Managing Children and Adolescents with Type 1 Diabetes During the COVID-19 Pandemic

Managing Children and Adolescents with Type 1 Diabetes During the COVID-19 Pandemic

Table of Contents

  1. Common COVID-19 Symptoms in Children & Adolescents
  2. Managing Type 1 Diabetes with a COVID-19 Infection
  3. General Tips: Planning for Sick Days
  4. Additional Information and References

Keywords: Type 1 Diabetes, Management, Diabetic Ketoacidosis (DKA), Sick Days, Insulin

1. Common COVID-19 Symptoms in Children & Adolescents

Symptoms that have been reported in children and adolescents diagnosed with the COVID-19 infection include1:

  • Fever
  • Fatigue
  • Muscle pain (myalgia)
  • Cough
  • Sore throat
  • Runny nose
  • Sneezing
  • Diarrhea
  • Nausea* or vomiting*
  • Abdominal pain*

On May 12, 2020, the CDC added additional pediatric COVID-19 symptoms as follows:

  • Shortness of breath
  • Headache
  • Nasal Congestion (rhinorrhea)
  • Poor appetite

For more information see here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html

View the clinical guidance by the Canadian Pediatric Society (CPS) on Multi-system inflammatory syndrome in children (MIS-C) here: https://www.cps.ca/en/documents/position/pims

* Note: these can also be symptoms of DKA; make sure to check ketone levels and not assume these symptoms are always related to COVID-19 infection. Contact your healthcare provider. This symptoms list may change as more information becomes available. Please consult with the adult symptoms list as children may show similar symptoms.

Gastrointestinal symptoms (including abdominal pain, diarrhea, nausea and vomiting) were reported in a minority of adult patients and one pediatric patient so far.

2. Managing Type 1 Diabetes with a COVID-19 Infection:

Whether on injections or insulin pumps, it is important to follow sick day guidelines as recommended by the healthcare team in the case of a COVID-19 infection. Here are some general guidelines that can help2-6:

1. Monitor glucose and ketone (blood or urine) levels around every 4 hours. Keep track of the trends and apply the sick day management protocols provided by the diabetes healthcare team.

a. Aim for a blood glucose level between 4 -10 mmol/L or 72-180 mg/dL. 

b. If experiencing low blood glucose (hypoglycemia; glucose level lower than 4 mmol/L or 72 mg/dL), then give simple carbohydrates (e.g. 15 grams of carbohydrates is what is in ½ cup of juice, 1.5 sticks of popsicle, 1 cup of regular Gatorade, ½ cup flat 7-up or ⅓ cup Jell-O) and check again in 15 minutes to make sure the blood glucose levels are rising above 4 mmol/L (72 mg/dL)5,6.

The amount of carbohydrates given depends on the child’s weight, as per the chart below:

Weight (kilograms)1515-3030+
Amount of carbohydrate (grams)51015

c. If experiencing high blood glucose (hyperglycemia; glucose level greater than 14mmol/L or 252 mg/dL) twice in a row, check for blood/urine ketone levels.

Utilize the Insulin Dose Adjustment Guidelines (an example is provided below) to correct the blood glucose. Utilize this supplemental (extra) insulin as needed generally every 3-4 hours to correct the glucose to the target level and avoid DKA.

Contact the diabetes healthcare team if there is hyperglycemia with ketones and giving supplemental insulin is not helping deal with them. Seek medical attention if there is vomiting with hyperglycemia and ketones.

Insulin Dose Adjustment Guidelines5

This table refers to the amount of supplemental (extra) insulin to be given if there are ketones present.

Example: If the glucose level is 16 mmol/L (or 288 mg/dL), ketone level is 1.6 in the blood or moderate in the urine, and the patient is on 10 units of Lantus (long-acting) insulin per day, and 4 units of rapid-acting insulin pre-meals.

Answer: Calculate the total daily dose of insulin (10 units of Lantus (long-acting) insulin per day, and 4 units of rapid insulin three times per day at meals = total daily dose of 22 units). Following the chart, administer 3 units of rapid-acting insulin to clear the ketones. If eating at that time, add the 3 units of rapid-acting insulin to the meal-time insulin dose.

Administering a Mini-Dose Glucagon5

If blood glucose level is below 4 mmol/L (or 72 mg/dL) and if it is not possible to take sugar/carbohydrates by mouth (due to refusal, illness, or vomiting), consider administering mini-dose glucagon. Utilize the chart below to aid with the calculation of the amount to give.

d. If you have access to a continuous glucose monitoring (CGM) device, utilize this to help fine-tune insulin dose adjustments. Be aware that some CGM sensors (Dexcom G5, Medtronic Enlite, and Guardian) are impacted by Acetaminophen (Tylenol). Check with finger sticks to ensure accuracy 3.

2. NEVER STOP INSULIN: If not able to eat, give sugary drinks so that insulin can be given.

3. Drink water frequently to stay well-hydrated.  

4. Treat underlying illnesses and symptoms.

3. General Tips: Planning for Sick Days6

4. Additional Information and References

For more information on the topics covered in this section, or to read more about general sick day management and DKA prevention, please see the following resources. 

  1. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, Tong S. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020 Mar 1. https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf 
  2. Canadian Paediatric Society. Current epidemiology and guidance for COVID-19 caused by SARS-CoV-2 virus, in children: March 2020. https://www.cps.ca/en/documents/position/current-epidemiology-and-guidance-for-covid-19-march-2020
  3. American Diabetes Association. https://www.diabetes.org/coronavirus-covid-19
  4. Laffel L, Limbert C, Phelan H, Virmani, A, Wood J, Hofer S. Chapter 13: Sick day management in children and adolescents with diabetes. International Society for Pediatric and Adolescent Diabetes. https://www.ispad.org/page/sickday
  5. Paediatric Diabetes Network – Illness Management Guidelines. Provincial Council for Maternal and Child Health. https://www.pcmch.on.ca/health-care-providers/paediatric-care/ontario-paediatric-diabetes-network/paediatric-diabetes-network-illness-management-guidelines/?fbclid=IwAR0FzpxIvuF9CPckdPEzQHm_Pw9vsInxCPdkG7Ys29mwjHFHM9gKOLzrat4
  6. Diabetes Canada. https://www.diabetes.ca/

This page was updated on Wednesday, July 8, 2020

Disclaimer: The information regarding COVID-19 is changing constantly as more data become available. The information provided in this website is not meant to replace diabetes healthcare team or public health agencies recommendations, and is intended for information purposes only. Please check with your healthcare providers for any deviations from your care plans.


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