Guideline on Sick day rules for children and young people with diabetes on insulin

Guideline on Sick day rules for children and young people with diabetes on insulin META DATA Title: Guidelines on Sick day rules for children and young people with Diabetes taking insulin Version: 1.0 Approved by: Diabetes Clinical Lead Date approved: July 2014 Ratified by: Clinical Lead Endocrinology and Diabetes Date ratified: July 11 th 2014 Name of Melanie Kershaw originator/author: Name of responsible Wolfgang Hogler and Diabetes Operational Group committee/individual: Revision date: Revision approved Date issued 25 th July 2014 Review date July 2016 Target audience: ED, PICU, HDU, All Departments managing Children with Diabetes Stored Centrally DHC M Drive, P drive Linked Trust Policies: 1

DEFINITON Guidelines on sick day rules for children and young people with diabetes taking insulin AIMS OBJECTIVES To provide Trust Diabetes staff with guidance on best practice in relation to managing illness for children who have diabetes and are taking insulin. To facilitate the safe care of children as outpatients with intercurrent illness. To prevent the acute diabetes complications of diabetic ketoacidosis and hypoglycaemia To identify children who require hospital assessment of their diabetes during illness To minimise gaps and avoid duplication of information and communication To ensure trust Diabetes staff have appropriate knowledge, understanding, skills and resources to manage diabetes during intercurrent illness. To ensure all follow a plan which underpins their practice and facilitates continuity and consistency of care. LEGAL CONSIDERATIONS 2

Contents Page Introduction 4 Safety of home management and when to advise to attend the Emergency Department Assessing suitability for home management 5 Sick day rules for all CYP on insulin 5 Insulin Doses during Illness 8 4 How to Calculate the IIlness insulin Dose Using illness doses on MDI, TDS or BD insulin 8 8 Adjustment of usual doses on MDI, TDS or BD insulin 8 Using Illness doses on Insulin Pump therapy 9 Adjustment of usual doses on Insulin Pump therapy 10 References 10 Appendix 1. Insulin pump check list for Hyperglycaemia 11 Appendix 2. My sick day rules management plan (12+) 12 Appendix 3. My Child s sick day rules management plan 15 Appendix 4. 18 Tables 1 Guidance on fluid intake 6 2 3 Insulin management for children on MDI according to blood glucose and ketones levels Insulin management for children on Pump according to blood glucose and ketones levels 8 11 3

Introduction These guidelines are intended to guide Diabetes staff in the management of children and young people (CYP) with Diabetes during inter-current Illness who take multiple daily injections or are on insulin pump therapy. Children with high blood glucose values or illness who are inpatients will be managed by the Endocrine team on call (please call the Endocrine Registrar 9am-5pm bleep 55192, or Endocrine Consultant via switch out of hours) Most children with high and low glucose during illness can be managed at home with advice to prevent hyperglycaemia, Diabetic Ketoacidosis, or hypoglycaemia. When telephoned about a child or young person with Diabetes who is unwell the first question to consider is whether there are any features to indicate the child will not be safe at home. It is not safe to manage the child at home if there are any of the features listed below: Rapid breathing Drowsiness, difficult to rouse or confusion Ketones not falling despite additional insulin dose Prolonged hypoglycaemia Recurrent vomiting Concerns regarding the carer s/ young persons ability to cope Blood Ketones > 3 mmol/l If features above please advise to attend Emergency Department immediately using the ambulance service if necessary Notify ED of expected attendance. If weekday 9am-5pm notify endocrine registrar covering the wards (bleep 55192) of expected attendance. 4

Assessing suitability for home management It is important to consider the following questions. They will guide whether you are comfortable providing advice for home management or require them to attend for medical review: How long the child has been unwell? Is there any fever? What have they managed to eat or drink in the last 48 hours? What insulin has been given in the last 48 hours? What have the blood glucose levels been in the last 24-48 hours? Any hypo or hyperglycemia? Any vomiting or diarrhea? if yes, how long and how often? Any infectious contacts? Who is looking after the child, and are they well? Be cautious if is not the child s usual carer. What is the diabetes control usually like? (recent HbA1c > 75mmol/mol (9%) = higher risk of DKA) Have there been previous episodes of DKA? Are there any family circumstances that will make it difficult to manage the illness at home? Do they have a copy of their sick day rules plan Sick Day Advice for all CYP on ANY insulin treatment. If there are no features or concerns requiring assessment at the hospital then the following advice should be given: 1. NEVER STOP INSULIN INJECTIONS or the INSULIN PUMP 2. The insulin dose may need increasing or decreasing, according to the results of blood glucose and ketone tests. For most illnesses more insulin is needed. 3. Check blood glucose at least 3-4 hourly including through the night. 4. If blood glucose is out of the child s normal daily target ranges or ketones are present they will need to check blood glucose 1-2 hourly, including through the night. 5. Check blood ketones at the onset of any illness and then continue to check regularly if BG high ( 14 mmol/l) or vomiting (2 hourly). 6. Take plenty of rest. Do not exercise as this can cause Diabetic ketoacidosis by increasing the body s demand for insulin at a time when the body is trying to cope with an illness. Encourage child/ young person to sit quietly, read, watch TV etc. Younger children will often settle in front of DVDs, or listen to stories. 5

7. Drink plenty of fluids Use the table 1 below to guide fluid intake to avoid dehydration. Taking fluids slowly and steadily reduces the likelihood of vomiting. If vomiting is only intermittent some of the fluids and carbohydrate taken in is still likely to have been absorbed. This can be checked by monitoring the blood glucose and ketones levels. Table 1: Guidance on fluid intake. The daily recommended amount based on average weight for age and standard fluid calculations is given. The hourly and 15 minutes amount assumes that 12 hours of the day is spent sleeping (ie. not drinking). More fluids may be needed is a child has diarrhea. By Age (years) Normal Fluid intake / 24 hours in mls If all fluid taken in 12 hours of day ml/hr Or every 15 mins 1-5 1000-1500 80-125 20-30mls 6-11 1500-1700 125-140 30-35mls 12-14 1700-1900 140-160 35-40mls 14-16 1900-2400 160-200 40-50mls 30mls= 1 oz =2 tablespoons or 6 teaspoons 8. Take Carbohydrate. When blood glucose levels are low, such as with diarrhoea and vomiting then carbohydrate should be taken to correct any hypoglycaemia. Once hypoglycaemia is corrected in illness then continuing carbohydrate intake is important to avoid a catabolic state. Suitable foods are outlined below. If foods below cannot be managed then regular drinks containing glucose and electrolytes eg sports drinks or dioralyte should make up some of the fluids consumed. This will help replace the salts lost in diarrhea and vomiting too. Soup Toast Boiled rice Ice-cream Rice pudding Jelly Yoghurt Banana Glucose containing drinks - Dioralyte, sport drinks, fruit juice/ Milk / lucozade/ sugar containing squash/ Cola 9. Ensure you have contact with the CYP and family at least every 4-6 hours to review progress. More frequent contact may be needed when blood glucose or ketone levels are not in target. 10. Managing insulin will depend on their usual treatment dose, blood glucose and ketone levels, please see next section on insulin management 6

Insulin Doses during Illness The following principles about glucose and ketones generally apply. Please see MDI and Pump sections for specific additional insulin dose advice according to the glucose and ketones levels. a. Generally aim to keep the blood glucose at least between 4 and 14 mmol/l during illness using the table below to guide doses. Correction Doses of insulin may be required as often as 2 hourly. b. If Blood glucose is high but ketones are normal, standard correction doses for that blood glucose may be sufficient. c. If blood glucose is high and ketones are raised, higher additional insulin doses are needed. d. If blood glucose is normal and ketones are high this may be starvation ketones eg. if a child has not had enough carbohydrate. It is usual that both additional carbohydrate and fluid is needed. Do ensure that the normal blood glucose is not purely due to a large insulin bolus having been given in an unwell child. If in doubt arrange for attendance to ED to enable a blood gas to be checked as normoglycaemic DKA can be seen if large doses of insulin have been given as correction doses e. If blood glucose is low and ketones high more carbohydrate is needed to correct hypoglycaemia. This can happen in diarrhea and vomiting. Sometimes it is necessary to reduce the basal insulin and/or give IV fluids in hospital The illness dose of insulin should be calculated. This is dependent on the child s usual, or typical, total daily insulin dose. Illness dose = 10% of the usual total daily dose. The tables below show when to give a half the illness dose, the whole illness dose, or twice the illness dose, depending on blood glucose and blood ketone levels. Using Illness Doses on MDI, TDS or BD insulin Calculate the iilness insulin dose as above Table 2 provides a guide to giving additional insulin when a child is unwell according to blood glucose and ketone levels. 7

The insulin doses in table 2 can be repeated after 2 hours if blood glucose or blood ketones are not falling. If ketones rise after repeating the illness dose, or the blood glucose and ketones are not falling then a review in ED is needed. If blood ketones are above 3mmol/ L and do not fall with one double illness dose of insulin then assessment in ED is required as there is significant risk of DKA. Table 2: Insulin management for children on MDI according to blood glucose and ketones levels (adapted from ISPAD 2009 1 ) Blood glucose mmol/l Low or less than 5.5 5.5-10 High 10-14 Very High Above 14 Ketones mmol/l None <0.6 0.6-1.5 More than 1.5 Treat any hypos, Take glucose containing drinks Reassure. Keep drinking and have usual diabetes treatment Take carbs with insulin for carbs plus additional usual correction dose Take half insulin illness dose. Recheck glucose and ketones 1-2 hours Full Illness Dose = 10% of TDD Treat hypos, take glucose containing drinksstarvation ketones likely Take plenty of carbs and fluids with normal insulin for carbohydrates. Take carbs plus half illness insulin dose. Recheck glucose and ketones 1-2 hours Take full illness insulin dose. Recheck glucose and ketones 1-2 hours Treat hypos, take glucose containing drinks. Consider IV if not tolerating orals. Starvation ketones likely *Take fluids, carbohydrates and half of insulin illness dose. Recheck glucose and ketones 1-2 hours Take fluids and carbohydrates plus full insulin illness dose Drink plenty Take twice the insulin illness dose Recheck glucose and ketones 1-2 hours Adjustment of usual insulin doses on MDI, BD or TDS therapy. If persistent corrections are needed it is worth considering increasing the background insulin (Lantus or Levemir) by 10% until blood glucose readings settle when a child is on MDI or TDS insulin. For a child on BD insulin the insulin mix ie. Novomix 30 or Humalog Mix 25 doses can be similarly increased by 10%. 8

Using Illness doses on Pump Therapy The same principles about glucose and ketones and insulin doses also apply to insulin pump therapy provided the following rules and table 3 are followed: a. If blood glucose is high even when unwell the standard checks should be made according to the Pump hyperglycaemia checklist (see Appendix A) b. High blood glucose values with ketones must be initially corrected with an insulin pen and the pump set and infusion checked and changed. The pump should then be restarted as per the hyperglycaemia on pump guidance. Corrections doses should continue to be delivered with the pen until the blood glucose and ketones come under control. c. High blood glucose levels (in the absence of ketones) that do not respond to a correction bolus after 1 hour using the pump, need to be corrected using an insulin pen, and the hyperglycaemia on pump guidance should be followed. d. If correction doses are not fully effective then the ISF for corrections may need increasing. To do this the Illness insulin dose must be calculated (page 8). Table 3 shows how to give corrections using the blood glucose and ketone levels. e. If blood glucose values remain high and or ketones persist then assessment in the Emergency department is required. Table 3: Insulin management for children on Pump according to blood glucose and ketones levels (adapted from ISPAD 2009 1 ) Blood glucose mmol/l Low or less than 5.5 5.5-10 High 10-14 Very High Above 14 Ketones mmol/l None <0.6 0.6-1.5 More than 1.5 Treat any hypos, Take glucose containing drinks Reassure. Keep drinking and have usual diabetes treatment Take carbs with insulin for carbs plus additional usual correction dose Take normal correction dose. Recheck glucose and ketones 1-2 hours Full Illness Dose = 10% of TDD 9 Treat hypos, take glucose containing drinksstarvation ketones likely Take plenty of carbs and fluids with normal insulin for carbohydrates. Take normal correction dose. Recheck glucose and ketones 1-2 hours Take full illness insulin dose with pen device. Recheck glucose and ketones 1-2 hours Treat hypos, take glucose containing drinks. Consider IV if not tolerating orals. Starvation ketones likely *Take fluids, carbohydrates and normal correction Recheck glucose and ketones 1-2 hours Take fluids, carbohydrates and normal correction Recheck glucose and ketones 1-2 hours Drink plenty Take twice the insulin illness dose with pen device. Recheck glucose and ketones 1-2 hours

Adjustment of usual insulin doses on Insulin Pump therapy. a. When blood glucose rises above the normal range in a child who is unwell and regular correction doses are being needed then temporary basal rates must be considered. Up to 150-200% of normal basal rates may be needed. b. If hypoglycaemic episodes are frequent during the illness then a temporary reduction in basal rate must be considered. References 1. ISPAD Clinical Practice Consensus Guidelines 2009 Sick day management in children and adolescents with diabetes Pediatric Diabetes 2009: 10 (Suppl. 12): 146 153 10

Appendix 1 Insulin Pump checklist for hyperglycaemia Check: The correct basal rate has been set The correct bolus dose has been administered The pump s alarm history to see if an error has been identified The infusion set (also know as the catheter) is compatible with the reservoir There is no leakage from the infusion set or reservoir The infusion set has been primed There are no large air bubbles in the infusion set The reservoir has not run empty There is no blood in the infusion set The cannula has not become dislodged The cannula and infusion set has not been in for over 72 hours The infusion set has not kinked The site for signs of irritation, discomfort, scarring or infection The battery has not run down If you are on a Medtronic pump check the pump is functioning properly by carrying out a self test. Other Pumps do this automatically at regular intervals. The insulin has not expired, been in use for over one month, near the end of the vial, crystallised, cloudy or exposed to extreme temperatures 11

Appendix 2 My sick day rules plan When I am poorly: I will need to tell a grown up straight away because this can lead to Diabetic Ketoacidosis (DKA) which is a dangerous Diabetes emergency which needs hospital admission. I will need my parent or carer to stay with me I will need to drink plenty: at least cups every day I will need to take plenty of rest, stay at home, and avoid any type of activity. My blood glucose levels can go up or down, but will usually go up. I will need to test my blood glucose at least every 3-4 hours if glucose stays in my target range including overnight. I will need to test my blood glucose every 1-2 hours if glucose is above or below my target or I have ketones. This includes testing during the night. My parent or carer will need to help me with this. I will need to check my blood ketones. I will need to keep taking my insulin, even if I am not eating. I am likely to need to take extra insulin doses (illness doses) I must contact the Diabetes team on 0121 333 9272 or via switchboard 0121 333 999 out of hours if I: have ketones (more than 0.6 mmol/l) am feeling too sick to eat or drink normally am vomiting have high or low blood sugars for more than 4 hours am not sure what to do 12

My illness insulin dose I will probably need higher doses if insulin when I am unwell, even if I am not eating. This is because my body will need to make energy to fight the illness and will release more glucose from the bodies stores. This higher insulin dose will depend on the total amount of insulin I usually take each day and is called the Illness insulin dose I will discuss my blood glucose and ketone test results with the diabetes nurse on call to plan extra insulin doses My additional illness dose will be needed if: My Ketones are above 1.5 mmol/l and my Blood glucose is above 14 mmol/l My Ketones are above 0.6 1 mmol/l and my Blood Glucose is above 14 mmol/l But if Ketones are above 1.5 mmol/l and Blood glucose above 14 mmol/l I will take double my illness dose How to calculate my illness Dose To find your usual total daily dose add the doses below together: (Do not include correction doses. Don t forget to include both doses if you take your levemir or lantus twice a day) Levemir or Lantus or daily basal total dose is units Typical Breakfast dose Typical Lunchtime dose Typical Teatime Typical Suppertime dose Typical Snack dose. Add all the doses above together: = This is my Total daily insulin dose (If on pump you can also look this up in your insulin pump menu) Your illness Insulin dose will be one tenth of the total daily dose Eg. Total Daily Dose divided by 10 = = illness Insulin dose For example if you usually take 46 units per day your illness insulin dose will be 46/10= 4.6 units as you cannot give 4.6 units you will use 4.5 units If your total daily dose is 18 units -18/10= 1.8 units- your insulin illness dose will be 2 units. 13

What do I do now? I will keep re-checking blood glucose and ketones every 1-2 hours If ketones are rising I will let the diabetes team know and attend ED to check I am not going into DKA. If ketones and blood glucose remains high (but are not getting higher) I may need to take correction doses every 2 hours. I will keep in touch with the Diabetes team when blood glucose and ketones are not in target Having carbohydrates when I am poorly I still need to try to eat or have carbohydrate when I am not well, so I can use the glucose to make energy. Useful carbohydrates to have if I cannot eat properly are: Soup Toast Milk Icecream Boiled rice Banana Jelly Sports drinks And also if I m using an Insulin Pump: I am at higher risk of DKA so Yoghurt Lucosade Coca cola I will need to follow the hyperglycaemia rules and checklist for my insulin Pump. If I am poorly with a high glucose and ketones I will need to give my insulin dose using a pen If I am poorly with high blood glucose and need to take corrections regularly then I should discuss with the Diabetes Nurses as I may need a temporary basal rate to increase my background insulin. I may also need to increase my correction doses. If my blood glucose and or ketones do not fall after 1 hour with a correction via the pump I should give a pen injection of rapid insulin and undertake a set change and recheck in 1-2 hours. If still high discuss with Diabetes Nurses. Signs of DKA The following can be signs of DKA. If I have any of these I should go to the Emergency Department. Frequent vomiting Continuing High blood glucose and or ketones, 14 Fast, deep or noisy breathing Cold hands and feet Drowsiness

Appendix 3: My child s sick day rules plan When my child is poorly: I will need to be very careful because this can lead to Diabetic Ketoacidosis (DKA). This is a dangerous Diabetes emergency which needs hospital admission. I will need to stay with my child My child will need to drink plenty: at least day cups every My child will need to take plenty of rest, stay at home, and avoid any type of activity. My child s blood glucose levels can go up or down, but will usually go up. I will need to test my child s blood glucose at least every 3-4 hours if glucose stays in their target range including overnight. I will need to test my child s blood glucose every 1-2 hours if glucose is above or below target or they have ketones. This includes testing during the night. I will need to check my child s blood ketones. I will need to keep giving my child insulin, even if they are not eating. My child is likely to need to take extra insulin doses (illness doses) I must contact the Diabetes team on 0121 333 9272 or via switchboard 0121 333 999 out of hours if my child: has ketones (more than 0.6 mmol/l) is feeling too sick to eat or drink normally is vomiting has high or low blood sugars for more than 4 hours or I am not sure what to do 15

My Child s illness insulin dose My child will probably need higher doses if insulin when I am unwell, even if they are not eating. This is because their body will need to make energy to fight the illness and will release more glucose from the bodies stores. This higher insulin dose will depend on the total amount of insulin they usually take each day and is called the Illness insulin dose I will discuss my child s blood glucose and ketone test results with the diabetes nurse on call to plan extra insulin doses My Child s additional illness dose will be needed if: My child s Ketones are above 1.5 mmol/l and Blood glucose is above 14 mmol/l My child s Ketones are above 0.6 1 mmol/l and Blood Glucose is above 14 mmol/l But if Ketones are above 1.5 mmol/l and Blood glucose above 14 mmol/l I will give double the illness dose How to calculate my child s illness Dose To find your child s usual total daily dose add the doses below together: (Do not include correction doses. Don t forget to include both doses if your child takes levemir or lantus twice a day) Levemir or Lantus or daily basal total dose is units Typical Breakfast dose Typical Lunchtime dose Typical Teatime Typical Suppertime dose Typical Snack dose. Add all the doses above together: = This is my child s Total daily insulin dose (If on pump you can also look this up in your child s insulin pump menu) Your child s illness Insulin dose will be one tenth of the total daily dose Eg. Total Daily Dose divided by 10 = = illness Insulin dose For example if your child usually takes 46 units per day their illness insulin dose will be 46/10= 4.6 units as you cannot give 4.6 units you will use 4.5 units 16

What do I do now? I will keep re-checking my child s blood glucose and ketones every 1-2 hours If ketones are rising I will let the diabetes team know and attend ED to check they my child is not going into DKA. If ketones and blood glucose remains high (but are not getting higher) I may need to give correction doses every 2 hours. I will keep in touch with the Diabetes team when blood glucose and ketones are not in target Having carbohydrates when my child is poorly My child still needs to try to eat or have carbohydrate when they are not well, so they can use the glucose to make energy. Useful carbohydrates to have if they cannot eat properly are: Soup Toast Milk Icecream Boiled rice Banana Jelly Sports drinks And also if my child is on an Insulin Pump: My Child is at higher risk of DKA so Yoghurt Lucosade Coca cola I will need to follow the hyperglycaemia rules and checklist for their insulin Pump. If they are poorly with a high glucose and ketones I will need to give their insulin dose using a pen If they are poorly with high blood glucose and need to take corrections regularly then I should discuss with the Diabetes Nurses as they may need a temporary basal rate to increase the background insulin. I may also need to increase their correction doses. If my child s blood glucose and or ketones do not fall after 1 hour with a correction via the pump I should give them a pen injection of rapid insulin and undertake a set change and recheck in 1-2 hours. If still high discuss with Diabetes Nurses. Signs of DKA The following can be signs of DKA. If my child has any of these I should go to the Emergency Department. Frequent vomiting Continuing High blood glucose and or ketones, 17 Fast, deep or noisy breathing Cold hands and feet Drowsiness

Appendix 4 Parent flowchart for sick days on Insulin Pump 18