1. Sick Day Management
Ragnar Hanas, MD, PhD, Department of Pediatrics, Uddevalla, Sweden
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

2. Pediatric and adolescent diabetes in Sweden
- Sparsely populated with large geographical distances
- High diabetes incidence (3rd in the world after Finland and Sardinia)
- ~7000 children and adolescents up to the age of 20 ~700 new cases/year (0 -18 years)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

3. How do we care for our patients?
- Almost everyone is cared for at pediatric departments, the majority by a pediatric diabetologist
- None are seen by GP:s
- 40 centers, the largest with ~ 500 patients, but most have
- Some travel km to see their diabetologist
patients / diabetologist
patients / diabetes nurse
- Teams with dietician, psychologist, counselor (social worker)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

4. Modern treatment of childhood diabetes
Traditional approach
- Insulin, diet, and exercise
”To dare is to lose foothold for a short while - not to dare is to lose yourself”
Sören Kierkegaard Danish philosopher
Diabetes treatment today
- Insulin, love and care
- Prof. Johnny Ludvigsson
- Knowledge -
There is nothing that is forbidden, you can always try something and find out what works for you
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

5. What goals do we have?
Must know more than the average doctor to manage your diabetes
The family is encouraged to take active part in diabetes and adjusting doses
- ”It is no fun having diabetes - but you must be able to have fun even if you have diabetes”
- Prof. Johnny Ludvigsson
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

6. Important to learn for life...
- After one year you will have experienced most things
- “Then we want to learn from you!”
- The clinic will function as an “intelligence center” with input from all families
”Give a man a fish and he will not go hungry that day. Teach him how to fish and he will not be hungry for the rest of his life.”
Chinese saying
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

7. Try to keep on living as usual in the family...
- It is our job to adjust the insulin doses to the child, not the other way around
- Your job is to continue with important things you used to do, like mountain-biking, going for skiing vacation or a trip on the sea
- It is important to come back to your ordinary parent-child rules in the family
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

8. Healthy or sick? Healthy - Start with the need of food in your body
- Take insulin to the food
- Adjust the dose according to the carbohydrate content
Sick
- Start with the need of insulin in your body
- Take food and drink to the insulin
- Eat and drink to give the insulin sugar “to work with”, for example sweet drinks in small but frequent sips.
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

9. Sick with fever
- The child usually eats less but the fever requires more insulin
- Begin by taking the same insulin doses as usual
- 100° F - often 25% increase of doses 102° F - up to 50% increase of doses
Monitor BG before and after each meal Urine ketones at every voiding & in blood if positive
Check blood/urine ketones if vomiting or nauseous
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

10. Insulin during sick days
Illness that raises BG
Increase doses if needed: High BG prior to a meal -  premeal dose by U or according to correction factor
Multiple inj. -  next day basal insulin by 1-2 U Pump -  basal rate by 10-20% (if needed up to 40-50%)
High BG h. after a meal -  next day premeal dose by U
- Adjust doses according to body weight
- Persons in remission phase may need to increase up to 1 unit/kg/day very quickly!
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

11. - Vomiting or nausea? - Caused by lack of insulin?!?
Beware of vomiting when having diabetes!
- Vomiting or nausea? - Caused by lack of insulin?!?
- High blood glucose? Ketones in blood or urine ?
- When a child with diabetes vomits it should always be considered a sign of insulin deficiency until the opposite is proven!
- Vomiting from gastroenteritis should be considered only when a lack of insulin has been excluded!
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

12. Gastroenteritis - Vomiting with diarrhea or only diarrhea
- Low blood glucose levels
Always check for ketones in blood or urine!
Vicious circle with ketones - nausea - eats less - more ketones
Decrease doses if needed: Low BG prior to the meal -  premeal dose by U or according to correction dose
Multiple inj. -  next day basal insulin by 2-4 U Pump -  basal rate by 20-40%
Low BG 1-2 h. after a meal -  next premeal dose by U
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

13. Gastroenteritis
Give drinks containing sugar (not Light) in small and frequent portions (several sips every min.)
Sweet ice cream or yoghurt may work well
Never miss a chance to give something containing sugar!
- Keep records of how much the child has had to drink
- Begin with solid foods as soon as the vomiting stops or decreases
- Mini-doses of glucagon work well when everything else fails < 2 years: 2 “units” in a U-100 syringe > 2 years: 1 “unit”/year up to 15 “units” (0.15 mg) Repeat after 1 hour or more if needed Haymond MW. Diabetes Care 2001;24:
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

14. Increased risk of ketoacidosis when ill
- Relative insulin deficiency if doses are not increased
- Nausea/vomiting makes it difficult to eat
- Therefore it may be difficult to increase insulin doses
Small insulin depot with a pump - insulin deficiency develops quickly if there is a pump failure when you are ill
Drink more to prevent dehydration! Sugar-free fluids if BG is > ~220 mg/dl Fluids containing carbohydrates if BG < ~220 mg/dl (~12 mmol/l)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

15. High blood glucose and ketones
Repeated BG > 270 mg/dl (15 mmol/l) and ketones
- Risk of developing ketoacidosis!!
0.1 U/kg with pen or syringe (preferably Humalog/NovoLog)
Risk of over-correction - hypoglycemia
Check BG and ketones every hour If BG is not decreasing: Repeat dose every 1-2 hours (/2-3 hours with regular insulin)
The blood ketone level may increase after 1 hour but should be much lower after 2 hours
Urine ketones stay elevated for many hours
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

16. Vad happens to the carbohydrates from the food?
Stored sugar in the liver (glycogen)
Insulin from the pancreas
- - -
Fat/muscle cell
Carbohydrates from food
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

17. A healthy cell Blood Urine test shows vessel 0 0 Cell Insulin O2 CO2
Water
Energy
Glucose Ketones
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

18. Starvation Blood Urine test shows vessel 0 + Cell (Insulin) in liver
Fatty acids
Ketones
Glucose Ketones
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

19. Diabetes - lack of insulin
Cell
Blood
vessel
Urine test shows
in liver
Fatty acids
Ketones
Glucose Ketones
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

20. Ketone bodies in a healthy person
Blood vessel
Liver cell
Fatty acids
Mitochondrion
Fatty acyl CoA
Starvation Low insulin High fat diet
Ketone bodies are used by the heart, kidneys, muscles, and brain as fuel
Acetoacetate
Acetoacetate
Ketones +
Acetone
Beta-hydroxybutyrate
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

21. Starvation ketones in people without diabetes
- 15 prepubertal children 10 adult men 10 adult women
- Children fasted for 30 h. (part of clinical evaluation for hypoglycemia symptoms) Adults fasted for 86 h.
- Children had much higher ketone levels than adults
mmol/l
men
Blood ketones (Beta-hydroxybutyrate)
children
women
Time, hours
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

22. Ketone bodies increase when there is a lack of insulin
Blood vessel
Liver cell
Fatty acids
Mitochondrion
Fatty acyl CoA
Low insulin
Acetoacetate
Acetoacetate
Ketones
+++
Acetone
Beta-hydroxybutyrate
Fruity breath (Kussmaul breathing)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

23. Urine ketones can be false neagative!
Blood vessel
Liver cell
Fatty acids
Mitochondrion
Fatty acyl CoA
Low insulin
Acetoacetate
Acetoacetate
Beta-hydroxybutyrate
Ketones
Ketones can only be detected by blood testing
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

24. Urine ketones decrease slowly after insulin treatment
Blood vessel
Liver cell
Fatty acids
Mitochondrion
Fatty acyl CoA
High
insulin
Acetoacetate
Ketones
+++
Acetoacetate
Acetone
Beta-hydroxybutyrate
Acetone is deposited in fat tissue
Acetone
Beta-hydroxybutyrate
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

25. Effects of insulin treatment
DeFronzo RA et al. Diabetes Reviews 1994;2:
How is the blood glucose decreased when treating ketoacidosis?
- Blocked production of ketones in the liver
Blocked production of glucose in the liver
Increased uptake of glucose in tissue
Increased dose needed
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

26. Blood ketones and ketoacidosis
55 children, age 10.4 ± 3.9 y. with BG > 11.1 mmol/l (200 mg/dl) and ketones in urine. 37 had ketoacidosis (pH < 7.30)
Good correlation between patient method and lab. method
Blood ketones > 1.5 mmol/l - 85% had ketoacidosis but only 2 pat. with blood ketones < 2.9 mmol/l had ketoacidosis.
Lab b-hydroxybutyrate
Ham MR et. al. Ped Diab 2004;5:39-43.
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

27. Measuring ketones in blood vs. urine
>100,000 episodes of DKA annually in the U.S.
86 children, ages 2-18 (>0.5 units insulin/kg/day) unless <5 years old, with >0.3 units/kg/day.
73 children on intensified insulin regimes and 18 used pumps.
3900 concurrent pairs of blood and urine ketone tests were obtained.
7783 concurrent pairs of BG and blood ketone tests were obtained.
Laffel LMB. Diabetes 2002;51(suppl 1):A105.
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Slide from S Brink
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

28. Measuring ketones in blood
Precision Xtra meter
Accuracy has been well demonstrated Cembrowski GS,Diabetes 1999;48.Suppl:Abstract Byrne HA, Diabetes Care 2000;23:
Linear response mmol/L beta-hydroxybutyrate (b-OHB)
5 µL blood sample
Results in 30 seconds
No interference by acetoacetate, acetone, lipids, etc.
No interference by common therapeutic agents (Captopril, L-DOPA, vitamin C, etc.)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

29. Measuring ketones in urine
KetoStix
It detects acetoacetate.
Results read from a color chart are Negative, trace (5 mg/dL), small (15 mg/dL), moderate (40 mg/dL), and large ( mg/dL).
User timing is required. Read color at exactly 15 seconds after removing reagent strip from urine.
Proper read time is critical for optimal results. Must ignore color changes that occur after 15 seconds.
False-negative results when sticks have been exposed to air och after eating much vitamin C (acidic urine)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

30. Measuring ketones in blood vs. urine
Relationship between blood and urine ketones
On 15 occasions blood ketones were moderate to large but the urine ketones were negative!
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Slide from S Brink
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

31. Measuring ketones in blood vs. urine
Relationship between blood and urine ketones
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Slide from S Brink
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

32. Measuring ketones in blood vs. urine
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Slide from S Brink
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

33. Measuring ketones in blood vs. urine
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Slide from S Brink
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

34. Measuring ketones in blood vs. urine - conclusions
Use of urine ketones may lead to inappropriate decisions regarding the severity of illness in insulin-treated children.
The advantages of monitoring blood ketones include:
- Real-time direct measurement of the predominant ketone body - Patient acceptance and improved compliance
Careful monitoring of BG and blood ketones, plus supplemental insulin and hydration, may enhance sick-day guidelines and help to prevent ketoacidosis in children.
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

35. Measuring ketones in blood vs. urine - conclusions
123 children aged 3-22 years
Check ketones: When blood glucose was consistently > 13.9 mmol/l (250 mg/dl) During acute illness or stress
6 months follow-up: days 578 sick days
Frequency of ketone measurements
60% fewer hospitalizations 40% fewew emergency assessments
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Laffel LMB. Diab Med 2005;23:
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

36. How should blood ketones be interpreted?
Ketones BG mg/dl >400 mg/dl
< 0.5 mmol/l No problems Test again after 1-2 hours
mmol/l Test again U/kg 0.1 U/kg mmol/l Eat and take 0.1 U/kg 0.1 U/kg, x U/kg
mmol/l Eat and take 0.1 U/kg. x U/kg. x U/kg
> 3 mmol/l Eat and take 0.1 U/kg, x U/kg, x U/kg Contact your diabetes team or emergency ward!!
Samuelsson, Diabetes Tech Laffel, poster 426, ADA 2002
- Every pump user should be able to test blood ketones
- Also very helpful for younger children
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

37. How should blood ketones be interpreted?
Ketones BG < 250mg/dl mg/dl >400 mg/dl
< 0.6 mmol/l No change 5% 10%
mmol/l No change 5% 10% mmol/l 0-5% 10% 15%
≥ 1.5 mmol/l 0-10% 15-20% 20%
- Extra insulin to be given in percentage of total daily insulin dose
- Don´t use % of daily dose when in remission phase!
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Laffel LMB. Diab Med 2005;23:
CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

38. Sick day rules
- Monitor glucose (with adult supervision even in adolescents) every 3-4 h. and occasionally every 1-2 h. with results recorded in a log book
- Test for ketones every 2-4 h. Check blood ketones if positive in urine
- Continue monitoring in the middle of the night (no matter how tired the child or parent is)
Increased salty fluid intake to combat dehydration. Always drink something containing sugar
Check weight every 8-12 h. to monitor for clinical dehydration
Necessary medical treatment for underlying condition (antibiotics for tonsillitis, otitis, urinary tract infection)
Stu Brink. Diab. Nutr. Metab ;12:122-35
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

39. Sick day rules - Antipyretics (acetaminophen) to treat fever
- Antiemetics if severe vomiting prevents adequate fluid intake
- Continue to give insulin and administer extra doses for as long as blood glucose and/or ketones are high
Recognize of when insulin dose (rarely) needs to be temporarily decreased due to hypoglycemia (needs more sugar intake)
Contact your health team or hospital if symtoms persist, worsen or do not get better.
All too frequently a physician or nurse advises omission of insulin because the child is ill and not eating!!!
Stu Brink. Diab. Nutr. Metab. 1999;12:122-35
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

40. When do you need to go to the hospital?
- Large or repeated vomiting
- Increasing levels of ketones or laboured breathing
Continued high BG level > 270 mg/dl (15 mmol/l) despite extra insulin
Unable to keep BG > 70 mg/dl (3.5 mmol/l)
The underlying condition is unclear
Severe or unusual abdominal pain
The child is confused or his/her general well-being is affected
Adapted from Silink M. (Ed.) APEG handbook 1996
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

41. When do you need to go to the hospital?
The child is young (< years) or has another disease besides diabetes
Exhausted patients/relatives, for example due to repeated nighttime waking
Always call if you are in the least unsure about how to manage the situation
Adapted from Silink M. (Ed.) APEG handbook 1996
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

42. Diabetes and surgery Schedule surgery first thing in the morning
I.v. insulin best for major surgery with general anesthesia
For minor surgery with local anesthesia, take only basal insulin (Lantus or pump)
Emergency surgery: I.v. insulin to bring down BG before surgery
Ketoacidosis can give abdominal pain of the same magnitude as appendicitis
Parents are the “diabetes experts” when their child is at a pediatric surgery ward!
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

43. Insulin resistance in changed by the BG level
High level due to infection - Õ insulin resistance a
Increased doses - lower BG a
Back to normal insulin resistance again a
Blood glucose level
After a couple of days BG will be lower - doses need to be lowered a
1-2 weeks a
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

44. Insulin requirements increase with fever
Cold with fever a
Insulin requirements
Infection cureda
Continued insulin resistance a
Increased insulin resistance due to fevera
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

45. Insulin requirements decrease when having gastroenteritis
Gastroenteritis with vomiting, diarrhea a
Insulin requirements
Infection cureda
Continued low insulin resistance due to low BGa
Decreased insulin resistance due to low BG levelsa
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

46. Beware of vomiting when using a pump!
- Vomiting or nausea? - Caused by lack of insulin?!? Especially true when using an insulin pump!!
- Vomiting caused by pump problems may easily be mistaken for illness!!
- When a child with a pump vomits it should always be considered as a pump problem until the opposite is proven!
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

47. Insulin kinetics increseases ketoacidosis risk
20 adults with type 1 diabetes Short-acting 125I-insulin CSII with infusion in the abdomen
2.24U/h
1.12U/h
1.12U/h
Hildebrandt P, Diabetic Medicine 1988;5:434-40
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

48. How quickly will the ketones rise?
- 10 adults with pump, crossover with Velosulin and Humalog - Pump stopped between 7AM and 12 AM. - Blood glucose was ~ 5 mmol/l higher with Humalog after 5 hours
Humalog
Velosulin
Betahydroxy-buturate, mmol/l
- All patients with pumps have blood ketone meters
Guerci B et al. J Clin Endo Met 1999;84:
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

49. Increased risk of ketoacidosis with pump
- Blood glucose will rise quickly when insulin supply is interrupted
- Always check ketones in the urine when you are not feeling well
Ketones!!
mg/dl x x 20 18 16 14 12 10 8 6 4 2 x
360
324
288
252
216
180
144
108 72 36 x x x
Blood glucose mmol/L x x x x x x
Example of pump problems:
Time 10 AM 12 2 PM
pH Ketones BG high mg/dl
AM PM AM Time
Needle came loose
New needle inserted
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

50. Diabetes equipment to bring on the trip
Extra insulin pen and/or syringes (pre-filled pens are handy for this)
Store in separate hand luggage
Thermometer to check the temperature of the refrigerator
Test strips + meter
Extra meter 1 mmol/l = 18 mg/dl
Finger-pricking device + lancets
Test strips for ketones (blood and/or urine)
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

51. Diabetes equipment to bring on the trip
Dextrose/glucose tablets and gel
Glucagon
Clinical thermometer
Fever suppressing drugs: Paracetamol/acetaminophen and/or aspirin /salicylic acid (adults only)
Oral rehydration solution
ID indicating that you have diabetes and a necklace/bracelet
Telephone and fax. numbers for your diabetes clinic at home
Insurance documents
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

52. Always call your home team
- You are never longer away from home than a telephone call
- Ask for a doctor’s contact before leaving home Check for names of doctors
- Staying at a hospital where you don’t understand the language is a difficult experience
- Try to find a children’s hospital in an emergency situation
- With glucagon and frequent monitoring you can prevent most emergencies!
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden

53. Preventing “The revenge of Montezuma”
Antibiotics for diarrhea when travelling to Asia, Africa, Latin/South America or Southern Europe:
Lexinor® (norfloxacine) Not for children younger than 12 years old or pregnant women.
Dose: 200 mg twice daily for prophylactic use or 400 mg twice daily for 3 days if you are having acute diarrhea.
Co-trimoxazole®, Colizole® (trimethoprim + sulphamethoxazole) or similar for children younger than 12 years old.
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CWD, Orlando R Hanas, Dept of Pediatrics, Uddevalla Hospital, Sweden