9.1. Intercurrent illness

Illness associated with fever tends to raise blood glucose due to higher levels of stress hormones, gluconeogenesis and insulin resistance. Illness associated with vomiting and diarrhoea (for example, gastroenteritis) may lower blood glucose and possibility cause hypoglycaemia.¹⁵

We found no studies that evaluated advice for treatment of intercurrent illness in children and young people with type 1 diabetes.

A consensus guideline provided the following guidance regarding management of children and young people with type 1 diabetes during intercurrent illness.¹⁵ [evidence level IV]

The diabetes care team should provide clear guidance on managing diabetes during intercurrent illness to avoid the complications of dehydration, ketoacidosis and hypoglycaemia. Guidance should include the following:

• Never stop insulin.
• Advice should be available on alterations of insulin dose.
• When to contact the diabetes care team, general practitioner or hospital.

More frequent monitoring:

• Frequent blood glucose testing (at least 4 times daily) with appropriate changes to insulin dose facilitates optimal management during illness.
• Urinary ketone tests will guide management.
• Adequate supplies of blood glucose and ketone test strips should be available to avoid complications during intercurrent illness.

Loss of appetite:

• Replace meals with easily digestible food and sugar-containing fluids.

Maintaining hydration:

• Hyperglycaemia, fever and excessive glycosuria increase fluid loss.
• Encourage frequent intake of fluids, for example, water or reduced sugar fluids.

Specific medical advice:

• Treat fever, malaise and headache with antipyretics such as paracetamol.
• Vomiting may be caused by the illness itself (when blood glucose may be low) or lack of insulin (when blood glucose will be high and ketones may develop).
• Consider treatment of vomiting with a single injection of an anti-emetic to help oral intake of carbohydrate.
• Sugar-free medicines for children and young people are advisable but not essential.
• Infection associated with hyperglycaemia with or without ketosis:
• Recommend additional doses of short or rapid-acting insulins with careful monitoring to reduce blood glucose, prevent ketoacidosis and avoid hospital admission.
• The dose and frequency of insulin injections will depend on the age of the child, the level and duration of hyperglycaemia, the severity of ketosis and previous experience with alterations of insulin.
• For example, for a sick child, blood glucose 15 to 20 mmol/l with or without ketosis, advise to take 10 to 20% of total daily insulin dose (or 0.1 units/kg body weight) as short- or rapid-acting insulin analogue every 2 to 4 hours until blood glucose falls to <15 mmol/l. Thereafter any additional doses might be 5 to 10% of the total daily dose.

Infections associated with hypoglycaemia:

• These infections are often associated with nausea and vomiting with or without diarrhoea.
• Advise replacing meals with frequent small volumes of sugary drinks and careful blood glucose monitoring.
• Reduction of insulin dosage by 20 to 50% may be required.
• If hypoglycaemia (and nausea or food refusal) persists, an injection of glucagon may reverse the symptoms of hypoglycaemia and enable oral fluids to be re-established.

In a child or young person with intercurrent illness, urgent specialist medical or nursing advice must be obtained when:

• the diagnosis is unclear
• vomiting is persistent (particularly in children)
• blood glucose continues to rise despite increased insulin requirements
• hypoglycaemia is severe
• ketonuria is heavy and persistent
• the child becomes exhausted or confused, is hyperventilating or dehydrated, or has severe abdominal pain.

When metabolic control is persistently unsatisfactory or if blood glucose monitoring is inadequate or unavailable, intercurrent infections may be more frequent and more severe. In such situations:

• Advise more frequent urinary glucose and ketone testing
• Give clear guidance on alterations of insulin dosage to prevent ketoacidosis.

If sudden repeated episodes of hyperglycaemia with vomiting occur, it should be recognised that this may be due to omission or inadequate administering of insulin.

This section of the 2004 guideline included a recommendation to offer clear guidance and protocols (‘sick day rules’) for children and young people with type 1 diabetes during intercurrent illness. The guideline development group for the 2015 update replaced this recommendation with a more specific recommendation highlighting the need during intercurrent illness and episodes of hyperglycaemia for monitoring of blood glucose and blood ketones (rather than urine ketones as reflected in the guidance reviewed above as part of the 2004 guideline) and for adjustment, if necessary, of insulin and food and fluid intake and when and where to seek further advice or help. This was considered important because such advice could reduce the risk of diabetic ketoacidosis (DKA).

9.2. Surgery

We found no studies that investigated the management of children and young people with type 1 diabetes before, during or after surgery.

A consensus guideline made the following recommendations regarding children and young people with type 1 diabetes who require surgery or fasting.¹⁵ [evidence level IV]

Children and young people with type 1 diabetes who require surgery:

• should be admitted to hospital for general anaesthesia
• require insulin, even if they are fasting, to avoid ketoacidosis
• should receive glucose infusion when fasting before an anaesthetic to prevent hypoglycaemia.

Elective surgery:

• Operations are best scheduled early on the list, preferably in the morning.
• Admit to hospital the afternoon prior to surgery for morning and major operations, or early morning for minor operations later in the day.
• Earlier admission is important if glycaemic control is poor.
• Admission should be to a paediatric diabetes or paediatric surgical ward.

Evening prior to elective surgery:

• Frequent blood glucose monitoring is important especially before meals and snacks and before bedtime (and urinary ketones should be checked).
• The usual evening or bedtime insulin(s) and a bedtime snack should be given.
• Ketosis or severe hypoglycaemia will necessitate correction, preferably by overnight intravenous infusion, and might cause delay in surgery.

Morning operations:

• No solid food from midnight.
• Clear fluids may be allowed up to 4 hours pre-operatively (this should be checked with the anaesthetist).
• Omit usual morning insulin dose.
• Start intravenous fluid and insulin infusion at 6.00 to 7.00 a.m.
• Hourly blood glucose monitoring pre-operatively, then half-hourly during operation and until woken from anaesthetic.
• Hourly blood glucose monitoring 4 hours post-operatively.
• Aim to maintain blood glucose between 5 and 12 mmol/l.
• Continue intravenous infusion until the child or young person tolerates oral fluids and snacks (this may not be until 24 to 48 hours after major surgery).
• Change to usual subcutaneous insulin regimen or short-acting insulin/rapid-acting insulin analogue before the first meal is taken.
• Stop insulin infusion 60 minutes after subcutaneous insulin is given.
• For minor operations it may be possible to discharge from hospital after the evening meal if the child is fully recovered.

Afternoon operations:

• Give one-third of the usual morning insulin dose as short-acting insulin if the operation is after midday.
• Allow a light breakfast.
• Clear fluids may be allowed up to 4 hours preoperatively.
• Start intravenous fluids and insulin infusion at midday at the latest.
• Then as for morning operations (see above).

Emergency surgery:

• Diabetic ketoacidosis may present as ‘acute abdomen’.
• Acute illness may precipitate diabetic ketoacidosis (with severe abdominal pain).
• Nil by mouth.
• Secure intravenous access.
• Check weight, electrolytes, glucose, blood gases and urinary ketones pre-operatively.
• If ketoacidosis is present, follow protocol for diabetic ketoacidosis and delay surgery until circulating volume and electrolyte deficits are corrected.
• If there is no ketoacidosis, start intravenous fluid and insulin infusion as for elective surgery.

Minor procedures requiring fasting:

• For short procedures (with or without sedation or anaesthesia) and when rapid recovery is anticipated, a simplified protocol may be organised by experienced diabetes/anaesthetic personnel and may include either early morning procedures (for example, 8.00 to 9.00 a.m.) with delayed insulin and food until immediately after completion, or reduced usual insulin dose (or give repeated small doses of short/rapid-acting insulin).
• Glucose 5 to 10% infusion and frequent blood glucose monitoring are recommended in all these situations.