●Long procedures (≥2 hours) – During long procedures, glycemic control can be maintained by switching from the usual insulin 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 [4]. 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 [3]. Ongoing BG 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 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 that BG 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 BG 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 BG 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. Strategies are outlined in the table (table 3). (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 insulin sensitivity and insulin:carbohydrate ratios do not need to be adjusted. Similarly, this needs to be adjusted back to local time after the patient returns. Changing time zones with insulin pumps is always the easiest approach to this travel scenario.

●Multiple-dose injections – Children being treated with multiple doses of insulin who are changing time zones require some thought and ingenuity in management. If the child is advancing time zones by more than two hours for an extended time period, the simplest strategy is to adjust the time of insulin glargine injections by two hours each day to a time that is more appropriate for the new time zone.

●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 (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 (BG) levels, give insulin injections under the supervision of a knowledgeable adult, and be treated for hypoglycemia in close proximity to the school classroom [5-7]. 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 [8].

An appropriate school staff member should be identified and appropriately trained to support and apply the prescribed treatment regimen for the student [6,7]. 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 [6,7]. 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 and is more likely to be administered when needed [9]. 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] – Detailed clinical guidance for sick-day management

●Children with Diabetes – Online community and resource, including guidance for completing 504 plans for school

●Juvenile Diabetes Research Foundation – 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 [10] and Helping the Student with Diabetes Succeed: A Guide for School Personnel [11], 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 5^th to 6^th 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 10^th to 12^th 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: Managing 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

●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):

•Monitor blood glucose (BG) and ketones (as blood beta-hydroxybutyrate [BOHB] or urine) frequently, and maintain hydration.

•Adjust insulin therapy and diet based on BG concentrations, presence of ketones, and ability of the child to consume adequate carbohydrates and fluids, as outlined in the table (table 1). Give additional doses of rapid- or short-acting insulin for elevated BG and ketones. (See 'Insulin and carbohydrate dosing' above.)

-Continue insulin to maintain glucose metabolism; the basal insulin dose may need to be decreased if the child is not eating, to avoid hypoglycemia.

-For children on insulin pump therapy, malfunction of the pump or infusion set is a very common cause of hyperglycemia and ketosis/ketoacidosis. Therefore, the initial bolus of additional insulin should be given using an insulin pen or syringe and functionality of the pump and infusion set or pod should be assessed before using it for subsequent insulin delivery.

●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 (table 3). 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 (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 appropriate adult staff member 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