PEDIATRICS
TREATMENT
■ Initial management is focused on fluid resuscitation with isotonic saline.
■ Mineralocorticoid replacement is usually reserved for long-term management,
whereas glucocorticoid replacement is usually done in both the acute and
chronic setting.
■ Salt wasting during infancy can be a true life-threatening emergency and
urgent diagnosis and hospital admission are warranted.
Diabetes
Most children with diabetes have type 1/IDDM (insulin-dependent diabetes
mellitus). An increasing number of type 2/NIDDM (noninsulin-dependent dia-
betes mellitus) are being seen, thought to be due to the increasing epidemic of
obesity. Most cases of new-onset diabetes, even if not in DKA, are admitted to the
hospital for initiation of therapy and education.
DIABETICKETOACIDOSIS(DKA)
SYMPTOMS/EXAM
■ Signs of DKA include Kussmaul respirations, tachypnea, acetone breath,
vomiting, abdominal pain (sometimes mimicking an acute abdomen) and
altered mental status.
■ Cerebral edemais the most feared complication; early manifestations
include headache, lethargy, and altered mental status, eventually progress-
ing to obtundation, seizures, and posturing.
DIAGNOSIS
■ Increased anion gap metabolic acidosis
■ Elevated glucose
■ Elevated osmolarity
■ Elevated ketones
■ Additional labs to consider: Triglycerides, HgbA1C, antiislet cell and anti-
insulin and anti-GAD antibodies, urinalysis, and ECG
TREATMENT
■ Judicious rehydration. Use normal saline bolus of 20 cc/kg in most cases
(10 cc/kg if signs of altered mental status present). Cornerstone of manage-
ment is insulin replacement usually by continuous infusion and IVF with
replacement of potassium. Do not bolus insulin to start treatment.
■ Avoid overaggressive rehydration or lowering serum glucose too quickly;
both can lead to cerebral edema.
COMPLICATIONS
Cerebral edema from overaggressive rehydration. Risk factors include low
PaCO 2 and high BUN on presentation, treatment with bicarbonate and intu-
bation with hyperventilation to a PaCO 2 lower than 22.
Inborn Errors of Metabolism
ORGANICACIDURIAS
Characterized by ketoacidosis and abnormal urinary excretion of organic
acids; include MMA (methylmalonic acidemia), PPA (propionic acidemia),
and IVA (isovaleric acidemia)