Patient handout

Pediatric diabetic ketoacidosis (DKA)

PRODUCTION

1. Your condition

This handout is for pediatric diabetic ketoacidosis (dka). Your care team identified this based on: polyuria, polydipsia, weight loss in a child (ispad 2022).

Other reasons your team may use this plan: tachypnoea / kussmaul breathing in known or suspected diabetic child (ispad 2022); altered mental status in known or suspected diabetic child (ispad 2022); bg >200 mg/dl + bicarbonate <18 + ketones in a child (ispad 2022).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
insulin_regular_infusion	0.05-0.1 U/kg/h IV; NO bolus	IV	continuous	ISPAD 2022 — bolus not recommended; lower-dose 0.05 acceptable in mild DKA and <5 yr
insulin_glargine	0.3 U/kg/day total daily dose split basal/prandial in new-onset; otherwise resume home dose	SC	once daily	Overlap with IV × 30-60 min before stopping infusion
insulin_lispro	0.05-0.1 U/kg with meals; correctional sliding scale	SC	with meals	Prandial coverage at transition
normal saline / lactated Ringer's	10 mL/kg over 1 h ONLY if shock (max 20 mL/kg); routine isotonic over 48 h replacing deficit + maintenance	IV	continuous	PECARN FLUID — neither rate nor tonicity worsened cerebral edema risk; remain conservative; bolus restricted to shock
potassium_chloride	Add 40 mEq/L if K+ 4-5; 60 mEq/L if K+ 3.5-4; hold if K+ >5.5	IV	continuous	Insulin drives K+ intracellular; hypokalemia risk
potassium_phosphate	Replace as 50/50 KCl + KPhos when phosphate <1 mg/dL	IV	continuous	Avoid hypocalcaemia from over-replacement
mannitol	0.5-1 g/kg IV over 20 min	IV	single dose, may repeat in 30 min	Cerebral edema rescue — alternative or adjunct to 3% saline
hypertonic saline 3%	5 mL/kg IV over 30 min	IV	single	Cerebral edema rescue — first-line at many centers
sodium_bicarbonate	1-2 mEq/kg IV over 1 h ONLY if pH <6.90 with hemodynamic compromise	IV	single	Routine bicarbonate is harmful — increases cerebral edema risk

Plan: Pediatric DKA — ISPAD 2022 / PECARN-aligned

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent DKA episode → ED + admit + adherence/psychosocial deep-dive (ISPAD 2022)
HbA1c > 9% × 2 consecutive visits → intensify support, consider CGM/pump if not on; investigate adherence + psychosocial barriers (ADA 2026 §16)
Severe hypoglycemia event (requiring assistance OR seizure OR LOC) → endo urgent visit + glucagon-kit verification + CGM low-alert audit (ADA 2026 §16)
Disordered eating screen positive OR insulin omission for weight control → mental-health urgent referral (ADA 2026 §16; ISPAD 2022 disordered-eating consensus)
School/home support breakdown → social work + extended family education (ADA 2026 §16)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Severe HA, GCS decline, posturing, bradycardia + HTN, fixed pupil, irregular respirations, vomiting late (ISPAD 2022; Glaser 2001)(life-threatening)
pH <7.10 OR HCO3 <5 (ISPAD 2022)
K+ <3.5 at presentation (ISPAD 2022)
Hypotension + poor perfusion (uncommon in pediatric DKA) (ISPAD 2022)
New-onset T1D + age <5 + severe DKA (ISPAD 2022; Glaser 2001)
Sub-overt cerebral-edema prodrome — emerging headache + bradycardia + HTN (Cushing's triad components) WITHOUT yet meeting overt GCS-drop / focal-neuro criteria; act NOW before overt features (ISPAD 2022; Glaser NEJM 2001 PMID 11172164)(life-threatening)
Insulin infusion started CONCURRENT with fluid resuscitation OR before 1 h of fluid has been delivered (ISPAD 2024 update — insulin must start ≥ 1 h AFTER fluid resuscitation begins; concurrent start raises cerebral-edema risk)
Sodium bicarbonate administered for DKA correction WITHOUT meeting the narrow rescue criteria (pH < 6.90 + hemodynamic compromise); bicarbonate is an INDEPENDENT cerebral-edema risk factor (Glaser 2001 OR 4.2, 95% CI 1.5-12.1; ISPAD 2022 strong recommendation against routine bicarbonate)
K+ < 3.0 mEq/L at presentation OR during treatment; extreme hypokalemia requires repletion to ≥ 3.5 BEFORE insulin start OR HOLD insulin if already running (ISPAD 2024 update; insulin drives K+ intracellular)

5. Follow-up

Pediatric endocrinology, diabetes education, family sick-day rules + glucagon kit; annual screening (ADA 2026 §16; ISPAD 2022)

6. Sources

Guideline: ISPAD 2022 + 2024 update + PECARN FLUID NEJM 2018 + BSPED 2020 + Glaser NEJM 2001 (cerebral-edema risk model)