When people come down with minor illnesses such as flu, cold, urinary tract infection, or intestinal problems, they usually lose their appetites and have very low energy levels. Most would want to stay in bed, take some over-the-counter medication, sleep, and let the medication and their immune systems do their jobs to kick the illness to the curb. However, for individuals with diabetes, a common sickness or infection is not as easy to fight off. Without careful care management, the fluctuation of glucose and ketone levels can trigger severe complications. If left unattended, these complications can become life-threatening medical emergency cases such as diabetic coma. To avoid such daunting situations, the best way to cope with a minor illness is to learn, plan, and prepare ahead of time. So when you do become sick, you will know exactly what to expect and what protocols to follow under different scenarios. At the same time, you will already have all the supplies at home. This way, you will feel safe and secure, and you can concentrate on getting better. In order to help you prepare for a sick day management plan and kit, this article will cover these topics:
- What Happens to Your Body and Your Blood Glucose When You Are Sick?
- Prevention Is the Key
- Planning Ahead
- General Sick Day Advice
- Keep Your Logbook Handy
- Specific Type 1 Diabetes Advice
- Specific Type 2 Diabetes Advice
- How to Calculate Your Dosage Adjustment
- When to Call For Help?
- Sick Day Food and Drinks
- Drinks Providing Approximately 15 Grams of Carbohydrate Table
- Food Providing Approximately 15 Grams of Carbohydrate Table
- What Food to Avoid?
- What to Do If You Keep Food or Liquid Down?
- When to Return to Normal Meal Plan?
- Checklist for Sick Day Management Kit
- Medications to Look Out For
- When Are You Too Sick For Work?
- Advice for Pregnant Women and Nursing Mothers
- Advice for Taking Care of Children with Diabetes
- Insulin Adjustment Guidelines
What Happens to Your Body and Your Blood Glucose When You Are Sick?
Depending on general health, age, and hormonal differences, each person reacts slightly different to illness. But generally, when you are sick, you are under stress. To counteract, your body releases stress hormones such as adrenaline and cortisone into the bloodstream to activate glucose production in the liver. This reaction leads to a rise of blood glucose levels above normal level and desensitization of the blood glucose-lowering effects of insulin. Under these circumstances, even the most stable diabetes becomes much harder to control within the target range. Also, vomiting and diarrhea can reduce nutrient absorption and affect your blood glucose levels. For type 1 diabetes individuals, if your body does not have enough carbohydrates, it will start burning fat for energy and produces ketones in the process. As a result, your ketones levels will escalate.
If the condition persists, the above-normal levels of ketones may lead to ketoacidosis or even diabetic coma. For people with type 2 diabetes, especially seniors, you can develop a similar condition called hyperosmolar hyperglycemic nonketotic coma. Both of these conditions are extremely dangerous and can be fatal. The good news is that you can learn to manage your blood glucose and ketones levels at home by following appropriate advice and protocols. By knowing exactly what to do in these circumstances, you will feel less stressful since you are not facing the complications in the dark. It will also give you an idea of how to manage your illness by yourself and when to call for help.
Prevention Is the Key
Although planning the sick day management is essential for individuals with diabetes, many people forget that prevention is equally important. Here are several tips that may help you avoid getting sick:
- Keep up with your flu shots.
- Wash your hands properly and often when you come home from public places. Always wash your hands before you eat. Bring wet napkins or hand sanitizer gels in your bag in case there is no place for you to wash your hands.
- Stay six feet away from a coughing or sick person.
- Avoid badly ventilated public areas during flu seasons. Bring a surgical mask in case you have no way of avoiding these places.
- When you sense that your immune system is down, take extra vitamins, eat more fruits, and drink more water for several days. The boost in vitamins and fluids will kick your immune system back to normal.
- Clean your home often to get rid of germs that may make you sick.
- If you feel that your throat is acting up, gargle with salt water in the morning and evening after you brush your teeth. The salt will help kill off the germs and decrease the chance of infection.
- Always stash an extra layer of clothing in your bag or your car when you go out
- Exercise often and eat healthy foods will give you a general boost the immune system and in your overall health.
Don’t wait till you are sick before you ask this question. Work with your doctor, or diabetes educator to prepare a plan for sick days in advance. In your plan, you should have these things:
- A plan of medication adjustment when your blood glucose drops too low.
- A plan of medication adjustment when your blood glucose gets too high.
- How often you should measure your blood glucose and urine ketones.
- What medications to take and what medications to stop when you are sick.
- What food you should eat when you are sick.
- When you should call your doctor, educator, dietitian, or emergency on-call doctor. And make sure you know how to reach your doctor, educator, and dietitian at night, on weekends and holidays.
- A log-book or app program to keep all your data as well as all the emergency information, emergency contact numbers, and your insurance information.
- An emergency supplies kit
General Sick Day Advice
- Whether you have type 1 or type 2 diabetes, the Number 1 rule of thumb is to continue taking your insulin medication. Most people require an increase in medication either by oral blood glucose lowering medications or insulin (please refer to “How to Calculate Your Dosage Adjustment” for more information about dosage readjustment and “Advice for Taking Care of Children with Diabetes” for information for children).
- Blood glucose and ketone levels should be checked every 2 to 3 hours to readjust your medication plan. Set a timer to remind yourself. Remember to double check if your ketone testing strips have expired as they are only good for 6 months after the bottle has been opened.
- You should drink plenty of fluids to maintain hydrated. It will help flush the ketones from your system and lower your body temperature.
- You should try to keep your carbohydrate intake as normal as possible even when you are sick. Your body needs sugar for making energy and balancing your insulin level. Even when your appetite is low, try to eat food that contains carbohydrate such as dry biscuits, toast, and boiled rice. If you have no appetite at all or the illness is preventing you from swallowing properly, you can replace your meals with drinks. If your blood glucose levels are below 15 mmol/l, your drinks should contain glucose; if your blood glucose levels are above 15 mmol/l, they should be unsweetened. There are various reminder apps to help you maintain a regular eating/drinking schedule.
- Getting plenty of rest is critical. Stop all vigorous exercise routines that will stress out your body even more and be kind to your body.
- Always alert at least two friends or family members of your illness in case you need assistance or emergency care later. Note that your doctor will want to hear from you under these circumstances:
- When you have been sick or have had a fever for 2 to 3 days and are not getting any better
- When you have vomited or diarrhea for more than six hours
- When your blood glucose is consistently higher than 250 mg/dl despite having taken extra insulin
- When you have taken only oral medication and your blood glucose level has stayed above 250 mg/dl for more than 24 hours
- When you have any symptoms of DKA
- When you are unsure about your symptoms or fluctuations of ketone and blood glucose levels
- Keep logging all your information in a notebook for several reasons. When you are sick, you cannot remember as well about what you ate and when was the last time you took your medicine. By logging all your information down, you can easily refer to your previous activities and judge whether you are getting better or worse. You will need all these information if you need to consult your doctor or diabetes educator. Should you need emergency care, you will probably be too sick to answer all the questions properly. By handing over the notebook, your emergency care doctors and nurses can quickly figure out what to do to treat the complications.
Keep Your Logbook Handy
If there is no way you can remember all the information when you are well, you can be sure that you will not be able to remember anything at all when you are sick. Instead of looking for all the information you need when you are sick, compile a list of information in your logbook binder.
- The insulin adjustment guidelines from this article and your doctor’s fine-tuning tips
- The food intake guidelines from this article
- Phone number of your doctor, diabetes educator, dietician, and the hospital emergency care hotline
- Phone number of your emergency contact friends and family members
- All your emergency information including all your existing medical conditions, allergies, and medicine treatments (If you have certain information charted on your smartphone, remember to write down your phone password and the apps you are using for tracking various vital records)
- Your diabetes information: your usual glucose level and insulin dosage treatments
- Your blood glucose level readings on your sick days
- You results of ketone tests on your sick days
- Your insulin adjustment dosages and administration schedule
- Your fluid intake and schedule
- Any symptoms such as vomiting, diarrhea, stomach cramps, or headaches
- Your body temperature
- Your food intake (especially items with sugar in it)
- Your weight fluctuation
- Your pulse rate
Although it is a daunting task to write down everything when you feel crummy, you must keep a log to manage your diabetes properly while you are sick. However, if you write down all your information without a template guide, you are very likely to end up with a sheet of jumbled facts. To help organize your input information, here are 2 different templates you can follow. These 2 guides are catered to individuals with different stages treatment needs:
- The first one is designed for individuals who have very little change in their blood glucose and ketone levels. It is a simple chart for keeping track of your blood glucose level, your medication dosage, your insulin readjustment, and your carb intake throughout your day. Click here to download simple logbook
- The second template is designed for individuals who have type 1 diabetes and require intensive management of their sick day progress. It includes an hour-to-hour monitor of your weight, your blood glucose and ketone levels, your medication dosage and readjustment units, your food intake diary, and your fluid consumption record. This chart is also very useful for infants and younger children as their health conditions can fluctuate much drastically within shorter time interval. Click here to download advance logbook.
Specific Type 1 Diabetes Advice
If your blood glucose levels remain above 15 mmol/L, you should check for ketones (either blood or urine testing are fine) every 2 to 4 hours. If your ketones levels are above 1.5 mmol/L for blood sample testing or moderate/large for urine sample testing, this indicates there is a significant breakdown of fat. This also means that your body is deficient in insulin. If this situation occurs, check carefully to see if you have any symptoms of diabetic ketoacidosis (DKA). If you suspect that you are exhibiting DKA symptoms, immediately call your doctor or your hospital emergency hotline for medical advice.
As for your insulin medication, in addition to your usual regimen, you will require extra doses of rapid-acting insulin to fight off the possible ketosis due to insulin deficiency. To find out how much extra insulin you will need, you will need to calculate your extra insulin dosage in relations to blood glucose and ketones levels. Depending on your blood glucose and ketone level fluctuation, the recommendations include an increase of between 5% to 20% of your total daily rapid-acting dosage amount for every 2 hours.
Specific Type 2 Diabetes Advice
Individuals with type 2 diabetes may also need a temporary increase in oral medication or even the temporary addition of insulin. Talk to your doctor or educator about what to do if a situation arise when you have problem swallowing your oral medications. Just like type 1 diabetic individuals, you will need to know how to readjust your medication dosage if you are sick enough that you cannot eat. For example, if you are currently using sulfonylurea, you may need to reduce the medication as it can increase the risk of hypoglycemia. If you are currently using metformin, you may need to switch to insulin during a serious illness (for example, gastrointestinal flu) or when you are experiencing vomiting or diarrhea because it may lead to dehydration and decreased kidney function, and can increase the risk of a rare complication such as lactic acidosis. If you have any concern or uncertainty about your medication, you should immediately contact your doctor or the hospital emergency hotline for assistance.
How to Calculate your Dosage Adjustment
Here is a general guideline of insulin adjustment for both type 1 and type 2 diabetic individuals. Please check with your doctor and diabetes educator before using these guidelines.
- When your blood glucose level is higher than 14 mmol/L, you will need extra rapid or short acting insulin based on your total daily dose of insulin (TDD). To calculate your TDD, add your usual unit doses of all your pre-meal and basal insulin.
- For example, if you usually take 10 units of rapid insulin at breakfast, 10 units of rapid insulin at lunch, and 10 units of rapid insulin at dinner and 20 units of long acting insulin before bed, you TDD is going to be 10 + 10 + 10 + 20 = 50 units.
- Your sick day adjustment will then be a percentage of your TDD. It may be 5%-20% of your TDD based on your blood glucose and ketone levels. Please refer to the table below for the amount you will need to add for your insulin dosage (Please note that this is for adult use only. Please refer to the Children section for the dosage adjustment).
- Using the table provided, you can calculate how much extra insulin you will need.
- For example, if you TDD is 50 units, 10% will be 5 extra units, 15% will be 7.5 extra units (round to 8 units), and 20% will be 10 extra units.
- After you find out your adjustment dosage, you can take the extra rapid or short acting insulin dosage by 2 ways:
- Adding the extra dosage to your usual unit at the usual time schedule
- Take an extra insulin injection:
- Rapid acting insulin can be administered every 3 to 4 hours
- Short acting insulin can be administered every 4 to 6 hours
- If your blood glucose level is:
- 4 to 14 mmol/L: you should take your usual basal and rapid or short acting insulin doses and use your usual correction dosage.
- Less than 4 mmol/L: you should treat your condition as hypoglycemia and use fast-acting carbohydrates. At the same time, you may need to decrease your insulin dose slightly.
|Blood Glucose Level||Urine Ketones||Extra Insulin (Rapid or Fast Acting Insulin Only)|
|14 to 16 mmol/L||Moderate to Large||10% of TDD|
|16.1 to 22 mmol/L||Negative to Small|
|16.1 to 22 mmol/L||Moderate to Large||15% of TDD|
|22.1 or more||Negative to Small|
|22.1 or more||Moderate to Large||20% of TDD|
You can also follow the table below for finding out your insulin adjustment dosage.
|Total Daily Dose Units (TDD)||Extra 10% Rapid or Short Acting Insulin||Extra 15% Rapid or Short Acting Insulin||Extra 20% Rapid or Short Acting Insulin|
|1 to 10||0.5 to 1 unit||0.5 to 1 unit||0.5 to 1 unit|
|11 to 20||1 to 2 units||1 to 2 units||1 to 2 units|
|21 to 30||2 to 3 units||2 to 3 units||2 to 3 units|
|31 to 40||3 to 4 units||3 to 4 units||3 to 4 units|
|41 to 50||4 to 5 units||4 to 5 units||4 to 5 units|
|51 to 60||5 to 6 units||5 to 6 units||5 to 6 units|
|61 to 70||6 to 7 units||6 to 7 units||6 to 7 units|
|71 to 80||7 to 8 units||7 to 8 units||7 to 8 units|
|81 to 90||8 to 9 units||8 to 9 units||8 to 9 units|
|91 to 100||9 to 10 units||9 to 10 units||9 to 10 units|
It is important to note that sometimes illnesses like gastroenteritis can decrease your blood glucose levels. In such cases, your diabetes medication dosage needs to be lowered. There are also certain medications (for example, prednisone) that can cause exaggerated hyperglycemia symptoms. If such situation occurs, you will need to increase the frequency of your blood glucose monitoring and adjust your dosage accordingly. If at any time you are unsure about your condition or your dosage adjustment, don’t hesitate to call your doctor or the hospital emergency hotline for help. If you feel that your condition is deteriorating in any way (for example, vomiting increases or drowsiness occurs), seek urgent medical help immediately. These may be early symptoms of DKA in people with type 1 diabetes, and hyperosmolar hyperglycemia state (HHS) in people with type 2 diabetes. Both of these complications are life-threatening medical emergencies and cannot be treated at home.
When to Call For Help?
Although a cold or a stomach bug may seem harmless, you will probably want to call for advice and help if certain events or symptoms occur. For example:
- You have a fever or have been sick for several days and you are still not getting better
- You have been throwing up or having diarrhea for more than 6 hours
- You have a moderate to large quantity of ketones levels in your urine or blood sample for 2 or more tests
- Your glucose levels are higher than 240 and you have been taking extra insulin dosages according to your medication schedule
- You have taken medication for your diabetes and your blood glucose level escalates to higher than 240 before meals and remains for more than 24 hours
- You have symptoms that may indicate ketoacidosis, dehydration, or some other serious complications (for example, chest pain, trouble with breathing, fruity-smelling breath, dry tongue, and cracked lips)
- You have a fever of 100°F (37.7°C) or higher
- You have difficulty moving your arms or legs
- You are experiencing vision, speech, or balance problems
- You are experiencing confusion or memory problems
- If you are losing weight while your temperature, breathing rate, and pulse are increasing
- If you are feeling tingling or numbing sensation in your left arm
- You are uncertain what to do or how to take care of yourself
If you cannot reach your doctor or diabetes educator right away, try calling the hospital emergency hotline for advice and assistance. If there is no emergency hotline service available, don’t wait. Go to the emergency clinic for help. This is especially important if you have vomited or experienced diarrhea for more than 4 hours. If this situation occurs, remember to also call your friend or family member and alert them of the situation or even ask them to meet you at the clinic. Don’t forget to bring your logbook with you as you will have to be ready to tell the emergency care doctors and nurses what medications and what dosages have your been taking, how long have you been sick, whether you can eat and keep food down, whether you have lost weight, what is your body temperature, what are your blood glucose level and urine ketone level. By handing over your logbook, they simply have to refer to your information to quickly map out a treatment plan for your current situation.
Sick Day Food and Drinks
Eating and drinking can be a big problem when you are sick. But it is vital to stick as close to your normal meal plan as possible. In addition to your normal meals, drink a lot of non-caloric fluids to keep hydrated and flush out the ketones in your body. Some examples of non-caloric liquids are water and diet soft drinks. Try to target at least twelve 8-ounce cups of fluid a day.
Other fluids you can drink if you are dehydrated include:
- Club soda
- Diet soda (caffeine-free)
- Tomato juice
- Chicken broth
(You should try to stay away from tonic water as quinine may affect your blood pressure and your blood glucose level.)
For any reason if you cannot stick to your normal meal plan, you should still try to take in your normal amount of calories by eating easy-on-the-stomach foods in small meals.
- Bagels or bread
- Cooked cereal
- Mashed potatoes
- Noodle or rice soup
- Saltines crackers
- Non-diet gelatin (such as Jell-O)
- Graham crackers
- Steamed fish
If these mild foods are too difficult to eat, you may have to stick to drinking fluids that contain carbohydrates. Should you choose a liquid diet, aim for 50 grams of carbohydrate every 3 to 4 hours. Your sick-day meal plan may include regular soft drinks (not diet soft drinks) and other high sugar content food that you normally do not eat. Other examples of high-carbohydrate liquids and almost-liquids are juice, frozen juice bars, sherbet, pudding, creamed soups and fruit-flavored yogurt. Although broth has much lower carbohydrate count, it is still a good choice as it contains many nutrients.
If your blood glucose level is lower than 100 mg/dL or falling rapidly, it is alright to drink fluids that have sugar in them. Remember to monitor their effects on your blood sugar in the same way you monitor how other foods affect your blood glucose level.
Liquids you can drink if your blood sugar is low include:
- Orange juice
- Apple juice
- Grapefruit juice (You will need to stay away from Grapefruit juice if you are currently taking blood-thinning medication as grapefruit is known to have natural blood-thinning properties.)
- Gatorade or other sports drink
- Tea with honey (Try to choose decaffeinated tea as caffeine is a diuretic and will actually make you urinate more often.)
- Lemon-lime drinks
- Ginger ale
|Drinks providing approximately 15 grams of carbohydrate|
|Milk||1 cup (250 mL)|
|Milk and Flavoring||¾ cup milk + 1 tablespoon of Milo, Actavite, or Quik|
|Fruit Juice||¾ cup|
|Tea or Coffee||Add 1 tablespoon of sugar or honey|
|Hot Lemon Juice||Add 1 tablespoon of sugar or honey|
|Herbal Tea||Add 1 tablespoon of sugar or honey|
|Ordinary Soft Drink or Cordial (Not Diet)||¾ cup|
|Sport Drink (e.g. Gatorade)||1 cup|
|Milkshake (low-fat milk)||½ cup|
|Milkshake (ice cream)||½ cup|
|Chicken noodle soup||1 cup|
|Food providing approximately 15 grams of carbohydrate|
|Crackers or Crispbread||3 Sao, Ryvita, etc.|
|Dry Toast||1 slice|
|Plain Sweet Biscuits||3 Milk Arrowroot or Morning Coffee|
|Mashed Potato||½ cup|
|Breakfast Cereals||½ cup Special K, 2 Weetbix|
|Porridge (made with water)||1/3 cup|
|Ordinary Jelly or Custard||½ cup|
|Cooked cereal||½ cup|
|Frozen Yogurt||½ cup|
|Regular ice cream||½ cup|
|Regular pudding||¼ cup|
|Rice cake (4 inch diameter)||2|
What Food to Avoid?
There are some food that should be avoided when you are sick. In general, stay away from caffeine as much as possible as it is a diuretic and it will make you lose bodily fluid at a more rapid rate. If you are having stomach problems, avoid beans, onions, broccoli, cabbages, and dairy products as they may cause bloating and cramps. As mentioned earlier, you should avoid grapefruit as its enzyme reacts with many medicine (If you are currently taking blood pressure medication or blood-thinning medication, you should never eat grapefruit even when you are well as it may cause an overdose reaction). Though not as severe as grapefruit, you should note that Seville oranges (a favorite choice for marmalade) and limes contain the same ingredients as grapefruit and should be avoided as well. If for any reason you do not feel well after eating a specific food, remember to jot down the details in your logbook. This way, you can avoid the same mistake in the future.
If you throw up, do not eat or drink anything for 1 hour. Rest, but do not lie flat as it may trigger another nausea episode. After 1 hour, eat a little bit of cracker or toast and take several sips of soda in between. Rest and wait for your stomach to settle for 20 minutes. If you do not throw up during the waiting period, you may start taking sips of soda every 10 minutes. If you continue to vomit, you will require antiemetic medication to stop the vomiting immediately to avoid developing diabetic ketoacidosis. If you cannot even keep the oral antiemetic medication down, you may need an oral dissolve antiemetic tablet, a suppository antiemetic tablet, or an injection to stop the vomiting. If you cannot keep food or liquids down, go to the emergency room for treatment. You will receive fluids through intravenously.
When you start to feel better or sense that your appetite as returned, ease back into your normal daily carbohydrate intake slowly. Do not jump back to your normal food source right away as your stomach requires some adjustment to properly digest hearty food again. For the meantime, drink plenty of fluids to continue flushing the last bit of bacteria and ketones from your body. In no time, you will be back to healthy again.
Checklist for Sick Day Management Kit
Items you want to include in your sick day kit:
- Your logbook
- Over-the-counter pain reliever such as acetaminophen (it also functions as a fever suppressor), ibuprofen, Motrin, aspirin (Please note that some pain medicine must be taken with food or else you will risk damages to your stomach lining)
- Tissues and wet napkins
- Hand sanitizer
- Timer or alarm clock to help you monitor blood glucose levels and ketones regularly (you can also use your smartphone apps as reminders)
- Sugar-free cough drops, syrups, and throat lozenges (In addition to looking for the word sucrose in the ingredients list, you should also search for dextrose, fructose, glucose, and just about anything else that ends in “ose”. These are usually types of sugar. However, if you don’t have sugar-free products in the house, the sugar amount in the regular product should be small and should not have much effect on your blood glucose level.)
- An 8-ounce measuring cup to help make sure you are drinking enough liquids
- Antidiarrheal and anti-vomiting medicines in oral and depository forms (You may also request oral dissolve and injection forms of antidiarrheal and anti-vomiting medicines from your doctor)
- Blood glucose monitoring supplies
- Glucose strips
- Alcohol Swabs
- Ketone test strips (make sure that your strips are still effective as they expire 6 months after you open the bottle)
- Glucose tablets or gel
- Insulin syringes
- Glucagon emergency kit hypoglycemia (A glucagon kit requires a prescription from your doctor. Please check to see if the kit has expired before use.)
- Shelf-stable foods such as unopened jars of applesauce, canned soup, peanut butter, canned tuna, powdered milk, protein shake, canned fruits such as peaches and pears, instant rice and porridges, candy, powdered gelatin, crackers, tea
- Shelf-stable drinks such as bottled water, boxed juice, sport drinks, regular soft drinks, sugar-free beverages, honey
- Decongestant (Decongestants can raise blood glucose levels even when they are sugar-free. Nasal sprays will have lesser effects than oral products.)
- A sliding scale for dosage adjustment for diabetes medicines
- A case of bottled water so that you don’t have to worry about refilling your cup
Medications to Watch Out For
When you are sick, you will need extra medications other than your usual diabetes medications. For example, if you have a cold, you may want to take a cold medicine, pain relief medicine, and decongestant. Before you purchase any over-the-counter medications, always check the label to see they contain any sugar. Even though small doses of medicines with sugar are usually fine, it is always safer to ask the pharmacist, your doctor, or diabetes educator about sugar-free medicines.
There are also many medications that may affect your blood glucose levels even if they don’t contain carbohydrates. For example, large doses of aspirin can lower blood glucose levels. Some antibiotics will lower blood glucose levels in people with type 2 diabetes who take oral diabetes medication. Decongestants have a tendency to raise blood glucose levels. Two common decongestants, pseudoepinephrine and phenylephrine are both related to a hormone called epinephrine. This “fight or flight” hormone triggers the opening of air passages and sinus pathways.
But at the same time, it will increase your heart rate and blood glucose levels. Although each person reacts differently to these two decongestants and some people have no reaction to these medications, you should always monitor your blood glucose level more closely if you decide to use a decongestant. If you are one of the individuals who are sensitive to these medications, make sure you readjust your insulin dosage to keep your blood glucose level under control. At the same time, instead of taking oral decongestant, opt the nasal spray decongestants as they have a less tendency to affect your blood glucose level.
As a general precaution, always remember to read labels and follow the dosing instructions. Do not think that more is better when it comes to medication. By taking more than the instructed dosage, you may become overdosed or create a new complication. For example, high doses of acetaminophen is toxic to the liver. If you ignore the dosing instruction and overdose yourself, you may end up going to the emergency room for liver failure. And if you are using more than one medication to treat symptoms, you should check the labels to make sure you are not taking the same medicine from multiple sources. For example, some cold medication already comes with decongestant ingredients in the mix. If you take a nasal decongestant at the same time, you will have overdosed yourself and cause a large fluctuation with your blood glucose level.
If you must go to the emergency room or see a different doctor than usual, be sure to say you have diabetes and have your identification bracelet in plain sight. At the same time, you MUST list all the medications that you are taking and all the medication allergies you have (For example, some people have an allergic reaction to any medication that contains sulfur).
When Are You Too Sick For Work?
When it comes to determining whether you should take a sick leave from work, here are several deciding factors:
- Is your illness contagious?
- Will your current condition put yourself at risk of having an accident or injuring others?
- Is there any medication that will incapacitate you and will put you at risk of having an accident, injuring others, or causing major mistakes in your work?
If you answer yes to these questions, you should say home.
If you decide to stay home, remember to call your workplace as soon as possible, let your superior officer know of your current condition, how many days you will need to recuperate, and any vital information about your current projects. In order keep a good relationship with your boss, be proactive and offer resolution ideas how you can catch up on your workload or meet your deadlines. Let them know the best way to contact you in case there is an emergency situation at the workplace.
Remember that keeping a line of communication between you and your coworkers will play a big role in whether they will be supportive of your health condition in the future. When you are healthy, it is always a great idea to rack up some brownie points among your coworkers by helping them out on certain tasks or covering for them when they are sick.
If, for any reason, your boss is being unsupportive about you taking sick days even though you are following the company policy regarding annual sick time. You should address your rights as a person with a disability and you are protected by the discrimination law under the Americans with Disabilities Act and Rehabilitation Act of 1973. If you are wondering if you qualify as an individual with a disability, by federal law definition:
A disability is defined… as a mental or physical impairment that substantially limits one or more major life activities. Diabetes is a disability because it substantially limits major life activities such as the functioning of the endocrine system, among others.
Should you need evidence to proof that you are an individual of disability yet qualified for your current job, you should have your doctor write a letter stating of your disability issues and that with proper management of your diabetes, you are fully qualified for your job.
Under the federal law, your employer:
- Cannot refuse to hire or promote you because of your diabetes
- Cannot terminate you because of your diabetes unless you pose a direct threat
- Must offer you with reasonable accommodations that help you perform the essential functions of your job
- Must not discriminate you regarding employer-provided health insurance
At the same time, under the Family and Medical Leave Act (FMLA), you are allowed up to 12 weeks of sick leave per year because of your own illness or your immediate family member’s serious health condition.
If you are fired due to your diabetes health issues, contact the American Diabetes Association for legal assistance as soon as possible. You can reach their hotline at 1-800-DIABETES. It is in your rights to file a discrimination charge against your employer with the Equal Employment Opportunity Commission (EEOC) or your State’s Fair Employment Agency. And if you are currently in a work union, you also have the option to file a union grievance or negotiate your work rights with your employer through union mediation help.
Advice for Pregnant Women and Nursing Mothers
The recommendations are generally the same when it comes to women with diabetes, nursing mothers, and individuals who are not pregnant. However, because your baby takes in anything you ingest, you should check with your obstetrician before you take any over-the-counter medication to make sure that it does not affect the development of your baby. Some of the over-the-counter products to avoid is decongestants as they may drastically affect your blood pressure and blood glucose levels. Instead, opt for more natural methods to deal with your stuffy nose and sinuses.
For example, try using the steaming method (It is the traditional method of covering your head with a towel and hovering over some hot water to unclog your nose and sinus. You can try adding some menthol essential oil in the hot water for a stronger effect) or the Neti Pot (Method of rinsing your nasal cavity with warm water. Like steaming, you can add one or two drops of menthol essential oil to the water before use. Another common practice is to boil some ginger in the water and cool the liquid to a lukewarm temperature before using it as a nasal rinse). These methods have proven to be very useful as a decongestant and herbal germ fighters.
Because you are eating and drinking for two, you should increase your fluid intake to stay hydrated (especially important for nursing mothers as your milk supply decreases when you are dehydrated) and eat more frequently to make sure you provide enough nutrients for your baby. Most important of all, during pregnancy, it is extremely important to keep a tight blood glucose level for the health of both mother and baby. Instead of checking every 3 to 4 hours, you should check your blood glucose level and ketones at least every two hours. If you see fluctuations, you should check every hour just to be safe.
When you are sick and you are either pregnant or with your newborn baby, always have a friend or family member with you as a safety precaution. If at any moment you feel any symptoms of DKA or you feel that your current condition is deteriorating, immediately contact your obstetrician or the hospital emergency hotline. Aside from your sick day emergency kit, you should have your labor hospital bag ready in case you need to go to the hospital for emergency assistance or even induced labor.
Advice for Taking Care of Children with Diabetes
Keeping calm and stay organized are the best things you can do for your child when he or she is sick. Just as adult diabetic individuals prepare their sick day kit, you should talk with your child’s medical team about formulating a personal sick-day plan and a sick-day kit. Unlike adults, children’s condition can fluctuate very rapidly. In order to keep track of all the changes, you must have a logbook for jotting down all the data and observation.
For examples how to create a logbook template, please refer to earlier section on Logbook Formats (please link to earlier section). In your logbook, aside from the suggested material as listed in earlier section, please remember to also include various materials that would entertain your child and divert their attention away from the illness. A tablet with comics, books, pictures, game apps, movies, and cartoons may help your child feel better.
- He or she is likely to need extra insulin medication.
- He or she will need to check blood glucose as often as every 2-3 hours
- He or she will need to check blood or urine ketones as often as every 4 hours (If your child still wears diaper, put several cotton balls in the diaper so that you can use it for ketone testing without needing to wake your child from sleep or wait for your child to urinate)
- He or she should drink lots of clear liquids to keep hydrated.
- He or she should continue taking their regular medicine.
- A fever for at least two days.
- Been throwing up or experiencing diarrhea for 6 hours.
- Cannot keep any fluids down, even small amounts of clear liquids.
- Glucose levels are out of target range even with additional insulin.
- Moderate or large urine ketones levels.
- Any symptoms of dehydration or ketoacidosis such as difficulty breathing, chest pains, fruity-smelling breath, dry lips, or sunken eyes.
To avoid ketoacidosis in your child with type 1 diabetes, follow these procedures whenever your child has a minor illness such as cold, flu, fever, vomiting, or diarrhea:
- Check blood glucose and check for ketones in urine or blood (Make sure ketone test strips are not expired as they expire 6 months after the bottle is opened).
- Continue to give the usual amount of long acting insulin or basal insulin. DO NOT STOP taking insulin EVEN if the child is not eating well!
- Give small sips of liquids frequently. Vomiting and diarrhea are most likely to cause low blood glucose levels and dehydration especially in younger children. The carbohydrate content of the liquids offered depends on the blood sugar level:
- If the blood glucose is over 200mg/dl; give sugar-free liquids such as water, broth, or diet drinks. Correct the high blood glucose level as appropriate, but no more frequent than every 3 hours.
- If the blood glucose level is under 200 mg/dl; offer fluids that contain carbohydrates such as juice, Gatorade, Pedialyte, or regular soda. The aim is to raise the blood glucose level so that you can safely give more insulin to prevent or lower the ketones levels. If your child can tolerate the fluids, re-check blood glucose in 30 minutes and then give fast-acting insulin to correct the high blood glucose level.
- If the blood glucose level is very low (less than 60 mg/dl) and juice or glucose tablets cannot be kept down because of vomiting, you can give a mini dose of glucagon with an insulin syringe (not the glucagon kit syringe) to prevent serious hypoglycemia. The dose is one unit per year of age, up to 15 units. If your child is younger than 2 years of age, consult with your doctor or the doctor on call the hospital emergency hotline for assistance. Please note that mini-dose glucagon should not be given if the urine ketones levels are moderate or large or the blood ketones levels are above 1.0. The child’s backup source of sugar (glycogen) may be too depleted and the glucagon may not have any effect. If this situation occurs, head to the emergency clinic for assistance immediately.
- If vomiting continues, you may consider using an anti-vomiting medication to stop the vomiting. Phenergan or Zofran are two good options. As children have more sensitive stomachs and are prone to vomit continuously once it starts, it is a better choice to administer a depository antiemetic medication to stop the vomiting rather than an oral antiemetic medication. Consult with your doctor to obtain a prescription and have the medicine available when you need it.
- If the blood glucose level is CONSISTENTLY high (over 300 mg/dl) with or without ketones, your child needs extra insulin to lower the blood sugar. Children on injections should use their fast acting insulin to take the high sugar correction and must wait for 3 hours between each correction. Children on an insulin pump can give the extra insulin by correcting boluses every 3 hours or by increasing the basal rate.
|Urine Ketones||Blood Ketones||Give This Much Extra Fast Acting Insulin|
|Negative||Under 0.6||No extra insulin; give correction every 3 hours.|
|Small||0.6-1.5||Increase correction by 5% and recheck blood glucose level in 3 hours.|
|Moderate||1.5-3||Increase correction by 10% and consult with your doctor or hospital on-call doctor. Check blood glucose in 3 hours.|
|Large||Over 3||Increase correction by 20% and consult with your doctor or hospital on-call doctor. Check blood glucose level in 3 hours.|
Ketone Checks for Children Using Insulin Pumps:
If the blood glucose level is over 300 mg/dl and ketones levels are negative, follow these steps below (for positive ketones, skip to the next section):
- Give correction dose calculated by the pump
- Recheck blood glucose level in 1 hour to confirm if the level has dropped at least 50 points. If the level has NOT dropped at least 50 points, you should assume the infusion set is not working properly and your child most likely did not receive the full correction dose you gave the previous hour. Follow these steps below:
- Take injection with a syringe or pen, NOT with the pump. Administer only half the correction dose you gave in Step 1. Checking the blood glucose level frequently is crucial.
- Next, change the infusion set and site.
- Finally, restart the pump and recheck the blood glucose level in 1 hour.
- If level has dropped at least 50 points, recheck the level according to your usual schedule.
- If the level has NOT dropped at least 50 points, check for ketones.
- If Ketone level is now positive, program a +10-20% temporary basal rate for 4 hours and re-examine blood glucose levels and need for further adjustment. Consult with your doctor or hospital on-call doctor.
If the blood glucose levels are 300 mg/dl and ketones are positive, follow these instructions:
- Give an injection with a pen or syringe instead of using the pump
- If ketones levels are moderate, increase the correction by 10%
- If ketones levels are large, increase the correction by 20%
- Disconnect the infusion set and set the correction you just gave into the pump. Allow the insulin to drip out (remember the pump is NOT connected to you). This procedure acts as a “fake” bolus to enable the pump to keep track of insulin on board.
- Change the infusion set and site.
- Set a +10-20% temporary basal rate for 4 hours and re-evaluate both blood sugar and a need for further adjustment. Consult with your doctor or hospital on-call doctor.
Additional Advice & Tips:
- Drink plenty of liquids to prevent dehydration. If blood glucose levels are over 200 mg/dl, drink sugar-free fluids. If blood sugars are under 200 mg/dl, drink small sips of sweetened fluids (sport drinks, Pedialyte, diluted juice, diet beverages, or popsicles).
- Most over-the-counter medications have little effect on blood sugar levels. For pain or fever, acetaminophen (Tylenol) or ibuprofen (Motrin or Advil) may be used as instructed on the package. Please note that sugary throat lozenges, decongestants, and asthma medications may elevate blood glucose levels. Oral steroids can also increase blood glucose level and may require and insulin adjustment. As a precaution, consult with your pediatrician regarding the use of over-the-counter medications.
- Call your doctor, your pediatrician or medical on-call doctor if:
- Your child has moderate to large amount of ketones
- You need advice on how much insulin to give when your child is vomiting and cannot keep down fluids
- Your child has a low blood glucose level that is not increasing despite treating 3 times
- Your child runs a temperature over 100°F for longer than 24 hours
- Your child has a condition you are concerned about and it is not affecting your child’s blood glucose level
- Go to the hospital if:
- Your child has severe abdominal pain
- Your child has difficulty breathing
- Your child exhibits signs of dehydration such as unusual sleepiness, dry mouth and skin, sunken eyes, or if your child continues an unusual amount of time without urinating.
- Your child has ketones, high blood glucose, or both, and you can’t get the level amount to decrease (especially if you are using insulin)
- Your child shows symptoms of diabetes ketoacidosis (DKA):
- Early symptoms of diabetes ketoacidosis:
- Thirst or a very dry mouth
- Frequent urination
- High blood glucose level (typically over 250 mg/dl, although ketones can occur at lower levels)
- High ketone levels in the urine or blood
- Later Symptoms of diabetes ketoacidosis:
- Constantly feeling tired
- Dry or flushed skin
- Nausea, vomiting, or abdominal pain
- Difficulty breathing
- Fruity odor on the breath
- A hard time paying attention or confusion
- Early symptoms of diabetes ketoacidosis:
You can also follow this flowchart for guidance as it gives a quick summary of what you should do under different circumstances:
Click here to download the PDF version of this flowchart.
Hopefully, we have covered all the topics concerning sick day management and preparation for diabetes individuals. If you have any comments, concerns, or questions, please don’t hesitate and email us. We would absolutely love to hear from you.