Diabetic ketoacidosis can be a rapidly changing condition, particularly in small children. Junior medical staff should routinely discuss such children with senior colleagues and should feel adequately supervised while undertaking treatment. Guidelines that are easy to understand and to use should be readily available in the hospital emergency department and on the wards, including high-dependency and intensive care units. The basic principles of management are as follows:

• correct the fluid losses

• reverse the acidosis and ketosis

• prevent complications such as aspiration of gastric contents, hypokalaemia, and cerebral oedema.

The guidelines that follow are based on those of the British Society for Paediatric Endocrinology and Diabetes (BSPED). These can be found in full on the BSPED website (, and a short algorithm version on the Diabetes UK website (www. These are very similar to the guidelines of the International Society for Paediatric and Adolescent diabetes (ISPAD; All of these are general guidelines for management. Note that treatment may need to be varied to suit the individual patient. Guidelines do not remove the need for frequent detailed reassessments of the individual child's progress. These guidelines are intended for the management of the following children:

• more than five per cent dehydrated

• and/or clinically acidotic.

Children who are five per cent dehydrated or less and not clinically unwell usually tolerate oral rehydration and subcutaneous insulin. Discuss this with the senior doctor on call.

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