Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting

Abstract

Purpose of Review Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults. Recent Findings Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. Summary With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.

Diagnosis and Acute Management of Hyperglycemic Hyperosmolar Syndrome in Children and Adolescents

“…Although HHS patients often present with AMS due to high serum osmolality, prior studies have shown that their risk of cerebral edema is actually lower than in DKA, where cerebral edema is the main cause of morbidity and mortality. 2,10,15 Nonetheless, HHS patients remain at theoretical risk of cerebral edema if serum osmolality and corrected sodium decline too rapidly. Osmolality decreases of 3 mOsm/h and sodium decreases of 0.5 mEq/L per hour should be targeted.…”

“…13 In children with HHS or mixed HHS/DKA with concern for cerebral edema, mannitol and hypertonic saline can be considered, with the caveat that hypertonic saline administration will likely worsen osmolality corrections. 13,15 "Hyperglycemic hyperosmolar syndrome places children at far greater risk for thrombosis than DKA. This is primarily due to hyperosmolar damage to endothelial cells and dehydration directly upregulating coagulation factors.…”

“…10 Although multiple types of venous occlusions are possible, sinus venous thromboses are a particular concern and can distort the mental status assessment. 1,15 Neuroimaging should be considered in children with acute changes in mental status despite slow electrolyte corrections, or in children whose mental status fails to improve. 1,2,15 Pulmonary embolisms are also frequently seen in adults with HHS.…”

“…1,15 Neuroimaging should be considered in children with acute changes in mental status despite slow electrolyte corrections, or in children whose mental status fails to improve. 1,2,15 Pulmonary embolisms are also frequently seen in adults with HHS. 13 As a result, prophylactic anticoagulation with low-molecular-weight heparin can be considered in children with HHS (especially if older than 12 years and have other thrombotic risk factors); we advise consultation with a pediatric hematologist if thromboses are identified and/or heparin is being considered.…”

Relationship Between Bedside Ketone Levels and Time to Resolution of Diabetic Ketoacidosis: A Retrospective Cohort Study

“…DKA is frequently encountered in daily clinical practice, in both newly diagnosed cases (up to 70%) and patients with established type 1 diabetes (T1D) (rate, 1-10% per case per year) [2]. The common risk factors for DKA include new diagnosis of T1D, young children, adolescent female patients, delayed T1D diagnosis, insulin omission, poor treatment on a sick day, accessibility to hospitals, and insulin pump injection errors [2][3][4][5][6][7].…”