Diarrhea and vomiting in children with diabetes can cause abrupt swings in their blood sugar levels. How then should one adjust the insulin dosage? How can one compensate best for the loss of fluid? Which medications can one take?

Diarrhea and vomiting? Everyone gets that – especially toddlers and school kids, who are particularly prone to catching infections as their immune systems are still in development. When bacteria cross the stomach barrier, they multiply in the intestinal tract and trigger diarrhea, vomiting, and sometimes fever. In children with diabetes, such loss of fluid and lack of carbohydrates can have a profound effect on blood sugar. Nevertheless, in most cases one need not go to the doctor, and admission to hospital is rarely required. Diarrhea and vomiting are unspecific conditions, that is, one can never be 100% sure as to the cause. If the condition continues, however, one should visit a paediatrician. S/he can categorize the disorder and give the appropriate treatment.

Triggers of Acute Stomach Disorders 
Most commonly, acute stomach disorders are triggered by infections or toxic substances taken in with food (for example, poisons in raw beans, or in food gone off).

In this country, infections are mostly caused by viruses and bacteria, for example, salmonella and staphylococcus, as well as by single-celled organisms present in the ground or in water (amoeba, giardia lamblia). Abroad, the immune system is more susceptible to germs as well as unfamiliar spices and food additives. 

Course of Ilness is Indication of Cause 
The clinical course of the illness is usually enough to determine the cause of the diarrhea and/or vomiting. Infections such as human rota virus or the Norwalk virus are extremely contagious and spread like wildfire. In the case of salmonella, the patient feels severely ill, experiences hefty stomach cramps, and the diarrhea contains blood and mucus. Tropical diarrhea is usually treatable with antibiotics. 

The Threat of Dehydration
Regardless of what the cause of the stomach disorder may be: the main problem that needs to be dealt with is the massive loss of fluid that causes dehydration and an elecrolyte imbalance. This can arise when the child cannot hold anything down, including fluids. If accompanied with high fever, the fluid loss is enhanced. The child will lose weight. How much weight is lost gives an indication as to the severity of the illness. 

How to Adjust the Insulin 
Diarrhea and vomiting presents a bigger problem in children with diabetes: How much insulin should be given, when the carbohydrates are being brought up all the time or races through the digestive system before it can be properly absorbed? How much carbohydrate does actually get absorbed in such cases? In addition, loss of appetite can present a problem, especially when normal insulin is being used, which requires an immediate intake of carbohydrates? In the case of rapid-acting insulin analogues, the injection can wait until after the child has eaten.

One must also take into consideration that, in the case of fever, more insulin is needed as the body releases more stress hormones. The parents have to tread a fine line: due to the enhanced effect of insulin, the insulin dose should not be too high and, on the other hand, it should not be too low to meet the higher insulin requirement. 

What To Do
Insulin therapy 

• Continue with the basal insulin unchanged or slightly reduced. 
  
• Give prandial insulin according to intake and, if the child appears to be able to keep the food down, inject after s/he has eaten. It is preferable, in the case of diarrhea and vomiting, to use a rapid-acting insulin analogue. 
  
• Monitor blood sugar every hour. If the fasting glucose is too high, inject rapid-acting analogue or raise the level of basal insulin. 
  
• Measure the ketones every time the child urinates, especially when the blood sugar is high, to watch for ketoacidosis. This also applies to children without diabetes, in which ketones in the urine are an indication of dehydration. 

Carbohydrate intake
It is more important to rehydrate the child than to try to get him to eat. First of all, administer carbohydrated drinks or isotone water sip-by-sip. Offer black tea with dextrose (2 teaspoons=100 ml) or coca cola (the real thing, not diet coke!). Shaking the cola first makes it easier to tolerate. Rehydration solutions such as GES 60® or Oralpädon® are also recommended. Although older children don’t seem to like these as much due to their salty/sweet taste, babys should certainly be given such liquids, as they contain the exact ratio of electrolytes to sugar.

When the liquid stays down, one can introduce easily digestible food such as crackers, stewed apple, crushed banana or salt sticks. Such food contains simple sugars (glucose, fructose) that are rapidly absorbed. Also, their minimal fat content makes them easier to tolerate.

Medication
In the case of uncontrollable vomiting, it may be useful to use suppositories to administer medication (Vomex®, Vomacur®, Emesan®). These medications, however, should be used with care – it is best to consult a doctor first. Suppositories are especially handy on trips to stop the vicious circle of uncontrollable vomiting, dehydration, fever, thereby preventing ketoacidosis.
In the case of diarrhea, protective bacteria in capsule form can also be useful (Perenterol®) to help build up the intestinal flora. In some situations, it is a good idea to take these as a preventative measure, for instance, before travelling abroad. This can help prevent a case of diarrhea, or at least to decrease its severity. 

A doctor should always be consulted. This applies especially when taking acute medications such as Tiorfan®, that are meant to put an actual stop to the diarrhea.  

In the case of fever, medications such as ibuprofen syrup or paracetamol should be used in the appropriate amounts. By reducing the fever, one reduces the fluid requirement. In addition, the insulin requirement is easier to regulate when the body is at normal temperature.

Clinic
If the child, despite everything, is still not able to hold liquid, or if symptoms of ketoacidosis start to appear, s/he should be taken immediately to the clinic where s/he will receive an intravenous infusion. 

In any case, do not be afraid to call one of the 24-hour hotlines available at the larger out-patient clinics for paediatric diabetes. 

Finally, before embarking on a trip to where unfamiliar climates and/or culinary habits are to be expected, consult the diabetes team to get information on preventative measures, and how to set up a proper emergency kit. 

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Dr Claudia Nestoris MD
For comments or further enquiries please contact: 
finkenauer(at)kirchheim-verlag(dot)de