Juvenile Diabetes Foundation

(Maharashtra Chapter)

Ketoacidosis and Sick Day Management

The most serious and perhaps the only life threatening complication of childhood diabetes encountered in the pediatric age group is diabetic ketoacidosis (DKA in short). In DKA, along with a marked rise in blood glucose, there is also a buildup of acetone in the blood stream. This leads to abdominal pain, vomiting, dehydration, breathlessness, a peculiar fruity odor in the breath, drowsiness, and finally coma.

There are two situations in which DKA can develop:

  1. When insulin is discontinued for some reason. (We hope you will never commit that blunder!).
  2. On days when you are sick if you fail to take supplemental doses of insulin as required.

To prevent DKA, therefore, never omit your insulin shots and make sure you are well-versed in what we call "Sick day management."

When you are sick your appetite goes down and so you would expect your insulin requirement also to decrease. However, it is usually the reverse that happens. Yes, additional insulin is almost always required.

If you do not know how to adjust your insulin dose as well as your diet in “sick days,” you are at risk for developing DKA. So please study carefully the guidelines given below:

Sick day guidelines

We will discuss these under four headings:

  1. Monitoring
  2. Insulin
  3. Diet
  4. When should you go to the hospital?


On sick days, check your blood glucose and your urine acetone every 2-4 hours all through the day and night.

In case you are not in a position to check blood glucose, you may resort to urine glucose testing, but remember, this is a far inferior alternative.

Each result will have to be interpreted and acted upon immediately as explained below.


Take your morning and evening doses as on any routine day except if your blood glucose is low (less than 100 mg/dl), in which case you may reduce your dose.

Most of the time, the blood glucose is elevated on sick days and you will need to take supplemental doses of plain (clear) insulin after studying each blood glucose and urine acetone result. When and how much of additional insulin does one take?

  • WHEN? This depends on the blood/urine glucose result.

Take additional insulin only if the blood glucose is >250 mg/dl (or urine glucose is 4+)

  • How much? This depends on the urine acetone. If urine acetone is absent or trace you need an insulin supplement equal to 10% of your routine day total insulin dose (clear + cloudy).

But if urine acetone is moderate or large, you should take an equivalent of 20% of your routine day dose.

For example, if you take clear insulin 8 units + cloudy insulin 12 units before breakfast, and clear insulin 4 units + cloudy insulin 6 units before dinner on routine day, then your total daily dose is 30 units, and 20% is 6 units, to be taken as clear insulin only when indicated.

Note: if your blood glucose is <250 mg/dl you do not need additional insulin irrespective of your urine acetone result.


When sick, you may not feel like eating your regular meals. But do make it a point to consume plenty of liquids. Take these in small and frequent sips so that you are more likely to retain them. Also remember that ice cold liquids are tolerated better.

If the blood glucose is >250 mg/dl, you need salty drinks in abundance. You may take buttermilk with salt, milk without sugar, vegetable soups, coconut water, and rice kanji.

When blood glucose is lower than 100 mg/dl, you must take in sweet liquids such as milk with sugar, fruit juices, soft drinks and ice-cream.

When do you need to rush to the hospital?

You need to be hospitalized if:

  1. You vomit more than three times.
  2. You require more than 2 supplemental doses of insulin
  3. You feel drowsy.
  4. You are breathless.

Remember, the earlier you go to hospital when the above stated criteria are present, the quicker will be your recovery from DKA.