DIABETES IN INFANCY: DIAGNOSIS AND CURRENT MANAGEMENT Gail L. Bland, MD, and Vernessa D. Wood, MD Washington, DC
This article reviews diagnosis and management of infants with diabetes. These infants present with signs and symptoms confused with other more common illnesses in this age group. A physician examining an ill-appearing dehydrated infant, without any obvious cause for the dehydration, should quickly screen the urine for glucose and ketones. Diagnosis of diabetes is a problem when an infant has only hyperglycemia or ketonuria. Febrile illnesses, convulsions, and dehydration can cause these laboratory abnormalities. Once the diagnosis of diabetes is made in the infant, management is complicated by the difficulty in administering small doses of insulin, monitoring blood glucose, complementing insulin administration with feedings, and hypoglycemia. The potential for brain damage with unrecognized episodes of hypoglycemia is always a concern in infants. This article offers suggestions for treating hypoglycemia as well as guidelines for making insulin adjustments when the infant is ill. The physician should be aware of the psychosocial issues involving the family of an infant with diabetes. Optimism and ongoing support From the Department of Pediatrics, DC General Hospital, Washington, DC. Address reprint requests to Dr Gail L. Bland, Department of Pediatrics, DC General Hospital, 19th & Massachusetts Ave, Washington, DC 20003. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 4
should be provided to the family, so that the infant can grow up healthy and possibly benefit from research on the cure of diabetes. (J Nati Med Assoc. 1991 ;83:361-365.) Key Words * insulin-dependent diabetes mellitus* infancy * diabetic ketoacidosis * management diagnoses Insulin-dependent diabetes mellitus (IDDM) is the second most common chronic disease in childhood.' The peak ages of onset are between 7 and 9 years and 11 and 13 years. I The pediatrician and family practitioner should be aware that diabetes can present at any age, even during the first year of life. Although presentation of diabetes in an infant under the age of 1 is rare, it does occur. Estimates of prevalence range from 0.5% to 1% of all children with IDDM.2 Early recognition of diabetes in this age group can prevent the high morbidity and mortality associated with this disease.3 Diabetes in an infant is often misdiagnosed initially because the symptoms of vomiting and dehydration are often attributed to a viral illness. An infant is more likely to present in diabetic ketoacidosis (DKA) and coma than an older child. This increases the mortality associated with diabetes by 50% in childhood.3 Management of diabetes in the infant can be even more challenging because infants cannot communicate effectively their symptoms of hypoglycemia or hyperglycemia and must rely on an astute caretaker to meet and recognize their needs. This 361
DIABETES IN INFANCY
article reviews diagnoses and current management strategies for the infant with IDDM.
DIAGNOSIS Young infants are known to manifest nonspecific symptoms for a variety of illnesses. Delay in diagnosis of diabetes or diabetic ketoacidosis (DKA) in an infant can be attributed to signs and symptoms associated with other illnesses. Infants with diabetes often present with irritability, vomiting, tachypnea, and dehydration. The classic symptoms for diabetes of polyuria and polydypsia often go unrecognized by parents and physician. Diagnoses such as gastroenteritis or viral upper respiratory illnesses are most often given to these infants. Initial treatment is an oral rehydrating solution or cold preparation, not insulin. If the physician does not test the urine and blood for glucose, the diagnosis of diabetes is often delayed, and the infant presents with severe DKA. Even on presentation to the physician or emergency room with DKA symptoms such as severe dehydration, tachypnea, and altered consciousness the infant is considered septic before the diagnosis of DKA is made. Laboratory testing of blood and urine for glucose and ketones can be confused with other diseases in infants. Hyperglycemia and glucosuria may occur following convulsive seizures, acute febrile illnesses, and central nervous system infections. However, the urine glucose is usually never more than 2% and serum glucose never more than 300 mg/dl in these illnesses. Likewise, ketonuria may occur in persistent vomiting and starvation, but usually is never more than moderate in the urine. Rarely are glucosuria and ketonuria present together in these other illnesses as in IDDM. The diagnosis of IDDM is made in a symptomatic infant when a random plasma glucose is more than 200 mg/dL or a fasting whole blood glucose is more than 120 mg/dL, provided there are no other contributing causes. Ketones are concomitantly present in the urine in most cases.4 Diabetic ketoacidosis is a hallmark of IDDM. The clinical symptoms and signs of DKA (vomiting, polyuria, anorexia, tachypnea, tachycardia dehydration, and altered consciousness) are confirmed by laboratory studies. In DKA, the blood glucose is more than 300 mg/dL, serum bicarbonate is < 15 mEq/dL, ketonuria is present, and pH is
This article reviews diagnosis and management of infants with diabetes. These infants present with signs and symptoms confused with other more common illnesses in this age group. A physician examining an ill-appearing dehydrated infant, without any obvious cause for the dehydration, should quickly screen the urine for glucose and ketones. Diagnosis of diabetes is a problem when an infant has only hyperglycemia or ketonuria. Febrile illnesses, convulsions, and dehydration can cause these laboratory abnormalities. Once the diagnosis of diabetes is made in the infant, management is complicated by the difficulty in administering small doses of insulin, monitoring blood glucose, complementing insulin administration with feedings, and hypoglycemia. The potential for brain damage with unrecognized episodes of hypoglycemia is always a concern in infants. This article offers suggestions for treating hypoglycemia as well as guidelines for making insulin adjustments when the infant is ill. The physician should be aware of the psychosocial issues involving the family of an infant with diabetes. Optimism and ongoing support From the Department of Pediatrics, DC General Hospital, Washington, DC. Address reprint requests to Dr Gail L. Bland, Department of Pediatrics, DC General Hospital, 19th & Massachusetts Ave, Washington, DC 20003. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 4
should be provided to the family, so that the infant can grow up healthy and possibly benefit from research on the cure of diabetes. (J Nati Med Assoc. 1991 ;83:361-365.) Key Words * insulin-dependent diabetes mellitus* infancy * diabetic ketoacidosis * management diagnoses Insulin-dependent diabetes mellitus (IDDM) is the second most common chronic disease in childhood.' The peak ages of onset are between 7 and 9 years and 11 and 13 years. I The pediatrician and family practitioner should be aware that diabetes can present at any age, even during the first year of life. Although presentation of diabetes in an infant under the age of 1 is rare, it does occur. Estimates of prevalence range from 0.5% to 1% of all children with IDDM.2 Early recognition of diabetes in this age group can prevent the high morbidity and mortality associated with this disease.3 Diabetes in an infant is often misdiagnosed initially because the symptoms of vomiting and dehydration are often attributed to a viral illness. An infant is more likely to present in diabetic ketoacidosis (DKA) and coma than an older child. This increases the mortality associated with diabetes by 50% in childhood.3 Management of diabetes in the infant can be even more challenging because infants cannot communicate effectively their symptoms of hypoglycemia or hyperglycemia and must rely on an astute caretaker to meet and recognize their needs. This 361
DIABETES IN INFANCY
article reviews diagnoses and current management strategies for the infant with IDDM.
DIAGNOSIS Young infants are known to manifest nonspecific symptoms for a variety of illnesses. Delay in diagnosis of diabetes or diabetic ketoacidosis (DKA) in an infant can be attributed to signs and symptoms associated with other illnesses. Infants with diabetes often present with irritability, vomiting, tachypnea, and dehydration. The classic symptoms for diabetes of polyuria and polydypsia often go unrecognized by parents and physician. Diagnoses such as gastroenteritis or viral upper respiratory illnesses are most often given to these infants. Initial treatment is an oral rehydrating solution or cold preparation, not insulin. If the physician does not test the urine and blood for glucose, the diagnosis of diabetes is often delayed, and the infant presents with severe DKA. Even on presentation to the physician or emergency room with DKA symptoms such as severe dehydration, tachypnea, and altered consciousness the infant is considered septic before the diagnosis of DKA is made. Laboratory testing of blood and urine for glucose and ketones can be confused with other diseases in infants. Hyperglycemia and glucosuria may occur following convulsive seizures, acute febrile illnesses, and central nervous system infections. However, the urine glucose is usually never more than 2% and serum glucose never more than 300 mg/dl in these illnesses. Likewise, ketonuria may occur in persistent vomiting and starvation, but usually is never more than moderate in the urine. Rarely are glucosuria and ketonuria present together in these other illnesses as in IDDM. The diagnosis of IDDM is made in a symptomatic infant when a random plasma glucose is more than 200 mg/dL or a fasting whole blood glucose is more than 120 mg/dL, provided there are no other contributing causes. Ketones are concomitantly present in the urine in most cases.4 Diabetic ketoacidosis is a hallmark of IDDM. The clinical symptoms and signs of DKA (vomiting, polyuria, anorexia, tachypnea, tachycardia dehydration, and altered consciousness) are confirmed by laboratory studies. In DKA, the blood glucose is more than 300 mg/dL, serum bicarbonate is < 15 mEq/dL, ketonuria is present, and pH is
