In a normal year, as the weather turns cooler, we might find ourselves searching for how to tell the difference between allergies and a cold, or a stomach bug versus the flu. And in little ones with type 1 diabetes, blood sugar would add an extra layer of worry to even run-of-the-mill sniffles and tummy trouble, whatever the cause. This year, on top of everything else, we now have to wonder if those sick-day symptoms could be COVID-19. And if they are, what that means for a child with an underlying medical condition.
Fortunately, type 1 doesn’t appear to increase the chance of contracting the coronavirus. Nonetheless, illnesses with symptoms like coughing, congestion, fever, or vomiting can lead to complications from high or unstable blood sugar in kids with type 1. So it’s important to be prepared ahead of time. Read on to hear from an endocrinologist, dietitian, and fellow D-parents on how to get ready to manage sick days this year.
First, it’s important to clarify that type 1 diabetes alone does not put children at higher risk for contracting the novel coronavirus. “Type 1 diabetes is not an immune-compromising condition,” explains Michael Gottschalk, M.D., Ph.D., chief of pediatric endocrinology at Rady Children’s Hospital-San Diego. A study published recently in the journal Diabetes Care tracked COVID-19 data among children and found no difference in infection rates for those with type 1 diabetes.
“We keep hearing in the news about diabetes being a risk factor, but what is meant is that in elderly adults who develop COVID-19, many have type 2 diabetes. These statistics do not apply to children with type 1, who are not at higher risk compared to other children their own age,” he explains.” [Note that the CDC states that having type 1 diabetes may increase your risk of severe illness from COVID-19.]
To lower the risk for coronavirus infection, Gottschalk advises that children with diabetes and their families follow the standard health precautions from the CDC. These include wearing a mask, physical distancing, and washing hands frequently.
If you’re concerned that symptoms could be related to COVID-19, get in touch with your child’s regular physician or healthcare provider to determine if your child should be tested. While diabetes doesn’t increase the risk of contracting coronavirus, Gottschalk is careful to note that “should a child with diabetes develop COVID-19, there is cause for added concern due to the risk for high blood sugars and ketones during sick days.” That means you’ll need to both treat the symptoms of the illness — which could include fever or chills, coughing, and fatigue — as well as manage your child’s blood sugar closely to avoid hyperglycemia. Your diabetes care team can help guide you through this.
Sick Day Management
The first rule of thumb for parents caring for their child’s diabetes through any viral bug is to be prepared to catch and respond to high blood sugars.
When a viral infection is present, the body sees the illness as stress and releases hormones increasing the amount of glucose into the bloodstream as part of responding to that stress. Children without diabetes simply produce extra insulin to manage higher levels of blood glucose, but in kids with type 1 diabetes, the result is often high blood sugar readings. “Hormonal changes are part of fighting off infection, and this can lead to higher glucose levels and hyperglycemia,” says Gottschalk.
Numbers may fluctuate suddenly — and widely — during illness, and parents will need to check their child’s blood sugar more frequently to make needed corrections for out-of-range numbers. Blood sugar may spike even before virus symptoms are obvious. As Gottschalk notes, “High blood sugar numbers are sometimes a tip-off the body has started fighting off an infection.”
Parents may be more accustomed to worrying about low blood sugar numbers; so what’s the concern with highs? “When blood sugar is elevated or uncontrolled, the child with T1D is at greater risk for ketones to build up to dangerous levels in the body,” Gottschalk explains. Ketones are chemicals produced in the liver when there is not enough glucose for energy and the body needs to break down fat for fuel instead. Elevated ketones mean that a child is not getting enough insulin. Very high levels of ketones can be a sign of diabetic ketoacidosis (DKA), a health complication that requires immediate medical attention.
“Good control of blood sugars is so important during sick days, and all the time,” he adds. “When there is poor control, the child’s risk for DKA increases.”
Because ketones are eventually excreted in the urine, levels can be checked with a simple urine ketone test strip. During illness, when risk for high blood sugar is higher, your care provider may advise you to regularly check for ketones, sometimes as frequently as every four hours or more. American Diabetes Association guidelines suggest testing for ketones whenever blood sugar readings are more than 240 mg/dl.
As you monitor blood sugar levels with even more vigilance, Gottschalk recommends also taking a close look at any over-the-counter cold and flu medications you may be giving your child. Make sure these are not unknowingly contributing to highs — some over-the-counter remedies (like some children’s cough syrups) contain enough sugar per serving that a dose could raise blood sugar levels.
Depending on the amount, you may need to adjust your child’s insulin to accommodate for the medication. Cough and cold remedies that are sugar-free or reduced-sugar are available at most pharmacies; ask your child’s healthcare provider if these are a good option.
Eating, Drinking, and Bolusing
Your child may not feel much like eating when they are sick, or they may not be able to keep much down. But eating and drinking to keep up carbohydrate and fluid intake are key to keeping diabetes from adding to a child’s illness, and keeping T1D management on track.
In general, it’s recommended to stick as closely as possible to your regular meal and snack times and carbohydrate goals. “If your child doesn’t feel like eating normal foods, try substituting soup and other comfort foods,” recommends Darcy de la Rosa, R.D., M.P.H., C.D.C.E.S., a clinical dietitian with Fresenius Medical Care North America in Newport, Oregon.
“The most important thing to remember is to not stop insulin during sick days for a child who has type 1 diabetes. The dose may need to be changed depending on glucose levels. Once insulin is administered, it is important that carbohydrates be consumed,” says de la Rosa.
Need suggestions for foods that queasy kids might tolerate? The following each contain about 15 grams (or 1 serving) of carbohydrates, and tend to be gentle on tummies:
- 1 cup soup
- 6 saltine crackers
- 1 slice dry toast (not “light” bread)
- ⅓ cup cooked rice
- ½ cup mashed potatoes
- ½ cup cooked cereal
- ½ medium banana
- ½ cup applesauce
- ½ cup regular ice cream
- ⅓ cup frozen yogurt
- ½ cup sherbet
- ½ cup custard
- 3 graham crackers
- 5 vanilla wafers
- ¼ cup regular pudding
Dehydration can also contribute to high blood sugar. To keep fluid intake up when you don’t want to add additional carbohydrates, try water and/or plain broth, or any of the following non-carbohydrate fluids:
- Sugar-free sports drinks and drink mixes
- Sugar-free frozen pops
- Sugar-free ginger ale
- Sugar-free flavored gelatin
For times when blood sugar is under the goal you and your healthcare team have decided upon for your child, the following carb-containing fluids contain approximately 15 grams of carbohydrates each:
- ½ cup regular soft drink
- 1 cup sports drink
- tea with 1 tablespoon honey or sugar
- ½ cup apple or orange juice
- ⅓ cup grape or cranberry juice
- ½ cup fruit drink
- 1 double-stick regular frozen pop
When to Call Your Doctor
It’s important for parents to talk to their diabetes care team before illness strikes as a way to get some general guidelines on what to do when the inevitable sick day arrives, and which symptoms mean it’s time to call your team for help.
These symptoms might include:
- blood sugars that remain above 400 mg/dL for more than four hours (even with extra insulin)
- developing a fever of greater than 101ºF
- nausea, vomiting, or diarrhea for more than 4 hours
- the presence of other serious or unusual symptoms such as chest pain, confusion, or trouble breathing
- signs of dehydration (dry mouth, sunken eyes, or poor urine output) or signs of ketoacidosis, which include fruity breath, deep rapid breathing, or vomiting
Parent to Parent
How are other families with diabetes navigating sick days in the time of COVID-19?
“This year, we’ve created a sick-day plan just in case my daughter or any family member gets coronavirus. I have a thermometer, oximeter, basic cold and flu remedies, humidifier, extra fluids and sick-day foods — regular and sugar-free — all stocked up and ready to go,” says California mom Andrea L., whose daughter Katie, 14, was diagnosed with type 1 diabetes at age 6. Andrea has also designated a spare room that can be more easily closed off as the “sick room,” and has a supply of masks and gloves for her own protection should she need to care for a sick family member. She also has diabetes gear that is designated only for use in the sick room.
“This may sound over-the-top, but I feel it’s needed. If my daughter or any of us gets sick, we will all need to isolate and won’t be able to go to the store. I feel a little better knowing that we’re prepared,” she says.
Even if your child just has a regular bout of a cold or flu, it can still be challenging to manage, especially if you work outside the home. “As soon as you can, line up additional trained caregivers who are available during the day so you don’t miss so much work,” recommends Kim P., a mom from Andover, Massachusetts, whose son Seth, now 19 years old, has had type 1 since he was a toddler. “I once hired an on-call nurse through a local agency because I had a big meeting at work that I couldn’t miss. It wasn’t cheap, but I knew my son was being cared for, and I was less stressed out.” Of course, finding childcare is even more difficult during the pandemic; but it’s all the more reason to search for arrangements in advance if possible.
As for all the missed classwork from being absent from school? “When you sit down to make up your child’s educational plan at the beginning of the school year, put in writing how you want to handle makeup work after a health-related absence. In our case, any time he’s absent for more than three days, our accommodation is to cut down makeup work to only the basics needed to understand instruction,” says Kim.
One more tip for getting through cold and flu season: “From my experience… the same things that worked for a child in the past before their T1D diagnosis to soothe and comfort during an illness still work now,” says Andrea. “In other words, kids with diabetes can still benefit from what I call the 3 Cs of sickness: the couch, cartoons, and plenty of chicken soup.”
Disclaimer: The experiences and suggestions recounted in these articles are not intended as medical advice, and they are not necessarily the “typical” experiences of families with a child who has type 1 diabetes. These situations are unique to the families depicted. Families should check with their healthcare professionals regarding the treatment of type 1 diabetes and the frequency of blood glucose monitoring.