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Diabetes at the RCH

Sick day management for insulin pumps

  • Looking after your diabetes when you are unwell (and using an insulin pump)

    When your child is sick, their blood glucose levels (BGLs) may be high or low due to illness. Ketone levels may also rise and these need to be actively managed.

    During illness, aim for BGLs to be between 4.0-10.0mmol/L and ketones to be less than 0.6mmol/L.

    Insulin amounts may need to be reduced if your child is not eating or eating less. However, insulin is NEVER stopped.

    Ketones are more common during illness. This may be due to less oral intake (starvation ketones) or insulin resistance (very common during times of illness).

    Whilst unwell, check ketones at least every four hours, even if BGL is in range. Check ketones every two hours if the last ketone check was 0.6mmol/L or higher or if your child is vomiting.

    Remember: vomiting and BGL 15.0mmol/L or higher and ketones 0.6mmol/L or higher MUST be managed as line failure and can result in Diabetes Ketoacidosis (DKA).

    Seek URGENT medical attention by presenting to your local ED or calling 000.

    General advice for managing illness

    • Seek medical attention from your GP in relation to the illness if required
    • When unwell, sensor glucose readings may be less accurate, particularly if you are dehydrated. Therefore, regular BGL checks are required. If these differ from sensor glucose, rely on BGL checks.
    • Maintain hydration with frequent sips of water or electrolyte containing fluids (e.g. hydrolyte fluid, gastrolyte ice blocks (there is limited carbohydrate in these products).
    • Boluses are still required for carbohydrate eaten. Missing food boluses can lead to ketone development.
    • If you are nauseated and unsure if you will tolerate food, initially bolus for a small amount of carbohydrate (e.g. 15 grams) and then bolus again if more food is consumed.
    • For illnesses where hypoglycaemia is problematic, consider a 50% reduction of the recommended food bolus amount (only do this if ketones are 0.5 mmol/L or lower).
    • Mini-dose glucagon may be required with persistent hypoglycaemia. If BGL’s remain low despite mini-dose glucagon, please contact diabetes sick day line.

    Management of ketones on an insulin pump

    BGL 15 mmol/L or higher Assume line failure if BGL high and ketones. Follow Ketone advice. Give urgent dose on NovoRapid insulin via pen. If your child is unwell AND not vomiting AND you know the pump line is working the high BGL and ketones may be related to illness. In this case give a correction bolus via the pump and add 50% onto the bolus amount calculated. This extra insulin will help clear the ketones. If the ketones are not clearing after two hours, treat as a line failure.
    BG 7.0 mmol/L - 14.9 mmol/L Give a correction bolus via the pump to help clear the ketones. Add an additional 10% to the bolus correction calculated by the pump. Check the BGL and ketones after two hours. After two hours, if ketones remain 0.6 mmol/L or higher, more insulin will be needed.
    • If the BGL remains between 7.0 mmol/L to 14.9 mmol/L repeat the above step
    • If the BGL is 15 mmol/L or higher, treat as a line failure following the advice with giving an 'urgent' pen dose of insulin
    Continue BGL and ketones checking until ketones are less than 0.6 mmol/L
    BGL 4.0 - 6.9 mmol/L Bolus as usual for carbohydrate eaten. Encourage small amounts of additional carbohydrate (e.g. small sips of diluted juice or lemonade icy poles) to maintain BGL and assist in clearing 'starvation ketones'.
    BGL Less than 3.9 mmol/L Treat hypoglycaemia and encourage sweet fluids. Consider mini dose glucagon if not tolerating hypo treatment. Consider using a temporary basal rate (for manual mode) or for Hybrid Closed Loop use the Temp Target (Medtronic)/Exercise Activity (Tandem T:Slim) or Ease Off (YpsoPump). Continue two hourly BGL and ketones, checking until ketones are less than 0.5 mmol/L or lower.

    Page updated November 2024

  • Seek urgent medical attention or call an ambulance by dialing 000 if: 

    • You have had 3 vomits or diarrhoea or continued stomach pains, especially if these pains are associated with high BGLs.

    • If at any stage, ketones are 3.0 mmol/L or higher, you should give an 'urgent dose' of rapid acting 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.  Remember signs of DKA include; vomiting, stomach pain, rapid breathing, drowsiness.

    • After following the above advice, ketone levels are increasing or remain 0.6 mmol/L or higher. 

    The Royal Children's Hospital (RCH) Sick day service phone number 9345 5522 ask for the 'Diabetes sick day call' 7am – 9pm Monday – Friday (for patients of the RCH).