Diabetes in a mildly ill child

Assessment

Occasionally an astute clinician makes the diagnosis of diabetes mellitus in a mildly ill child, with <3% dehydration, no acidosis and no vomiting. Baseline investigations should be carried out, as in the child with ketoacidosis. The diagnosis of diabetes mellitus brings with it a lifetime of treatment. The education and care of child and family should be taken over by a team including a pediatrician, nurses and a dietician. However, management can be initiated without admission to hospital.

Management

Initial insulin treatment. Give 0.25 units/Kg weight of quick-acting insulin s.c. stat. If the child is within 2 hours of a meal, give the meal-time dose only. Halve the dose if he or she is under 4 years old. Before breakfast and lunch (7.30 a.m., 11.30 a.m.) give 0.25 units/Kg weight of quick-acting insulin. Before the evening meal (5.30 p.m.) give 0.25 units/Kg weight of quick-acting insulin and 0.25 units/Kg weight of intermediate-acting insulin. If this is the first insulin dose, give 0.25 units/Kg weight quick-acting insulin only, followed by a further 0.25 units/Kg weight quick-acting insulin at midnight followed by a snack.

Ongoing insulin treatment. Once normoglycemia is achieved and ketonuria disappears, you should change the insulin to a twice daily mixture of short and intermediate insulins usually at 1 unit/Kg weight but this may need modification. It should be given as 2/3 in morning and 1/3 at night; 2/3 of each dose should be intermediate-acting, and 1/3 short-acting. Occasionally older adolescents go onto a basal bolus regimen of 30– 40% intermediate acting insulin given at 10 p.m., with the rest given as short-acting insulin in 3 equal doses before meals.

You must inform your consultant about all admissions of children with diabetic ketoacidosis.

Mildly ill hyperglycemic diabetic patients who are already on insulin Children who have already been diagnosed as having diabetes mellitus and who are already on insulin can present to the Emergency Department with a mild illness and hyperglycemia. They are usually advised to take 10% of total daily dose of insulin as rapid-acting insulin every 2 hours until normoglycemic (in addition to usual insulin). You should notify your consultant if there are any management issues that you want to discuss.