Children with type 1 diabetes are not at increased risk of illness or infection if their diabetes is well managed. However, children whose diabetes is not well managed may be more prone to illness or infection because of lowered immunity.

Illness and infection may have varying effects on BGLs, from little or no effect to high or low BGLs.

Managing sick days

1. Treat the underlying illness
Seek medical help early in case antibiotic or other treatment is required.

2. Relieve symptoms
Treat fever, headaches, aches and pains with paracetamol. Sugar free syrups and mixtures should be used where possible, however added sugar in medications taken in small amounts is not harmful.

3. Give plenty of fluids
High BGLs and fever cause more fluid loss when a child with diabetes is unwell. If high BGLs persist, then dehydration worsens. If BGL is above 15mmol/L, water or sugar free / low joule drinks should be offered to prevent BGLs going higher. If BGLs are low, sugar containing drinks are suitable. Follow the guidelines below for managing low or high BGLs during illness.

4. Don’t skip insulin
You may need to adjust your child’s insulin dose, discuss with your diabetes team.

5. Monitor BGLs
It’s important to monitor BGLs at least every 2 hours. Follow the guidelines below for managing low or high BGLs during illness.

6. Check for ketones
Check for ketones using ketone testing strips or a meter that tests for blood ketones. If ketones are present, your child will need extra insulin, contact your diabetes team for advice.

7. Replace meals with suitable alternatives
If your child is not tolerating normal meals, offer food and fluids that they can manage. If BGLs are low, ensure adequate carbohydrate by offering alternatives. Suitable sick day foods that provide one exchange of carbohydrate include:

• ½ - ¾ cup regular soft drink (eg. lemonade)
• 1 slice dry toast
• 2 plain sweet biscuits
• ½ cup regular jelly
• ½ cup mashed potato
• 100ml Lucozade
• 1 cup milk

If BGLs are high and your child's appetite is poor, water and sugar free fluids are sufficient.

8. Rest
If your child is unwell, avoid sending them to school. It is important that an adult stays with them. Your child should avoid vigorous physical activity, especially if ketones are present.

9. Seek medical advice
Seek medical advice when:
• Your child’s vomiting persists - this is a serious sign that the illness is worsening
• BGLs remain consistently under 4mmol/L
• BGLs remain consistently above 15mmol/L
• Ketones persist, despite giving extra insulin
• Signs and symptoms of DKA are apparent (DKA section)
• You feel unable to cope with managing your child's illness

Illness / Infections and high BGLs

Illness with high BGLs and the presence of ketones in the urine or blood is a sign of a lack of insulin and will require additional doses of short acting insulin as well as continued BGL monitoring. Use the information you have from the diabetes team to work out extra doses or insulin, or if unsure, contact your diabetes team.

This situation can progress quickly to DKA (DKA section) and needs urgent medical assistance and hospitalisation.

Illness / infections and low BGLs

Some illnesses and infections can cause low BGLs. These include those associated with nausea, vomiting and/or diarrhoea.

Illness with low BGLs requires frequent small amounts of carbohydrate containing fluids, BGL monitoring every 2 hours and a possible reduction of insulin. Oral rehydration solutions may also help replace fluid and salt losses. Discuss with your diabetes team.

If your child has consistently low BGLs during illness, cannot tolerate food or fluids by mouth and/or is vomiting, a subcutaneous injection of a small dose of glucagon (mini-dose glucagon) may reverse the low BGLs. This should be done under the supervision of your doctor or diabetes educator and may help avoid your child going to hospital. It's very important that you monitor BGLs frequently after giving glucagon. Discuss this with your diabetes team.

Managing sick days on an insulin pump

The same principles for managing sick days apply for children on insulin pumps and those on insulin injections. Children on pumps only use short acting insulin and have no reserve of long acting insulin. They may therefore rapidly develop high BGLs and are at greater risk of DKA. High BGLs must be taken seriously in children on insulin pumps.

If BGL is 15 mmol/L or above check for the problems with the insulin pump or site. Pens or syringes should be on hand to give insulin if the pump fails. Remember to check for ketones if BGLs above 15mmol/L. Follow the usual sick day management guidelines in conjunction with your diabetes team.

Mini-dose glucagon

Sometimes children with diabetes experience illnesses that are not severe, yet their blood glucose levels (BGLs) are low (under 4mmol/L) and they are reluctant or unable to eat or drink enough to raise the BGLs up to satisfactory levels. This is especially common in young children and toddlers. While this is not classed as severe hypoglycaemia it could become so, and if BGLs cannot be raised it may mean a visit to hospital for intravenous fluids.

The method of administering glucagon in a mini-dose has been developed as a way of raising BGLs in such circumstances until the child is eating or drinking better. It can help avoid an admission to hospital.

This method of sick day management is used by some of the Paediatric Diabetes Units in NSW, and should only be used in conjunction with phone advice from a diabetes educator or doctor. They will advise you of its suitability, how to administer it or whether your child will need to go to hospital.