A 12-year-old known type-1 diabetic presents with blood glucose 450 mg/dL, pH 7.12, bicarbonate 9 mEq/L, deep sighing respirations, and altered sensorium. Fluid resuscitation is commenced. Regarding insulin therapy in pediatric DKA, which of the following is the CURRENT recommendation?
- A Start insulin infusion at 0.1 unit/kg/hr immediately after fluid bolus
- B Withhold insulin until pH > 7.20 to avoid cerebral edema
- C Start insulin infusion at 0.05–0.1 unit/kg/hr after initial volume expansion (1–2 hours), WITHOUT a priming bolus ✓
- D Subcutaneous insulin only; intravenous insulin is contraindicated in children
Correct answer: C. Start insulin infusion at 0.05–0.1 unit/kg/hr after initial volume expansion (1–2 hours), WITHOUT a priming bolus
Explanation
Current ISPAD/BSPED guidelines recommend starting continuous low-dose insulin infusion at 0.05–0.1 unit/kg/hr only after initial fluid resuscitation (usually 1–2 hours), without a priming insulin bolus, as bolus dosing increases the risk of hypoglycemia and cerebral edema. Immediate insulin (before rehydration) can cause rapid fluid shifts. pH need not exceed 7.20 before insulin is started; correction of acidosis is primarily achieved by insulin therapy itself once volume is restored.
Reference: Ghai Essential Pediatrics, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.