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Diabetes at the RCH

Sick day and ketone management for injections

  • The following advice relates to days when you are unwell

    Insulin is essential in the body all the time. You can never stop insulin. 

    Insulin doses may need to be changed when you are unwell 

    Monitoring of glucose and ketones will increase

    Always check ketone levels when your child is unwell, regardless of what their glucose level is 

    If vomiting and ketones are present and you are unsure of appropriate treatment, call your diabetes treating team early for support with insulin dose adjustments.

    Check your fingerprick blood glucose levels as explained below, do not rely on continuous glucose monitor (CGM) for your glucose readings when you are unwell.  

    When to seek medical attention:

    Diabetic Ketoacidosis (DKA) is a medical emergency and signs include; vomiting, abdominal pain, rapid breathing, drowsiness. If your child has any of these symptoms or has ketones of 3.0 mmol/L or higher, present to your closest emergency department by calling 000 for urgent assessment by a doctor. 

    Sick day management falls broadly into two different categories:

    1) Illnesses that cause Hyperglycaemia (High BGL’s)

    • Illness can trigger stress hormones that cause insulin resistance. This can lead to high BGLs  
    • Insulin doses may need to be increased
    • Check BGL’s every 2 hours
    • Check blood ketones every 4 hours, if ketones are 1.0 mmol/L or higher, see the information below. 
    • See your GP to treat underlying the illness / infection
    • Some acute illnesses (asthma, croup etc) may be treated with steroid medication such as hydrocortisone, prednisolone or dexamethasone. Steroids such as these may cause high BGLs. 
    • Give pain relief to relieve headaches or sore throat
    • Encourage sugar free fluids to maintain hydration 
    • You are unsure about how to change the insulin doses for sick day support 

    Correcting high glucose levels when ketones are less than 1.0 mmol/L 

    2) Illnesses that cause Hypoglycaemia (Low BGL’s)

    • Vomiting, diarrhoea, nausea and reduced appetite can all lead to Hypoglycaemia.
    • Insulin doses may need to be decreased. Insulin can never be stopped but doses can be reduced to minimise the frequency of hypo with decreased appetite.
    • Check BGL’s every hour
    • Check blood ketones every 4 hours 
      Ketones can be produced during illness even with normal or low BGL’s
    • Sip on sugar containing fluids 
    • You are unsure about how to change the insulin doses for sick day suppor

    Mini doses of glucagon may be used to treat hypoglycaemia if unable to tolerate food or fluids

    What should I do if ketone levels are 1.0mmol/L or higher when using injected insulin?

    1. If BGL 15mmol/L or higher 

    • Give 10% of total daily insulin dose using rapid acting insulin (NovoRapid or Humalog) immediately
    • Check ketones in 2 hours and seek medical advice if ketones remain > 1.0 mmol/L
    • Extra insulin may be required if BGL remains >15mmol/L & ketones remain > 1.0 mmol/L after 2 hours
    • Seek medical advice if ketones continue to rise, there is persistent vomiting or any change in conscious state

    2. If BGL is between 8.0mmol/L - 15mmol/L

    • Consider giving 5 -10% of total daily insulin dose using rapid acting insulin.
    • Encourage extra carbohydrate to maintain BGL
    • Check ketones in 2 hours and seek medical advice if ketones remain 1.0 mmol/L or higher 

    3. If BGL is between 4.0mmol/L – 7.9mmol/L

    • Encourage extra carbohydrate to maintain BGL
    • Give normal insulin dose
    • Check ketones in 2 hours and seek medical advice if ketones remain 1.0 mmol/L or higher 

    4. If BGL is less than 4.0mmol/L

    • Treat hypoglycaemia and encourage sweetened fluids e.g. lemonade icy poles or diluted juice 
    • Seek medical advice if insulin is due – a reduction in the insulin doses may be needed 
    • Check ketones in 2 hours and seek medical advice if ketones remain 1.0 mmol/L or higher 

    If at any stage, ketones are 3.0 mmol/L or higher and your child is vomiting, you should give an 'urgent dose' of injected insulin as explained above and present to hospital for urgent medical assessment.

    This situation has a high risk of diabetic ketoacidosis (DKA) which is a medical emergency.  

    See your doctor or call an ambulance by dialing 000 if:  

    • Your child has had 3 vomits or diarrhoea or has unrelieved abdominal pain, particularly if associated with high BGLs
    • Your child is drowsy or lethargic  
    • After following the above advice, ketone levels are increasing or remain 1.0 mmol/L or higher 

    RCH Sick day service phone number 9345 5522 ask for the “Diabetes sick day call” (for RCH patients) 

    Last updated September 2024