Type 1 Diabetes in Children: Insulin, Hypoglycemia Treatment, the School Plan, and Sick-Day Rules
Teach that the child always needs insulin, including on sick days. Treat a glucose below 70 mg/dL with 15 g of fast-acting carbohydrate, or the smaller amount the team sets for a young child, recheck in 15 minutes, and repeat until glucose is 70 mg/dL or higher. Check ketones during illness, call the diabetes team for moderate or large ketones, and call 911 for vomiting with ketones, Kussmaul respirations, or confusion.
Who needs this teaching
Children and adolescents with type 1 diabetes, their parents, and the school nurse and staff. Autoimmune destruction of the pancreatic beta cells causes absolute insulin deficiency. Without insulin, the child develops hyperglycemia and diabetic ketoacidosis (DKA).
The priority teaching points
- Insulin is always needed. Give basal insulin every day, and give rapid-acting insulin with meals by the prescribed insulin-to-carbohydrate ratio and correction factor, or use the insulin pump as programmed. Never omit insulin, even when the child is ill or not eating.
- Glucose monitoring. Check blood glucose before meals and at bedtime, or use a continuous glucose monitor (CGM). The ADA target for most children is an A1C below 7%, with CGM time in range (70 to 180 mg/dL) above 70%, or the targets the diabetes team sets.
- Carbohydrate counting. Read the total carbohydrate grams and the serving size on food labels, and count the carbohydrate in each meal and snack.
- The school plan. The diabetes team writes a Diabetes Medical Management Plan. The school nurse coordinates care from it, and a Section 504 plan protects the child's rights. Fast-acting glucose and snacks stay with the child at all times.
- Hypoglycemia. Hypoglycemia is a glucose below 70 mg/dL. Signs in children are shakiness, diaphoresis, pallor, irritability, hunger, headache, and sudden changes in behavior. Young children do not reliably report symptoms. Apply the rule of 15: give 15 g of fast-acting carbohydrate, such as 4 glucose tablets or 4 oz of juice, recheck in 15 minutes, and repeat if glucose remains below 70 mg/dL. Give a snack if the next meal is more than 1 hour away.
- Glucagon. For severe hypoglycemia (the child cannot swallow safely, is unconscious, or has a seizure), give glucagon by nasal powder or injection in the prescribed dose, turn the child to the side, and call 911. Never give food or fluid by mouth to an unconscious child. Trained school staff give glucagon.
- Exercise. Check glucose before activity, and give an extra carbohydrate snack when glucose is below the pre-exercise target. Exercise lowers glucose for up to 24 hours afterward. Avoid vigorous exercise with moderate or large ketones.
- Sick-day rules. Continue insulin. Check glucose every 2 to 3 hours. Check ketones during illness or when glucose is above 250 mg/dL. Offer fluids every hour. Give extra rapid-acting insulin by the sick-day plan. Normal blood ketones are below 0.6 mmol/L.
- Age-appropriate tasks. School-age children perform fingerstick checks and recognize hypoglycemia, with adult supervision of insulin doses.
Red flags the parent reports
| Call the provider the same day | Call 911 or the local emergency number |
|---|---|
| Moderate or large urine ketones, or blood ketones 1.5 mmol/L or higher, without vomiting: call immediately | Vomiting with moderate or large ketones |
| Glucose above 250 mg/dL on 2 checks in a row | Deep, rapid (Kussmaul) respirations or fruity breath odor |
| Frequent hypoglycemia or readings outside the target range | Confusion, extreme drowsiness, or abdominal pain with vomiting |
| Illness with poor intake, or a pump or CGM failure | Unconsciousness or seizure from hypoglycemia (give glucagon) |
Teach-back questions
- "What will you do if your child is sick and not eating?"
- "Show me how you treat a glucose of 62 mg/dL."
- "Who gives glucagon at school, and where is it kept?"
- "Which signs mean you call 911?"
Teaching tips
- Write the targets, ratio, correction factor, and team phone number on the handout.
- Meet with the school nurse before the child returns to school.
Read more on NCLEXPace
- Insulin: Types, Timing, and the Questions Built On Them
- Diabetes Emergencies: DKA vs HHS, Step by Step
- Endocrine Map: DKA vs. HHS, Addison’s vs. Cushing’s, Thyroid Emergencies
Sources
- American Diabetes Association Professional Practice Committee. 14. Children and Adolescents: Standards of Care in Diabetes-2025. Diabetes Care. 2025;48(Suppl 1).
- Jackson CC, et al. Diabetes Care in the School Setting: A Position Statement of the American Diabetes Association. Diabetes Care. 2015;38(10):1958-1963.
- Phelan H, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Sick Day Management in Children and Adolescents With Diabetes. Pediatr Diabetes. 2022;23(7).
Why this matters for the NCLEX
Teaching is effective when the parent states, "I will give insulin even when my child is sick and not eating, and I will check ketones," and the school-age child states, "When I feel shaky, I tell my teacher and eat 4 glucose tablets." Statements requiring further teaching include, "I will skip the insulin when my child vomits," "I will put juice in my child's mouth while my child is unconscious," and "The glucose tablets stay in the office during recess."
Frequently asked questions
Does the parent hold insulin when the child is ill and not eating?
No. Illness raises glucose through stress hormones, and insulin omission causes DKA. The parent follows the sick-day plan for doses and ketone checks.
Why does a school-age child need adult supervision of insulin doses?
School-age children perform glucose checks and recognize symptoms, but dose calculation errors are common. Adults supervise insulin dosing through adolescence.
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