Neobook — clinical reference

DESCRIPTION

Illness associated with fever tends to raise blood glucose because of higher levels of stress hormones, gluconeogenesis and insulin resistance.

Illness associated with vomiting and/or diarrhoea may lower blood glucose, with the possibility of hypoglycaemia and the development of starvation ketones.

DIAGNOSTIC CRITERIA

Unstable blood glucose measurements as a result of illness, stress or starvation.
Increased insulin requirements are induced by a catabolic state and stress.
Ketonuria may also indicate the following:
- In the presence of hyperglycaemia, it is indicative of severe insulin deficiency and calls for urgent therapy to prevent progression into ketoacidosis.
- In the presence of low blood glucose levels, it is indicative of a starvation state or is the result of a counter-regulatory response to hypoglycaemia.

GENERAL AND SUPPORTIVE MEASURES

Monitor glucose more frequently.
Test urine for ketones.
Ensure adequate intake of calories and fluids on sick days to prevent ketogenesis. If insufficient calories are consumed, ketones will appear in the urine without hyperglycaemia. In this circumstance encourage the patient to eat whatever he/she feels like.
Treat underlying intercurrent illness.
Special circumstances:
- Gastroenteritis:
  If hypoglycaemia occurs especially with gastroenteritis, and there is mild ketonuria, ensure that the child takes regular frequent amounts of carbohydrate, using oral rehydration solution or intravenous fluids.
- Loss of appetite:
  Replace meals with easily digestible food and sugar-containing fluids.
- Vomiting:
  If the patient has difficulty eating or keeping food down and the blood glucose is < 10 mmol/L, encourage the patient to take sugar-containing liquids. Give small volumes. Some glucose will be absorbed. If there is no vomiting, increase the amount of liquid.

MEDICINE TREATMENT

Insulin therapy
Insulin must be given every day. Insulin injections should not be omitted because of sickness and/or vomiting. If vomiting occurs, IV fluids may be needed to avoid hypoglycaemia.

During an infection, the daily requirement of insulin may rise by up to 25%.

Generally, the body will require more energy during illness. Insulin allows more glucose to enter the cells, providing more energy to fight infection.

General guidelines when giving extra insulin:

If the blood glucose is > 14 mmol/L and capillary beta-hydroxybutyrate ≥ 1.5 mmol/L or if ketones > 1+ in the urine, the patient must seek urgent medical attention.
If no ketonaemia/ketonuria:
- Blood glucose 14–22 mmol/L: Add 5% of total daily dose (TDD) of insulin or 0.05 u/kg to ordinary bolus.
- Blood glucose > 22 mmol/L: Add 10% of TDD of insulin or 0.1 u/kg to ordinary bolus; drink sugar-free fluids.

Check blood glucose and ketones every 2 hours; repeat additional insulin if needed every 2–4 hours.

Extra fluids

In addition to taking extra insulin, extra sugar-free fluids are important to prevent dehydration. If blood glucose < 10 mmol/L (if intake is poor), sugar-containing fluid should be given (to prevent ketosis).

REFERRAL

In a child with inter-current illness, urgent specialist medical or nursing advice must be obtained when:
- the patient is unable to carry out the advice regarding sick days,
- the diagnosis is unclear,
- vomiting is persistent, particularly in young children,
- blood glucose continues to rise despite increased insulin,
- hypoglycaemia is severe,
- ketonuria is heavy or persistent, and
- the child is becoming exhausted, confused, hyperventilating, dehydrated or has severe abdominal pain.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 7: Endocrine, 7.5 Diabetes Mellitus, 7.5.1 Type 1 Diabetes Mellitus, 7.5.1.1 Guidelines For Management Of Diabetics on Sick Days