As I teach my medical students and residents on hospital rounds and in the outpatient setting, children do not usually present to their primary care doctors with a written sign that indicates a specific diagnosis. It is a tough job for primary care providers to sift out who is really sick. This intuition often takes years of practice and a feeling of knowing when something is just not right. It also is extremely important to pay attention to the child's family caregivers, who know their child best of all. In many cases, they will provide the important clues to diagnosis. Do not underestimate the intuition of the caregiver. It should be respected! There is an expression in medicine: Common things occur commonly. Thus, the diagnosis of diabetes should not necessarily be the first thing on your list when a child is ill. In the general population with no family history of type 1 diabetes, the incidence is 1 in 300 or 0.3 percent. However, there are warning signs that should alert caregivers to the possibility of a diabetes diagnosis. There are signs and symptoms that are common to all age groups. Depending on the age of the child, these findings may not specifically point to diabetes. As most people know, the general symptoms of diabetes include:
- Increased urination
- Increased thirst resulting in increased drinking
- Weight loss
- Increased hunger
There are often age specific (and sometimes physical markers) that may assist in the diagnosis of diabetes.
- Infancy. The diagnosis of diabetes in infancy is often subtle. Why? First of all, infants can't communicate verbally and can only exhibit behavior and response to stimuli. It is often based on atypical behavior of the infant that the caregiver notices that something is not quite right. These infants are often very fussy, appear extraordinarily hungry, may want to nurse continuously, have very wet and heavy diapers, become dehydrated (loss of tears, dry mucous membranes, sunken fontanel, etc.) and develop yeast diaper rashes in many cases. Caregivers are changing diapers very frequently. Because the symptoms may be very subtle, these infants often become very ill and develop lethargy in association with rapid breathing, a fruity odor to their breath, and present to the emergency department with extremely high blood sugars and diabetic ketoacidosis. In many cases, infants end up in the pediatric intensive care unit and receive insulin by insulin drip initially as well as fluid resuscitation. They are then transferred generally to the medical care unit to receive insulin by injection. Infants that are diagnosed less than 6 months of age should definitely be worked up for Permanent Neonatal Diabetes (PND). Those between 6 and 12 months of age are less likely to have PND, but workup may be considered. The remainder of these infants generally have type 1 diabetes.
- Toddlers. Toddlers have better communication skills than infants and may alert the caregiver that they do not feel well. If they are still in diapers, the caregiver will once again note that they may be changing them frequently. Yeast diaper rashes also may occur. They will generally demand fluids because they are thirsty and weight loss may be more apparent as they become dehydrated. Loss of tears, dry mucous membranes, and increased heart rate may be noted. Behavior becomes more erratic with increased temper tantrums and the caregiver will note that the child is not acting "normal". If they have been potty trained, they may start having more accidents during the day and wet the bed at night. The key is to notice this change in behavior. They may want to nap more and be listless. Unfortunately, toddlers often end up being diagnosed with diabetes only after ending up in the emergency department and pediatric intensive care unit as the symptoms and signs may not be specific and lead the caregiver to think diabetes. Check also for an acetone/fruity smell to the child's breath as well as rapid breathing that may be indicative of ketones and diabetic ketoacidosis.
Next week: age specific diabetes diagnosis of school aged children, adolescents, and young adults