2. Sick day management in children with diabetes Dr. Hashemi Pediatric Endocrinologist Assistant Prof. of Isfahan University Of Medical Sciences

3. Risk of illness in diabetic patients Children whose diabetes is under good metabolic control should not experience more illness or infections than children without diabetes. ISPAD 2014

4. Risk of illness in diabetic patients In children with poor metabolic control : Impaired leukocyte function Low IgG concentrations Reduction in C4B ISPAD 2014

5. The effects of illness on diabetes ● Increased insulin requirements ● Decreased insulin requirements Up to date

6. Increased insulin requirements Increase in counter-regulatory hormones Raise peripheral insulin resistance Illnesses associated with fever Up to date

7.  37.8 - often 25% increase of doses  38.9 - up to 50% increase of doses

8. Decreased insulin requirements Reduced oral intake Decreased appetite Poor absorption  illness associated with vomiting and diarrhea Up to date

9. The effects of illness on diabetes Cont,…. There are increased insulin requirements during the incubation. The increased need for insulin may persist for a few days after the illness. ISPAD 2014

10. Complications Hypoglycemia Significant hyperglycemia Diabetic ketoacidosis Ketosis, independent of hyperglycemia Up to date

11. Case 1 دختر 9 ساله ای که به دیابت مبتلا است و دچار تب و گلو درد شده است به درمانگاه آورده شده است. الف ) چه توصیه هایی به مادر می کنید ؟

12. Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness ISPAD 2014

13. More frequent monitoring Glucose BG should be monitored at least every 3 – 4 h including through the night and sometimes every 1–2 h

14. More frequent monitoring Ketones

15. 00;18 A healthy cell Insulin O2O2O2O2 CO 2 WaterEnergy Urine test shows Glucose Ketones 0 0 Bloodvessel Cell

16. 00;18 Diabetes - lack of insulin Cell in liver Fatty acids Ketones Urine test shows Glucose Ketones +++ +++ +++ +++ Bloodvessel

17. How patient can measure ketones? Urine strips measure acetoacetate (AcAc) and acetone. Blood strips measure beta-hydroxybutyrate (BOHB).

18. Relationship between urine and blood ketones

19. When patient can measure ketones? Checking for urinary ketones with each void.

20. Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

21. Never stop insulin The most common mistake is complete omission of insulin ‘the child is ill and not eating,’ Even in the fasting state, some insulin is still required for basal metabolic needs.

22. Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

23. Maintaining hydration with salt and water Hyperglycemia Fever Excessive glycosuria Ketonuria Contribute to increased fluid losses.

24. Maintaining hydration with salt and water Liquids ( Chicken soup or clear broths )

25. Maintaining hydration with salt and water If appetite is decreased or the BG is falling below 180 mg/dL, sugar-containing fluids should be considered (e.g. diluted fruit drinks, colas.)

26. Maintaining hydration with salt and water Intravenous fluids may be required if nausea, vomiting or diarrhea are persistent.

27. Sick-day management rules More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

28. Daily dose of the NPH can be reduced by 30 to 50 %. Glargine can be continued at the usual rate or slightly decreased by 10 to 20 %. ISPAD 2014 Additional insulin

29. 0.05 to 0.1 units/kg (5 to 10 percent of the total daily dose), given every two to four hours as needed based upon blood glucose. ISPAD 2014

30. When patients in remission phase are ill (during ‘the honeymoon phase’) there may be a need to increase insulin up to 1 U/kg/day very quickly. Additional insulin

31. Up to date BS> 400 mg/dl 250 < BS < 400 mg/dl 180 < BS < 250 mg/dl 1oo < BS < 180 mg/dl BS < 100 mg/dl Urine ketones 0.1 IU/KG0.05 IU/kg No need extra insulin Neg / trace 0.1 IU /kg Extra carbohydrates & fluid 0.05 IU/kg Extra carbohydrates & fluid Small to moderate 0.1 IU/ kg Extra carbohydrates & fluid 0.1 IU / kg Extra carbohydrates & fluid 0.05 IU/kg Extra carbohydrates & fluid Moderate to large

32. Case 1 مادر راجع به نحوه ومیزان تزریق انسولین از شما سوال می پرسد. ب ) چه پاسخی می دهید ؟

33. Case 1 Our case : NPH morning = 10 IU NPH evening = 8 IU …….. In sick day = 9 IU ( 6 – 3 IU )

34. 10 AM : BS = 300 mg /dl ketone = small …….. Extra insulin ( 0.05 IU/kg ) Case 1

35. 1 : 00 PM : BS = 400 mg /dl Ketone = moderate ……. Extra insulin ( 0.1 IU /kg ) Case 1

36. Case 2 پسر 10 ساله ای به گاستروانتریت مبتلا شده است. وی تحت درمان با انسولین گلارژین 10 واحد و انسولین آسپارت هر وعده 4 واحد می باشد. قند فعلی = 80 و کتون ادرار متوسط می باشد. مادر وی راجع به نیاز به تغییر انسولین با شما مشورت می کند. چه پاسخی می دهید ؟

37. Case 2 Gelargine = 10 IU ……. In sick day = 8 IU BS = 80 mg/dl Extra carbohydrates & fluid Repeat BS 1 – 2h …… BS = 170 mg / dl, ketone large …….. Extra insulin ( 0.05 IU/kg )

38. When do your patients need to go to the hospital? - - Large or repeated vomiting -Increasing levels of ketones -Continued high BG level > 270 mg/dl -Unable to keep BG > 70 mg/dl -The underlying condition is unclear -Severe or unusual abdominal pain -The child is confused or his/her general well-being is affected Up to date

39. SUMMARY More frequent monitoring Never stop insulin Maintaining hydration with salt and water Additional insulin Treat the underlying precipitating illness

40. REFERENCES : Uptodate ISPAD 2014

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