Dear Colleagues,

As the world is currently dealing with the unprecedented coronavirus (COVID-19) pandemic and trying to minimise the rate of its spread, we felt it was timely to remind you about the potential adverse effect illness can have in children and young adults with type 1 diabetes. Please remind your patients and families.  The below downloadable wallchart can help to create awareness of adequate sick day management.

It is impossible to predict how a particular individual will respond to COVID-19. Many people will only have a minor illness, but others will be more severe. The more severe cases particularly occur in older people. It is not thought that young people with diabetes are more at risk of the effects of the virus. However, if there is an epidemic in your region, some young people with diabetes will get sick, like the general population. They will then be at risk of high-blood glucose levels (which can result in diabetic ketoacidosis) or sometimes low-blood glucose levels. The standard sick-day management rules apply:

• Never stop insulin. Doses may need to increase (or decrease) as appropriate.
• Extra fluids.
• Frequent checking of blood glucose levels and urine ketones
• If they become increasingly unwell, they should be cared for in a clinic/hospital setting staffed with health professionals experienced in managing type 1 diabetes.

• Many illnesses, especially those associated with fever, raise blood glucose levels because of the effect of stress hormones. The increased resistance to insulin can increase ketone production and increase the risk of life threatening diabetic ketoacidosis.
• Illnesses with gastrointestinal symptoms (e.g. diarrhoea and vomiting) may lead to lower blood glucose levels and hypoglycaemia due to decreased food intake, poor absorption and changes in intestinal motility. Nevertheless, when vomiting occurs in a child with diabetes, it should always be considered a sign of insulin deficiency (impending ketoacidosis) until proven otherwise.
• Additional insulin is usually necessary to control blood glucose levels (unless the illness causes hypoglycaemia).
• Aim for a blood glucose level between 4-10mmol/L (70-180mg/dl) when the child/young adult is ill and negative to trace urine ketones (blood ketones below 0.6mmol/L).
• Adequate fluid intake is crucial as fever and hyperglycaemia can cause increased fluid losses. Monitor and maintain hydration with adequate water and salt balance. Oral rehydration fluid provides a source of fluid, energy and electrolytes.

1. DO NOT STOP INSULIN during sick days, even though the child is ill and not eating normally. Insulin may need to be increased or decreased, based on the blood glucose level and food intake – see point 6 and 7 below.
2. Treat the acute illness: treat fever with paracetamol (not aspirin or ibuprofen)
3. Increase monitoring of blood glucose levels to 3–4 hourly (and more frequently if the glucose level fluctuates widely or changes rapidly).
4. If home monitoring test strips are not available, the child should be taken to a healthcare facility for regular testing.
5. Monitor urine or blood ketones 1-2 times per day if possible.
6. If blood glucose levels are elevated, with absence or small amount of ketones: Give 5-10% of total daily dose of insulin (or 0.05-0.1 U/kg) as short or rapid-acting insulin, and repeat every 2-4 hours. Total Daily Dose is the sum in units of all insulin injections on a normal day.
7. If blood glucose levels is elevated, with moderate or large amount of ketones: Give 10-20% of total daily dose of insulin (or 0.1 U/kg) as short or rapid-acting insulin and repeat every 2-4 hours.
8. Give sugary fluids and water.  If the child/young adult has no appetite or is vomiting, give small amounts of fluids frequently. Small children become dehydrated very quickly. Check weight to assess dehydration.
9. If blood glucose is low with ketones, (starvation ketosis) more sugary drink is needed until target blood glucose levels are achieved before more insulin is given.

• If nausea or vomiting persists for more than 2 hours and prevents the child or young adult from drinking; especially very young children may become dehydrated more rapidly
• If parents or young adult are unable to check blood glucose levels at home
• If supportive care as described in point 1 to 9 above cannot be ensured at home
• If the acute illness is severe
• If there is persistent (more than 4-6 hours) ketonuria (moderate or large amount of urine ketones) despite extra short or rapid acting insulin