1 Is the child fully conscious and alert? Can the child drink and retain oral fluids? Can home glucose monitoring be done and are all related supplies available in the home? Can ketones be measured at home, either in the urine with chemical test strips or in the serum with a point-of-care blood measurement device? Will the child have competent supervision at home? Does the family have access to both a telephone and transportation? Is there a clinician available with whom the family can communicate by telephone? Is the family comfortable with managing the mild acidosis at home? If these questions can be answered in the affirmative, the child may be sent home Recommendations should be made to the family regarding fluid intake, insulin administration, and monitoring Specific recommendations may vary with the age of the child and the experience of the family, but the following scheme may be helpful Oral intake should be about the same as would be given intravenously to resolve the deficit and provide maintenance (e.g., the 10-year-old child [30 kg] would normally receive a 300-mL bolus followed by 100 to 140 mL/hr, for a total of up to L during the first hours intravenously if they were hospitalized; therefore, the physician should suggest that the family try to get in 150 to 180 mL of liquid every hour for the next hours) It is best if this liquid is taken in as sips Supplements of short-acting insulin will be required in addition to the patient’s usual longacting doses In the ED, two decisions will need to be made regarding insulin First, how much short-acting insulin (lispro or regular) should be given to the child before discharge? One way to dose additional insulin is using the 5%–10% to 10%–15% rule If blood glucose is 250 to 400 mg/dL without urinary ketones, 5% of the child’s usual total daily dose will suffice If blood glucose is more than 400 mg/dL without ketones, or is 250 to 400 mg/dL with moderate or large ketones, 10% of the daily dose will be needed If blood glucose is more than 400 mg/dL and ketones are moderate or large, the child will need 15% of the daily dose and admission to the hospital should be reconsidered Second, how much insulin should be given at home and with what frequency? Once home, the preceding 5%–10% to 10%–15% rule is generally applicable and should be given every hours, based on blood glucose and blood or urinary ketones The family can begin using this algorithm once the child is able to return to a normal intake For any child to be safely discharged home, however, he or she must be able to maintain adequate oral intake and have frequent contact with a clinician who is comfortable managing pediatric diabetes Finally, hourly monitoring of blood glucose, urine output, and ketones is recommended with the expectation that the blood glucose should decline, the urine output should fall, and the ketones should begin to clear Failure to respond to these simple measures, whether in the ED or at home, should lead to a consultation with the child’s endocrinologist If oral fluids must be restricted and the child is hyperglycemic (e.g., a child with traumatic injury requiring surgery), IV fluids without glucose should be used and glucose should be monitored frequently As blood glucose concentration reaches 200 mg/dL, dextrose should be added to the IV fluid to maintain target blood glucose