What are the recommended sick‑day management guidelines for pediatric patients, including those with type 1 diabetes, adrenal insufficiency, asthma, epilepsy, and other chronic illnesses?

Sick Day Guidelines in Pediatrics

All pediatric patients with chronic conditions should receive education on sick day management, with specific protocols varying by underlying disease—most critically, children with adrenal insufficiency require immediate stress-dose hydrocortisone (2 mg/kg every 6 hours IV/IM), while those with type 1 diabetes need frequent glucose and ketone monitoring with insulin dose adjustments based on blood glucose levels.

Core Principles Across All Conditions

Universal Education Requirements

Every family must understand 1, 2:

• When to escalate care: Fever, vomiting, inability to take oral medications, altered mental status
• Emergency contact information: Direct access to specialist teams, not just general pediatric coverage
• Written action plans: Specific to their child's condition with clear thresholds for intervention
• Annual reinforcement: Education must be reviewed at every follow-up visit

Emergency Preparedness

All families should have 2:

• Medical alert identification (bracelet/card) specifying the condition
• Emergency medication kits at home and when traveling
• Training in emergency medication administration (injections, glucagon)
• Clear instructions on when to seek emergency care

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Condition-Specific Guidelines

Type 1 Diabetes

Blood Glucose Management 3, 4:

• Monitor blood glucose every 2-4 hours during illness
• Check blood or urine ketones with any glucose >250 mg/dL or with illness symptoms
• Continue basal insulin at all times—never stop insulin completely

Insulin Adjustments 5:

• If blood glucose is LOW: Hold rapid-acting insulin and sulfonylureas until glucose recovers; give simple carbohydrates
• If blood glucose is ELEVATED: Increase basal and bolus insulin by 10-20% empirically
• Give correction doses every 2-3 hours if hyperglycemia persists

Ketone Management 6, 7:

• Small ketones: Give extra rapid-acting insulin (10-20% of total daily dose) and increase fluids
• Moderate to large ketones: Contact diabetes team immediately; may need emergency department evaluation
• Blood ketone monitoring (β-hydroxybutyrate) is superior to urine ketone testing when available

Hydration and Nutrition:

• Maintain fluid intake even if not eating solid food
• Use glucose-containing fluids if unable to eat to prevent hypoglycemia
• Small frequent sips if nausea/vomiting present

Critical Warning: Up to 40% of parents don't know proper management with high glucose and high ketones 6—this represents a dangerous knowledge gap requiring intensive education.

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Adrenal Insufficiency (Primary or Secondary)

Oral Sick Day Dosing 1, 2:

• Mild illness (fever, minor infection): Double the usual hydrocortisone dose
• Moderate illness (requiring bed rest, antibiotics): Triple the usual dose, divided into 3 doses daily
• Continue increased dosing until 48 hours after symptoms resolve, then taper gradually

Emergency Injectable Hydrocortisone 2: Administer immediately for:

• Persistent vomiting (cannot keep down oral medication)
• Severe illness or trauma
• Loss of consciousness or severe lethargy
• Any signs of shock (hypotension, poor perfusion)

Dosing for Emergency Injection 2:

• Prepubertal children: 2 mg/kg every 6 hours IV or IM (or every 6-8 hours)
• Maximum single dose: 100 mg
• Can use subcutaneous route if IV/IM not immediately available (off-label)
• After injection, proceed immediately to emergency department

Intravenous Management in Hospital 2:

• Hydrocortisone hemisuccinate 2 mg/kg every 6 hours IV
• IV fluids: 5-10% glucose with NaCl 10-15 mEq/kg/day
• Monitor for hypoglycemia aggressively
• Clinical monitoring: BP, heart rate, glucose, urine output, electrolytes

Transition Back to Oral 2:

• Once eating/drinking normally, restart oral hydrocortisone at triple normal dose
• Taper over several days back to maintenance
• Restart fludrocortisone when hydrocortisone <50 mg/day (in primary adrenal insufficiency)

Critical Pitfall: 45% of families receive sick day advice from general pediatric registrars rather than endocrine specialists 6—this increases risk of inadequate management.

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Asthma

Medication Adjustments 8:

• Continue all controller medications (inhaled corticosteroids)
• Increase rescue bronchodilator use as needed (every 2-4 hours if symptomatic)
• Use spacer devices with MDIs for optimal delivery, especially in young children

Indications for Rescue Oral Corticosteroids 8:

• PEF <60% of personal best
• Symptoms progressively worsening day by day
• Sleep disturbed by asthma
• Diminishing response to bronchodilators
• Morning symptoms persisting until midday

Oral Steroid Dosing 8:

• Children: 1-2 mg/kg prednisolone daily for 1-5 days
• No tapering needed for short courses
• Continue until 2 days after control established

When to Seek Emergency Care:

• Severe respiratory distress
• Unable to speak in full sentences
• No improvement with rescue medications
• PEF <40% predicted or personal best

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Sepsis/Severe Illness (Any Chronic Condition)

Fluid Resuscitation 9:

• Isotonic crystalloid or albumin boluses: 20 mL/kg over 5-10 minutes
• Repeat boluses up to 60 mL/kg total, titrated to clinical response
• Monitor for hepatomegaly or rales—if present, start inotropes instead of more fluid

Corticosteroid Coverage 9:

• Mandatory for children with known or suspected adrenal insufficiency and fluid-refractory shock
• Hydrocortisone for catecholamine-resistant shock (Grade 1A recommendation)

Glycemic Control 9:

• Target glucose <180 mg/dL
• Always give glucose infusion with insulin therapy in children (unlike adults)
• Some children make no insulin; others are insulin-resistant—individualize approach

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Medication-Specific Sick Day Rules

Medications to WITHHOLD During Dehydrating Illness 5:

• ACE inhibitors/ARBs: Hold during acute dehydrating illness
• Diuretics: Hold to prevent worsening dehydration
• NSAIDs: Hold due to kidney injury risk
• SGLT2 inhibitors: Hold (if used off-label in type 1 diabetes)
• Metformin: Hold due to lactic acidosis risk

Medications to CONTINUE 5:

• Basal insulin: Never stop completely
• Inhaled corticosteroids: Continue for asthma
• Thyroid hormone: Continue
• Antiepileptic drugs: Continue (never abruptly stop)

Medications to ADJUST 5:

• Insulin: Adjust based on blood glucose (see diabetes section above)
• Hydrocortisone: Increase for stress (see adrenal insufficiency section above)

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When to Resume Normal Medications 5

Timing: Within 24-48 hours of:

• Resolution of acute symptoms
• Eating and drinking normally
• No vomiting for 24 hours
• Return to baseline clinical status

Gradual Resumption:

• Restart withheld medications one at a time
• Monitor for orthostatic hypotension when restarting ACE inhibitors/diuretics
• Ensure adequate hydration before restarting SGLT2 inhibitors or metformin

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Common Pitfalls to Avoid

1. Never stopping basal insulin in type 1 diabetes—this precipitates DKA 3, 4

2. Delaying hydrocortisone injection in adrenal insufficiency—families often hesitate; emphasize "when in doubt, give the injection" 2, 10

3. Relying on urine ketones alone—blood β-hydroxybutyrate measurement is more accurate and timely 11

4. Inadequate follow-up education—only 15% of families receive direct advice from diabetes specialists during sick days 6

5. Forgetting to provide written instructions—verbal education alone is insufficient; 46% of families lack confidence in emergency injection technique 10

6. Continuing nephrotoxic medications during dehydration—ACE inhibitors, NSAIDs, and diuretics must be held 5

7. Undertreating with oral steroids in asthma—parents often delay seeking help until severe distress develops 8

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Quality Improvement Measures

Healthcare systems should implement 2, 6, 10:

• Electronic health record alerts ("red flags") for patients with adrenal insufficiency
• Standardized sick day education sessions separate from routine clinic visits
• Annual competency checks for emergency medication administration
• Direct access protocols to specialist teams, bypassing general pediatric coverage
• Audit of sick day management to identify gaps in care delivery

The evidence strongly supports structured, condition-specific sick day protocols with regular reinforcement, yet implementation remains inconsistent across healthcare settings 6, 12.