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1
Those Challenging Times Sick Days, Holidays,
and Parties
Ragnar Hanas, MD, PhD, Department of Pediatrics,
Uddevalla, Sweden
Presented at the CWD conference, Orlando 2003
2
Pediatric and adolescent diabetes in Sweden
? Sparsely populated with large geographical
distances ? High diabetes incidence (3rd in the
world after Finland and Sardinia) ? 6500
children and adolescents up to the age of 20700
new cases/year (0 -18 years)
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 GPs ? 40
centers, the largest with 500 patients,but
most have 75 -150
? Some travel 150 - 200 km to see their
diabetologist ? 50 -100 patients /
diabetologist ? 75 - 150 patients / diabetes
nurse ? Teams with dietician, psychologist,
counselor (social worker)
4
Modern treatment of childhood diabetes
Traditional approach ? Insulin, diet, and
exercise
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
5
What goals do we have?

• ? 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

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
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
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.
9
Sick with fever
? The child usually eats less but the fever
requires more insulin ? Begin by taking the
sameinsulin doses as usual ? 100 F ? often 25
increase of doses102 F ? up to 50 increase of
doses

• ? BG tests before and after each mealUrine
  ketones at every voiding in blood if positive
• ? Check blood ketones if vomiting or nauseous

10
Insulin during sick days

• Illness that raises BG
• ? Increase doses if needed High BG prior to a
  meal à ? premeal dose by 1 - 2 U or according to
  correction dose
• Multiple inj. à ? next day basal insulin by
  1-2 UPump à ? basal rate by 0.1 - 0.2 (if
  needed 0.2 - 0.4) U/hour
• High BG 1 - 2 h. after a meal à ? next day
  premeal dose by 1 - 2 U

? Count doses according to body weight ? Persons
in remission phase may need to increase up to 1
unit/kg/dag very quickly!
11
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!
12
Gastroenteritis

• ? Vomiting with diarrheaor only diarrhea
• ? Low blood glucose levels
• ? Always check for ketonesin 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 1 - 2 U or according to
  correction dose
• Multiple inj. ? ? next day basal insulin by
  1-2 U Pump ? ? basal rate by 0.2 - 0.4 U/hour
• Low BG 1-2 h. after a meal ? ? next premeal dose
  by 1 - 2 U

13
Gastroenteritis

• ? Give drinks containing sugar (not Light) in
  small and frequent portions (several sips every
  10-15 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 failslt 2 years 2 units in a
U-100 syringegt 2 years 1 unit/year up to 15
units (0.15 mg)Repeat after 1 hour or more if
neededHaymond MW. Diabetes Care 200124643-45.
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 gt 220 mg/dlFluids containing
  carbohydratesif BG lt 220 mg/dl (12 mmol/l)

15
What happens if the pump stops?
? Humalog/NovoLog gives a smaller depot ? Must
be able to manage a night without insulin ? The
pump is stopped for 6 - 8 hours while the
patient is at the day-care ward
16
A healthy cell
Cell
Insulin
Blood vessel
Urine test shows
O2
Co2 Water Energy
Glucose Ketones 0 0
17
Starvation
Cell
(Insulin)
Blood vessel
Urine test shows
in liver
Fattyacids
Ketones
Glucose Ketones 0
18
Diabetes - lack of insulin
Cell
Blood vessel
Urine test shows
in liver
Fattyacids
Ketones
Glucose Ketones
19
Ketone bodies in a healthy person
Blood vessel
Liver cell
Fattyacids
Mitochondrion
StarvationLow insulinHigh fat diet
Fatty acyl CoA
Acetoacetate
Acetoacetate
20
Ketone bodies increase when there is a lack of
insulin
Blood vessel
Liver cell
Fattyacids
Mitochondrion
Low insulin
Fatty acyl CoA
Acetoacetate
Acetoacetate
21
Urine ketones can be false neagative!
Blood vessel
Liver cell
Fattyacids
Mitochondrion
Low insulin
Fatty acyl CoA
Acetoacetate
Acetoacetate
Ketones can only be detected by blood testing
22
Urine ketones decrease slowly after insulin
treatment
Blood vessel
Liver cell
Fattyacids
Mitochondrion
High insulin
Fatty acyl CoA
Acetoacetate
Acetone
Beta-hydroxybutyrate
Beta-hydroxybutyrate
23
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
x
20 18 16 14 12 10 8 6 4 2
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 7.28 7.31 7.36Ketones 3.6 3.0 0.2BG high 4
50 305 mg/dl
8 10 12 2 4 6 8 10 12 2 4
6 8 AM PM
AM Time
Needle came loose
New needle inserted
24
High blood glucose and ketones

• Repeated BG gt 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

25
How should blood ketones be interpreted?
Ketones BG 180-270 270-400 mg/dl gt400 mg/dl lt
0.5 mmol/l No problems Test again after 1-2
tim. 0.5 - 0.9 mmol/l Test again 0.05 U/kg 0.1
U/kg 1.0 - 1.4 mmol/l Eat and take 0.1
U/kg 0.1 U/kg, x 1-2 0.05 U/kg
1.5 - 3 mmol/l Eat and take 0.1 U/kg. x 1-2
0.1 U/kg. x 1-2 0.1 U/kg gt 3 mmol/l Eat and
take 0.1 U/kg, x 1-2 0.1 U/kg, x 1-2 0.1
U/kg Contact your diabetes team or emergency
ward!!
Samuelsson, Diabetes Tech. 2002Laffel, poster
426, ADA 2002
? Every pump user should be able to test blood
ketones ? Also very helpful for younger children
26
Sick day rules
? Glucose monitoring (with adult supervision
even in adolescents) every 3-4 h. and
occasionally every 1-2 h. with results recorded
in a log book ? Testing for ketones every 2-4
h.Check blood ketones if positive in urine ?
Continuation of 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. 199912122-35
27
Sick day rules

• ? Antipyretics (acetaminophen) to treat fever
• ? Antiemetics if severe vomiting prevents
  adequate fluid intake

• ? Continue giving insulin and administer extra
  doses for as long as blood glucose and/or ketones
  are high
• ? Recognition 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. 199912122-35
28
When do you need to go to the hospital?

• ? Large or repeated vomiting
• ? Increasing levels of ketones or laboured
  breathing
• ? Continued high BG level gt 270 mg/dl (15
  mmol/l) despite extra insulin
• ? Unable to keep BG gt 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
29
When do you need to go to the hospital?

• ? The child is young (lt 2 - 3 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
30
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 surgeryI.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!

31
Insulin resistance in changed by the BG level
High level due to infection ? ? insulin
resistance a
Blood glucose level
1-2 weeks a
32
Insulin requirements increase with fever
Cold with fever a
Insulin requirements
Increased insulin resistance due to fevera
33
Insulin requirements decrease when having
gastroenteritis
Gastroenteritis withvomiting, diarrhea a
Insulin requirements
Decreased insulin resistance due to low BG
levelsa
34
Holidays and travelling
35
Isnt it difficult to go abroad if my child has
diabetes?
When a problem is too large or seems
unsolvable, dont forget that you can eat an
elephant if you cut it into small enough
pieces Slavian saying
36
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 meter1 mmol/l 18 mg/dl
• ? Finger-pricking device lancets
• ? Test strips for ketones (blood and/or urine)

37
Diabetes equipment to bring on the trip

• ? Dextrose/glucose tablets and gel
• ? Glucagon

• ? Clinical thermometer
• ? Fever suppressing drugsParacetamol/acetaminoph
  en 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

38
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.
• ? Dose200 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.

39
Passing time zones

• Multiple injections/pump
• ? Going west (longer day) Extra meals and doses
  of mealtime insulinUsual dose of bedtime
  insulin/pump basal rate for the new night

• ? Going east (shorter day)Decreased number of
  meals and mealtime dosesUsual dose of bedtime
  insulin/pump basal rate for the new night
• ? Dont forget to adjust the clock of the pump!

40
Passing time zones

• 2-dose treatment
• ? Going west (longer day) Extra meals and doses
  of mealtime insulinUsual dose of bedtime
  insulin/basal rate to the new night

• ? Going east (shorter day)Decreased number of
  meals and mealtime dosesTake mealtime insulin
  with last meal before sleepingShort-acting
  insulin no bedtime insulinRapid-acting insulin
  small dose of bedtime insulin
• ? Reduce next intermediate-acting dose with 3-5
  per time shift hour on long flights Sane
  T. BMJ 1990301421-22

41
Always call your home team
? You are never longer away from home than a
telephone call ? Ask for a doctors contact
before leaving homeCheck www.ispad.org for names
of doctors
? Staying at a hospital where you dont
understand the language is a difficult
experience ? Try to find a childrens hospital in
an emergency situation ? With glucagon and
frequent monitoring you can prevent most
emergencies!
42
Diabetes camps
? Family camp - 9 Scout camp 10
-12 Skiing trip 13 -15 Sailing ship 16
-19 Diabetes education camp activities
43
Ice cream test at diabetes camp
Blood glucose Mmol/l.
16
NAME
14
andreas
mathias
12
kristian
10
linn
caroline
8
emma
6
sofia
4
ida
mililla
2
60 min.
30 min.
90 min. after
Before ice cream
? Nothing is forbidden, the important thing is to
experiment and find your own ways
44
Diabetes camps
? China 17 participants, 8-13 years, 2 days
campSignificant improvement in- Using
glucose-monitoring devices, drawing insulin,
injecting insulin and choosing the right
exchange of food. Lee YJ.
Zhonghua Min 199233280-5.
? USA 148 participants, 13-17 years, 1 week
campMore use of problem-focused strategies in
stressful situations and less use of avoidance
strategiesSmith KE. Diab Educator 19911749-53.
? Sweden 32 participants, 6 days campIncreased
diabetes knowledge after using Bodylink Hanas
R. Poster ISPAD 1994.
45
Diabetes camps
? USA 86 participants, 13-17 years, 1 week
campSignificant increase in adolescents ideas
on Expressing needs and views that differ from
othersExpressing feelings openlyMaking
requestsSaying no to unreasonable
requestsInitiating and concluding
conversationsSmith KE. Diab Educator
19931936-41.
? Italy 256 participants, 8-16 years, 8-15 days
campSignificant improvement in- Knowledge and
self-management.- HbA1c improved in 74 patients
that attended monthly meetings after camp.
Misuraca A. Diab Res Clin Pract 19963291-96.
46
School camps
? Important to be able to join friends ? No
medical staff that can handle emergencies ? Ask
one teacher or supervisor to take
responsibility ? Parent may need to accompany a
younger child ? School staff can attend at a
visit to the clinic
? Check the program for meals and activities in
advance and plan together with your child ?
Higher level of physical activity à lower doses ?
Check that hypo food is available, also at
off-hours
? Most important is to be able to have fun, not
to have a perfect BG!
47
Parties
48
What does it mean to have diabetes ?
49
Birthday parties

• ? Learn to eat the food that is served,i.e.
  dont bring a bag of diabetes food
• ? Check that diet soft drinks (Light) are
  available

• ? The children often play around a lot ? risk of
  hypoglycemiaProvide the host with hypo advice
• ? Take an extra unit for the cake if needed

• ? Bag of sweets can be brought home and eaten at
  suitable occasions
• ? Birthday parties should be FUN so it is better
  to have a slightly higher BG than a hypo!

50
Can you stay up all night...?
? All night parties Temporary night work ? Let
the pumpbasal rate run as usual or take Lantus
as usual ? Take usual dose of NPH insulin when
you go to bed if you intend to sleep 8-10
hours, otherwise decrease the dose
? Take bolus doses as usual when you eat every
4-5 hours ? Take the breakfast dose when it is
time to have breakfast ? Alcohol will make you
think less clearly!
51
What do kids eat in real life?
Blood glucosemmol/l
Ordinary snackChocolate bar
mg/dl
21518014511070
1210864
0 30 60 90 120 150 180 min.
Cedermark G. Eur J Pediatr 1993152635-39.

• ? A chocolate bar gives same blood glucose
  response as a sandwich with equal carbohydrate
  content
• ? No good for treating hypoglycemia!

52
Potato chips
? Potato chips, 1 oz., 28 g (one adult handful)
? same content of fat (10g) and
carbohydrate (15g) as a sandwich with
cheese
Blood glucosemmol/l
Ordinary snackChocolate barPotato chips
mg/dl
21518014511070
1210864
0 30 60 90 120 150 180 min.
Cedermark G. Eur J Pediatr 1993152635-39.
? Practical for preventing night-time
hypoglycemia after physical activity
53
Weekend candies
Blood glucosemmol/l
mg/dl
? Take a sandwich first!(or some potato chips)
? Candies after a meal are also OK take
insulin to cover the total amount of
carbohydrate ? Important to have the same rules
for candies as healthy siblings
21518014511070
1210864
3 sanwiches (white bread) 1 sandwich and 9 jelly
beans
0 30 60 90 120 150 180 min
Cedermark G et al. Act Ped Scand 199079473-74
54
Ice cream
Type 1 diabetes Diabetes insulin Without
diabetes
Blood glucosemmol/l
? Dairy type ice cream affects blood glucose
like a sandwich ? Good snack on the beach
1412108642
? No good for treating hypoglycemia! ? Insulin
with ice cream is a good idea ? Popsicles are
like frozen lemonade
-40 0 40 80 120 150
min Nathan et al. JAMA 19842512825-7. 100g
ice cream (24 carbohydrate, 11 fat)
Insulin 3 - 5 U
55
End