Sick days, Pedialyte and correction questions?


#1

I have been working on improving our sick day kit for my 12-year-old T1D son. We have never had a bad sick day when he could not keep anything down yet. This prepping brought a few questions to mind. I am curious what people actually do in practical terms. These questions only apply to sick days when you are throwing up most or all of what you are taking in (common issue with kids of course).

  • I am assuming you don’t pre-bolus before eating when you can’t keep things down? Stupid question I am sure.

  • Do you take rehydrating liquids (such as pedialyte) that have sugar in them? We have a bunch stockpiled (in powder form), but they all have sugar of course.

  • Do you administer most or all of the sick-day insulin as corrections (and basal)?

  • Do you take down your basal a bit just in case when you start throwing up? I know it is counter intuitive when you are sick - I worry about lows when you can’t keep anything down.

  • Do you follow the procedure of injecting a % of your TDD every 2-4 hours as a correction?

FYI, I have read the sick day procedure many times, and I understand (a) the need for insulin and (b) the option of micro-glucagon administration.


Son is having major BG issues after stomach bug & starting pump
#2
  • I am assuming you don’t pre-bolus before eating when you can’t keep things down? Stupid question I am sure.

We don’t prebolus at all. With a stomach bug carb absorption is hampered & sometimes even totally prevented. Prebolusing in this case can be dangerous.

  • Do you take rehydrating liquids (such as pedialyte) that have sugar in them? We have a bunch stockpiled (in powder form), but they all have sugar of course.

My sick day supply includes Pedialyte, but we usually mix it with something with a higher carb count (50/50 with Sprite). I keep Pedialyte pop ice bars, powdered Gatorade, peppermint sticks (old fashioned sugar sticks) & spearmint tea (helps soothe & settle the tummy), ginger ale, full sugar popsicles, regular Sprite/7up, Jello & applesauce cups.

  • Do you administer most or all of the sick-day insulin as corrections (and basal)?

For stomach bugs it’s mostly basal since carb absorption is a affected. I can’t remember ever needing to give a BG correction during a stomach virus, & my daughter seems to have at least a couple per year.

  • Do you take down your basal a bit just in case when you start throwing up? I know it is counter intuitive when you are sick - I worry about lows when you can’t keep anything down.

Basals are always adjusted as needed during illness of any kind. This is particularly true for stomach issues.

  • Do you follow the procedure of injecting a % of your TDD every 2-4 hours as a correction

Only with ketones.

Stephen Ponder’s sick day video. Good tips.


#3

I would suggest getting the precision blood glucose/ketone meter. I haven’t had to experience this with my children yet, but I know when my T1 husband gets sick getting fluids down him to get a urine sample to check ketones can be difficult. This way you can check for ketones even if your child’s urine output is not there.


#4

Blood ketones are also much more up-to-date and accurate than urine ketones.

I’d also put a glucagon kit and/or instructions for mini-dose glucagon (available on Children with Diabetes) with other sick supplies.


#5

I don’t know if you’ve see Bernstein youtube, he may have some valid points on his 9 ‘managing illness’ ones.
The first 3 are on deydration


#6

I’ve read Dr Bernstein’s book & have found quite a bit of good info. That said, his tips in this video would be of no use to me, & I don’t agree with his comments on ketone testing with an illness involving vomiting.

As I stated above, my daughter has battled stomach bugs numerous times. She has never had a high BG with any of them. In fact, she almost always runs low for 24-36 hours before symptoms, & we have to lower both basal & bolus for 1-2 weeks after. In discussions with other parents, this is the norm for their kids as well.

We keep Zofran tabs on hand for nausea. They dissolve instantly under the tongue. Before Zofran, we used Emetrol (available OTC) & I still keep it on hand for milder bouts of vomiting.

We absolutely check ketones regularly. We threw out the urine strips a couple of weeks after dx. The blood ketone meter is more timely, & they detect a different type of ketone. We expect to see a small amount of (starvation) ketones, but the goal is to give enough carby liquids to keep them below 1-1.5. Dr Ponder’s guidelines are focused more on kids. Dehydration & ketones are a bigger risk in kids, because they can spiral downward into DKA much faster.


#7

Rather than Pedialyte, simply use a no-sugar electrolyte which has become very common as a sports drink. You can walk into any grocery store and find them. I’ll often use Poweraid zero which comes not only premixed but as drops.


#8

It’s one in a series, perhaps your concerns are addressed in another?

He would agree with what you said though, wouldn’t he? From what I gather, normal/near norm BG and ketones is treated with food/glucose fluid and the appropriate bolus. To fix the starvation/hunger ketones? It can happen when a kid is off his food.

From what I saw, I took that he prioritises BG and hydration, although he does ask his patients to record their ketones, he doesn’t seem concerned with low levels. I guess he thinks if you focus on this, high ketones/DKA won’t happen.

In the series, he strongly disagrees with the standard practice of hooking someone with normal or high BG to a glucose drip, or saline containing glucose/sugars. In the video series he said, this can induce DKA and kids can have a 50% mortality. If I had a T1 child, I would look more deeply into this.


#9

Ive already said I’ve read Dr Bernstein’s book. It was among the first books I bought after my daughter’s dx. Ive also watched several of his videos, & sat in on some of his online presentations. I just disagree that this video is appropriate for treatment in kids.

My daughter’s last visit to the ER/hospital was at dx, almost 8 yrs ago. While I’ve never ruled out a trip to the ER during a battle with a stomach virus, following Dr Ponder’s guidelines has kept me from needing to.

The issue with even a low level of ketones in a sick child is simple. They’re not adults. Dehydration can occur more quickly, particularly since you can’t really force a child to drink when they’re sick. The biggest problem I’ve had with my daughter with this type of illness is keeping her BG up. You cannot give insulin to help clear ketones if the BG is already low & you can’t get them to drink enough carby liquids, & food can make the problem worse.

There’s no way I would follow his advice to check BG/ketones in 5 hrs. In that span of time a child could go from low-moderate ketones to DK. I don’t know rapid-acting insulin he’s referring to when he advises to check in 5 or 10 hours, but none of the 3 my daughter has been on has lasted near that long. Maybe the video is dated?


#10

@Brian_BSC, I thought you needed the sugar to keep nausea at bay when you take these electrolytes, and that shorting it would cause nausea? I could be wrong.


#11

I have never heard this. Why would sugar do anything to reduce nausea?


#12

It is the reason why you are supposed to drink electrolytes when you are throwing up. When your electrolytes are out of balance any liquid you drink that takes you away from electrolytic balance will tend to make you throw up more. That’s what the children’s pediatrician explained to me.

That is why, if you give clear water to a child who has been throwing up for a while, it will make him throw up more.

EDIT: but I am not 100% sure this applies to sugar.


#13

I didn’t see it that way, he prioritises hydration, It is very much hydration and BG, if the BG is right, there isn’t hgh ketones.

Just my take on it. If normal BG, you check every 5 hrs, if it’s high, correct and check frequently. 2 hourly checks and corrections if needed, would be the norm.

what hs is different with from what I have read, is that he doesn’t agree with dosing up high glucose and insulin with normal BG with low ketones. Most people on low carb have ketones anyway. you aren’t going to kick in sick day rules.

Just my take on it…Even if not on low carb, ketones are part of being sick and not eating. Normal ketones (including those from LC and lack of eating) aren’t a concern unless the BG is high, Then you treat the high BG and the ketones sort out. low ketones are a warning, they aren’t DKA… lack of hydration, high BG and low insulin leads to DKA

I’ve previously posted this link and chart to sick day rules, which seems to cover it well



#14

I think it’s well worth sacrificing one large dose of glucagon for 24 hours or more of mini-glucs for nausea. They usually go out of date quickly enough anyway.

I haven’t had to manage insulin and nausea in another person but it’s been relatively easy for me. If I feel nausea, I don’t eat or dose. I might sip on a sugar ginger-ale if needed. I think I do better if I fast or eat lightly.

I use a pump so I’d keep my basal running and have administered a high temp basal if there’s some kind of infection going on. I’ve gone as high as double to triple basal or more for extended multi-hour periods.

I know you’ve written about high temp basals in one of your comments and I was impressed that you seemed to be aware of the inconsistent high temp basal terminology between pump brands. Some pump use a “200%” high basal as a doubling of the background basal rate while my Animas uses the “+100%” terminology to mean 2x, “+200%” = 3x.


#15

what hasn’t been talked much about is intramuscular insulin injection, for those on MDI. That can be an option when the BG is peaking. I don’t know how well that can work on a pump as an ancillary method, but it might be worth talking to the endo.


#16

I was told to give the vomiting child teaspoons of sugar every half hour, just one teaspoon. They can usually keep that down for an hour or so and then you can increase to sips of water.


#17

Without question, Caleb does not absorb all his carbs when he has a stomach bug. It is a struggle to keep his blood sugar up. So bolusing rules are thrown out the window. We have a watch and react approach. Basal insulin continues, but at a lower level.

Caleb typically hydrates with water or gatorade if he needs it.

We’ve found an effective way to raise blood sugar is through a juice concentrate. A small frozen spoonful is usually easily tolerated.


#18

Don’t forget–just holding the spoonful of sugar (or honey, or maple syrup or Dex gel) in your mouth without swallowing will raise the BG–an old trick I last used with an unconscious hypoglycemic patient in 1980 ( with good results within ten minutes!). I had forgotten about it till my endocrine reminded me when I had bad gastroparesis with Bydureon & oral glucose seemed to take forever to correct hypoglycemia. Oral membranes in cheeks and under the tongue absorb glucose pretty quickly without aggravating nausea.

P.S. Glucagon has not always been available for home use–'twas only approved for medical use in 1960!


#19

My son was diagnosed at age 14 in August 2018 with T1D. We are also still in his honeymoon period. He he had his first stomach bug/flu last week. We struggled to keep his BG up because he was not eating much at all. He did gets lots of water and juice in him and some crackers. Because of that, we decreased his basal and didn’t bolus at all. He was on Tamiflu for 5 days and Tylenol for 2 days as well. He has been well for 3 days now but his insulin needs are still not back to where they were before sickness. He actually is not taking any insulin at all and we are watching his numbers. He wears a Dexcom G6. They stay around the 95-110 range between and before meals and at night. After regular meals of between 50-75 carbs, the highest BG we have seen so far is 169. His endocrinologist told us to watch closely and wait. It was just very odd the first day he was back to feeling well, any carbs he ate would only barely raise his BG. It is like his body was not absorbing carbs very much at all. I would love to hear from more people who have experienced this same or similar situation.


#20

@susanjackson

What is the lowest you have seen the BG go? When it went at this low number, how long did it stay low. What did you do to raise it and what number did it come up to?

Reason for question is people have EXTREMELY different ideas in their head when discussing “Low BG” and “High BG”. Without having a bit more concrete info around that then it is very easy for the conversation to not make much sense based on very different ideas in people’s heads and based on their own personal experiences.