What is a simplified sick day rule for a child with Type 1 Diabetes Mellitus (T1DM)?

Simplified Sick Day Rules for Children with Type 1 Diabetes

Never discontinue insulin during illness, and check blood glucose and ketones every 2-4 hours to prevent diabetic ketoacidosis (DKA), which remains a leading cause of morbidity and mortality in pediatric T1DM. 1

Core Principles

The fundamental goal of sick day management is preventing DKA, severe hyperglycemia, dehydration, and hypoglycemia through frequent monitoring and maintaining insulin administration. 1, 2 Illness triggers counter-regulatory hormone release that increases insulin requirements despite reduced food intake, making this a high-risk period. 3

Monitoring Requirements

Frequency of checks:

• Check blood glucose every 2-4 hours around the clock during illness 1, 2
• Check urine or blood ketones with every illness when blood glucose exceeds 300 mg/dL 1, 3
• Blood ketone (β-hydroxybutyrate) monitoring offers advantages over urine ketone testing for earlier detection of metabolic deterioration 3

Insulin Management

Critical rule: Continue basal insulin at all times 1

• Maintain usual long-acting/basal insulin doses even if the child is eating poorly 1, 2
• Give supplemental rapid-acting insulin every 2-4 hours based on blood glucose levels and presence of ketones 1, 2
• Increase total daily insulin by 10-20% when blood glucose remains elevated or ketones are present 2

Common pitfall: Parents often reduce or stop insulin when children aren't eating normally—this is dangerous and precipitates DKA. 1

Fluid and Nutrition Management

• Offer small, frequent sips of fluids containing both carbohydrates and salt (e.g., regular soda, broth, sports drinks) 1, 2
• If unable to tolerate solid food, provide easily digestible liquid carbohydrates to prevent hypoglycemia 1, 2
• Target 150-200 mL (5-7 oz) of fluid per hour for children to prevent dehydration 2

When to Contact Healthcare Provider Immediately

Call your diabetes team or seek emergency care if: 1, 2

• Blood glucose remains above 300 mg/dL despite supplemental insulin
• Moderate to large urine ketones persist or blood ketones exceed 1.5 mmol/L
• Vomiting occurs more than twice in 4 hours
• Signs of dehydration appear (dry mouth, decreased urination, lethargy)
• Difficulty breathing or altered mental status develops
• Abdominal pain is present

Age-Specific Considerations

Children under 6-7 years require special attention because they have "hypoglycemic unawareness"—they cannot recognize or communicate hypoglycemia symptoms, placing them at higher risk during illness when eating patterns are disrupted. 1 These young children may paradoxically need decreased insulin if appetite is severely reduced, requiring more frequent glucose monitoring every 2 hours. 1, 2

Parental Supervision Requirement

Sick day management must never be left to a child or teenager alone—adult supervision with telephone access to the diabetes care team is essential for successful management and prevention of life-threatening complications. 1, 2 The American Diabetes Association emphasizes that intercurrent illnesses are more frequent in young children, and inadequate sick day management leads to preventable hospitalizations for DKA with associated severe morbidity and potential mortality. 1

Prevention Education

Sick day rules must be established at diagnosis and reviewed periodically at every clinic visit, as many DKA admissions are preventable with proper education and early intervention. 1, 2 Parents and patients need written instructions covering glucose targets, supplemental insulin dosing, fluid requirements, and specific criteria for contacting healthcare providers. 1