What is a suitable basal bolus insulin regime for a 17kg child with resolved Diabetic Ketoacidosis (DKA)?

Basal Bolus Insulin Regimen for a 17kg Child with Resolved DKA

For a 17kg child with resolved diabetic ketoacidosis (DKA), the appropriate basal bolus insulin regimen should start with a total daily dose (TDD) of 0.5-0.7 units/kg/day, with approximately 50% as basal insulin and 50% as bolus insulin divided before meals.

Initial Insulin Calculation

1. Total Daily Dose (TDD) Calculation:

   • Weight: 17 kg
   • Initial dose: 0.5-0.7 units/kg/day
   • TDD = 8.5-11.9 units/day (starting with lower end is safer)

2. Distribution of Insulin:

   • Basal insulin (50% of TDD): 4.25-6 units once daily

     • Use long-acting analog (glargine or detemir)
     • Administer at same time each day (typically bedtime)

   • Bolus insulin (50% of TDD): 4.25-6 units divided into three pre-meal doses

     • Use rapid-acting analog (lispro, aspart, or glulisine)
     • Divide equally before breakfast, lunch, and dinner (approximately 1.5-2 units per meal)

Step-by-Step Implementation

Step 1: Initiate Basal Insulin

• Start with 4.25 units of long-acting insulin analog (glargine or detemir) once daily
• Administer at consistent time (evening preferred)
• Monitor fasting and overnight blood glucose levels to assess adequacy

Step 2: Initiate Bolus Insulin

• Start with 1.5 units of rapid-acting insulin before each main meal
• Administer 15 minutes before eating
• Adjust based on pre-meal glucose readings and carbohydrate intake

Step 3: Establish Correction Factor

• Initial correction factor: 1 unit per 50 mg/dL above target glucose
• Target blood glucose: 100-180 mg/dL
• Add correction dose to meal bolus if pre-meal glucose is elevated

Step 4: Monitoring and Adjustment

• Check blood glucose 4-6 times daily (before meals, at bedtime, and occasionally at 2-3 AM)
• Adjust basal dose if fasting glucose is consistently out of range
• Adjust bolus doses if post-meal glucose is consistently out of range

Practical Considerations

• Insulin-to-carbohydrate ratio: Start with 1 unit per 15-20g of carbohydrate 1
• Insulin sensitivity factor: Start with 1 unit to lower blood glucose by 50 mg/dL
• Insulin storage: Refrigerate unopened insulin; in-use insulin can be kept at room temperature for up to 28 days

Important Precautions

• Hypoglycemia risk: Ensure family understands signs, symptoms, and treatment
• Sick day management: Provide clear guidelines for insulin adjustments during illness
• Regular follow-up: Schedule frequent visits initially (every 1-2 weeks) to adjust regimen

Avoiding Common Pitfalls

1. Avoid insulin bolus when initiating therapy - IV bolus insulin is not generally recommended for children with DKA 1
2. Prevent hypoglycemia - Low-dose insulin regimens (0.05 units/kg/hr) during DKA treatment reduce risk of hypoglycemia and hypokalemia compared to standard doses (0.1 units/kg/hr) 2
3. Ensure smooth transition - After resolution of DKA (glucose <200 mg/dl, serum bicarbonate >18 mEq/l, venous pH >7.3), initiate the basal-bolus regimen 1
4. Adjust based on patterns - Modify insulin doses based on blood glucose patterns rather than single readings

This regimen provides a structured approach to insulin management for a child following DKA resolution, prioritizing glycemic control while minimizing risks of hypoglycemia and recurrent DKA.