Treatment of Children With Diabetic Ketoacidosis Differs From Adult Treatment

Timing is crutial when a pediatric patient presents themselves with the symptoms for DKA

Children with diabetic ketoacidosis (DKA) present differently and require different treatment than adults with DKA, according to newly published guidelines from the American Diabetes Association (ADA).

"This is the first time that the ADA has had a position paper on childhood DKA separate from the adult position paper on DKA and nonketotic hyperglycemic coma, in recognition of the fact that children are not merely small adults — they have specific needs," Dr. Mark A. Sperling from Children’s Hospital of Pittsburgh, Pennsylvania told Diabetes In Control.com.

Dr. Sperling and colleagues present a consensus statement on DKA in infants, children, and adolescents in the May issue of Diabetes Care.

The younger the child, the less likely it is that the physician will be able to obtain the classical history of polyuria, polydipsia, and weight loss, the authors explain, and diabetes is often misdiagnosed as pneumonia or other conditions.

For this reason, Dr. Sperling suggested that doctors "think of diabetes mellitus in any sick child whose cause of illness is not clear."

In addition, the report indicates, differences in metabolic rate and surface area between children and adults dictate greater precision in managing fluids and electrolytes. Particular attention should be paid to the management of insulin, potassium, phosphate, and acid-base status.

Because cerebral and other autoregulatory mechanisms may not be well developed in younger children, cerebral edema is a special concern, the statement points out. The most common cause of mortality in children with DKA, cerebral edema occurs in 0.5-1% of pediatric DKA episodes and leaves as many as one quarter of the survivors with permanent neurological injury.

The guidelines further emphasize that delay in diagnosis is the major cause of DKA in previously unrecognized disease in younger children, but omission of insulin is the leading cause of recurrent DKA, especially among adolescents.

"Recognizing the symptoms of diabetes early and treating it before metabolic decompensation begins is feasible — schools, kindergartens, nurses, teachers and the public must become aware of the increasing incidence of type 1 diabetes and refer to a doctor promptly," Dr. Sperling concluded. "Doctors must have diabetes high on their list as a possible diagnosis."

Diabetes Care 2006;29:1150-1159.

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FACT:
Hypoglycemia Not an Issue With Beta-Blockers: In patients with insulin-treated diabetes, some clinicians are concerned over the effect of beta-blockers reducing or eliminating the warning symptoms of hypoglycemia. Anthony H. Barnett, MD, and colleagues addressed this concern in a prospective study of 150 insulin-treated patients.1 Fifty insulin-treated subjects taking beta-blockers were compared with 100 insulin-treated subjects not on beta-blockers. The incidence of loss of consciousness from hypoglycemia was the same in both groups and was not related to the dose of beta-blocker used. All symptoms of hypoglycemia were similar in both groups, with the exception of diaphoresis (perspiration), which was more common in the beta-blocker group. Diaphoresis is a dramatic symptom, and it makes patients aware of a sudden change in their blood glucose. The theoretical concerns of hypoglycemia unawareness and blunted hypoglycemic response do not appear to be clinically important. Patients with diabetes treated with beta-blockers are no more likely to have serious hypoglycemic events than those not treated with beta-blockers. Clinicians should feel comfortable prescribing beta-blockers in patients with diabetes. Barnett AH, Leslie D, Watkins PJ: Can insulin-treated diabetics be given beta-adrenergic blocking drugs? Br Med J 280: 976–978, 1980