Scope
Supplemental-insulin algorithm for adults with Type 1 diabetes on MDI or pump therapy. Does not cover Type 2 diabetes
or inpatient DKA/HHS management.
Scope
Sick-day insulin adjustment for children and adolescents with Type 1 diabetes on MDI or pump therapy (ISPAD 2022).
Targets: glucose 3.9–10 mmol/L, ketones <0.6 mmol/L.
Glucose band:
Ketone band:
Mini-dose glucagon reference:
⚠️ Decision support only
Verify every dose against the current guideline and the patient's individualised sick-day plan. Supplemental doses are
given in addition to usual correction doses, not instead of them, and should not be given closer than 2 hours to the
previous rapid-acting dose (adult MDI) — see the age-appropriate frequency in the action plan.
Reference: ketone interpretation (adult)
Blood ketone
Urine ketone
Interpretation
<0.6 mmol/L
Negative
Normal
0.6–1.5 mmol/L
Trace/small
Increased ketone production
1.5–3.0 mmol/L
Moderate
Impending DKA
>3.0 mmol/L
Large
Probable DKA
Reference: fluid & carbohydrate intake
125–250 mL fluid/hour (unless fluid-restricted). If BGL <10 mmol/L, use carbohydrate-containing fluids; if
≥10 mmol/L, use carbohydrate-free fluids unless replacing a usual meal. If not eating normal meals, aim for
~15 g carbohydrate/hour during waking hours. ORS (Gastrolyte/Hydralyte) or diluted sports drinks help replace
electrolytes lost to vomiting/diarrhoea.
Escalate / present to hospital if
Ketones remain ≥1.5 mmol/L and BGL remains >13 mmol/L after two correction doses given 2 hours apart.
Ketones >3.0 mmol/L (probable DKA), or signs of DKA/HHS: vomiting, drowsiness, confusion, hyperventilation, severe abdominal pain.
Persistent vomiting (especially >4h, or blood/bile-stained), or unable to keep fluids down.
Unable to maintain BGL above 4 mmol/L, or persistent hypoglycaemia.
Signs of severe dehydration, or the person/carer cannot carry out the sick-day plan.
Source: NDSS / Australian Diabetes Educators Association — "Clinical guiding principles for sick day management of
adults with type 1 diabetes or type 2 diabetes: a guide for health professionals" (v4.1.0, June 2025).
Source PDF.
Reconstitute glucagon at 1 mg/mL; may repeat once after 30–60 minutes. This dose is deliberately smaller than the emergency severe-hypoglycaemia dose.
Reference: ketone interpretation (paediatric)
Target: ketones <0.6 mmol/L. 0.6–1.4 = trace/small–moderate; 1.5–2.9 = moderate/large (do not reduce TDD, add extra
dose); ≥3.0 = probable DKA (refer to ED). Ketones may rise 10–20% in the first 1–2h after extra insulin before falling.
Ketones remain ≥1.5 mmol/L (or urine large) despite extra insulin and hydration.
Glucose continues to rise despite extra insulin doses; fruity breath, Kussmaul breathing, or severe abdominal pain.
Change in neurological status, confusion, loss of consciousness, or seizures.
Vomiting persists beyond 2 hours (especially under 5 years), or unable to keep BGL above 3.9 mmol/L.
Child is very young (<5 years) — lower threshold for review generally.
Source: Phelan H, Hanas R, Hofer SE, et al. "ISPAD Clinical Practice Consensus Guidelines 2022: Sick day management
in children and adolescents with diabetes." Pediatr Diabetes. 2022;23(7):912–925.
Source.