How Do I Treat Her Vomiting When She has Diabetes and Can't Drink?

Patient Presentation
The mother of a 4-year-old female with Type I diabetes mellitus telephones because her daughter has woken up after her nap and has had two episodes of vomiting and one episode of diarrhea in the past 2 hours.
She has been taking some sips of water. Her blood sugar is 246 with small ketones in her urine. She is afebrile with no upper respiratory tract symptoms or rashes. She has been previously well but there is gastroenteritis at the church daycare program where she went yesterday.
This is her first significant illness since she was diagnosed with diabetes.
The past medical history reveals that she was diagnosed 5 months ago with diabetes after her parents noticed that she had increased thirst, urination and then began vomiting.
The family history showed coronary artery disease, and Type II diabetes mellitus in a maternal grandmother.
The mother reports that physically she appears tired but has no mental status changes. She is willing to drink but has only taken about 2 ounces.
The diagnosis of gastroenteritis with emesis in a child with Type I diabetes is made. The mother and the physician read over the illness treatment protocol together that the regional pediatric endocrinologist has supplied to both of them and asked them to follow.
The protocol tells the mother to give an extra 10% of the total daily insulin dose immediately and to give this extra dose as short-acting insulin. The mother will not give anything to eat or drink for two hours and then re-check the blood sugar and ketones. She will then give small amounts of water or diet soda every 10 minutes for the next 2 hours.
In 4 hours, if the blood sugar is still above 240 and ketones are still present, the mother will give another injection of short-acting insulin and will call the pediatric endocrinologist for more instructions. If the blood sugar and ketones appear to be improving the mother will call the local pediatrician to report on her daughter’s condition.
The mother is instructed to call the local pediatrician back sooner if her daughter seems to worsen.

Discussion
Diabetes mellitus type 1 is a chronic metabolic disorder caused by the lack of insulin.
Insulin is made in the Langerhans cells in the pancreas and congenital absence or destruction of the cells produced type 1 diabetes (or insulin-dependent diabetes mellitus) where patients are dependent on exogenous insulin.
Overall there is an incidence of 15/100,000 annually for diabetes. An estimated 3/1000 children develop type 1 diabetes by age 20.

Learning Point
Diabetes treatment is always improving because of ongoing research efforts. Aggressive monitoring and treatment for intercurrent illness is imperative so as not to worsen the catabolic state.
Treatment is directed at reversing the catabolic state and returning the patient to an anabolic state.

Ketone Treatment without Emesis

 Urine Ketones	Blood Ketones 	Treatment
 		in mmol/L
 Negative	<0.6		Monitor blood sugar and ketones
 Trace		1.5		Drink extra sugar-free fluids
				And if blood sugar is 240 mg/dl or higher also give
				an extra 20% of the total daily insulin dose as extra
				short-acting insulin (this is in addition to the regular
				daily insulin dosing)

Monitor blood sugar and ketones every 2 hours until ketones have cleared
In 4 hours if the blood sugar is still 240 mg/dl or higher and ketones are still present give another dose of short-acting insulin and contact diabetes doctor for more instructions
Extra insulin should not be given more than every 4 hours

Ketone Treatment with Emesis

  • Check blood sugar hourly until no longer sick
  • Check for ketones
  • If ketones are not present, and
    • Blood sugar is > 150 mg/dl, wait two hours without eating then begin giving small sips of water or diet soda every 10-15 minutes.
      • if vomiting recurs and blood sugar is still >150, wait another 2 hours and then try again.
      • if vomiting resolves, gradually increase fluids
    • Blood sugar is 80-150 mg/dl, give small sips of sugar-sweetened fluids or hard candy
    • Blood sugar is <80 mg/dl and vomiting persists, call diabetes doctor
  • If ketones are present, and
    • Blood sugar is >150 mg/dl and ketones are small to moderate, give an extra 10% of the total daily insulin dose as extra short-acting insulin (this is in addition to the regular daily insulin dosing)
    • Blood sugar is >150 mg/dl and ketones are large, give an extra 20% of the total daily insulin dose as extra short-acting insulin (this is in addition to the regular daily insulin dosing)
    • Blood sugar is <150 and any ketones are present, give small sips of sugar-sweetened fluids until the blood sugar is >150 mg/dl then give the appropriate amount of extra short-acting insulin
    • Blood sugar cannot be brought >150 mg/dl, call the diabetes doctor.

Extra insulin should not be given more than every 4 hours.

Patients and family members should contact their physician if:

  • Vomiting persists for more than 6 hours or if vomiting occurs 3-4 times in a row without keeping down fluids
  • Blood sugar continues to be < 80 despite taking quick-acting carbohydrates
  • Vomiting with ketones
  • Ketones continue despite taking 2 doses of short-acting insulin
  • Ketones are in the urine and blood sugar is < 240 mg/dl
  • After glucagon is given
  • If they are unsure about what to do to manage the problem

Questions for Further Discussion
1. How should a child's diabetes be managed who is undergoing surgery?
2. What are the different options for glucose monitoring?
3. What are the potential longer term complications of type 1 diabetes?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Diabetes, Type 1 and Diabetes
and at Pediatric Common Questions, Quick Answers for this topic: Diabetes

To view current news articles on this topic check Google News.

Sheetz J, Huff S, Sheehan A, Osterhaus J, Tsalikian E, Donohoue P, Tansey M, Nordine L, Coffey J. "Diabetes Care for Children
and Adolescents" University of Iowa. 2004: 43-48.

Burdick J, Harris S, Chase HP. The Importance of Ketone Testing. Practical Diabetology. 2004 June;3-11.

Lamb WH. Diabetes Mellitus, Type 1. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic581.htm (rev. 6/27/2006, cited 12/7/06).

Laffel LMB, Wentzell K, Loughlin C. Tovar A, Moltz K, Brink S. Sick Day Management Using Blood 3-hydroxybutyrate (3-OHB) Compared with Urine Ketone Monitoring Reduces Hospital Visits in Young People with T1DM: A Randomized Clinical Trial.
Diabetic Management. 2006;23:278-284.

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D'Alessandro, MD
    Associate Professor of Pediatrics, Children's Hospital of Iowa

    Michael Tansey, MD
    Associate Professor of Clinical Pediatrics, Children's Hospital of Iowa

    Date
    January 8, 2007