The diagnosis is rarely difficult except in younger children, where the acidotic breathing pattern may easily be confused with an
Table 2.1 Differential diagnosis of diabetic ketoacidosis in children
Glycosuria/hyperglycaemia Acidosis predominant
Physical stress, e.g. intercurrent Alcoholic ketoacidosis infection with transient hyperglycaemia MODY Severe sepsis
Renal tubular defects Certain inborn errors of metabolism
Corticosteroid treatment; N.B. may precipitate metabolic decompensation Hyperosmolar non-ketotic coma Type 2 diabetes
MODY = maturity onset diabetes of the young.
upper or lower respiratory tract infection. In a small child, the characteristic smell of ketones on the breath may be attributed to fasting, but the diagnosis of diabetic ketoacidosis must be considered in any sick child, as the consequences of missing the diagnosis can be devastating. Further differential diagnoses are considered in Table 2.1.
Hyperosmolar non-ketotic hyperglycaemic coma (see Chapter 3) is rare in children; serum osmolality usually exceeds 300 mOsmol/L and ketosis is absent. The mechanism is likely to be prolonged dehydration with relative insulin sufficiency; it is more common in children with mental impairment. The management is similar to that of diabetic ketoacidosis, except that it has been recommended that insulin and fluids are given more slowly to prevent too rapid a fall in blood glucose and plasma osmolality.
Maturity onset diabetes of the young (MODY) is inherited in an autosomal dominant fashion and does not usually present with major metabolic decompensation. Insulin treatment is not usually required but may be necessary during intercurrent illness. The diagnosis should be firmly established using clinical and genetic criteria before any decision is made to discontinue insulin therapy. This also applies to the increasingly common situation wherein type 2 diabetes is diagnosed in childhood or adolescence.
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