Diagnostic Tips, Initial Management Strategies

Q: What should primary care pediatricians do--and what should we not do--when we encounter a patient with newly diagnosed diabetes?

A:The appropriate management of the patient with new-onset diabetes in the pediatrician's office depends primarily on the severity of the patient's illness, proximity to specialized pediatric care, and the practice patterns of the local pediatric diabetes service.

In most cases, the role of the pediatrician is to establish the diagnosis by eliciting symptoms and signs consistent with diabetes and to order the appropriate diagnostic tests. In any child with a typical history of increased thirst and polyuria, blood should be drawn to measure glucose levels. In addition, the urine should be tested for glucose and ketones. This testing should be done on the day of the office visit, when glucose levels are more likely to be elevated. It is inappropriate for the child to return the following morning for a fasting blood glucose test because the return of the blood glucose level to normal early on in the disease process only delays diagnosis.

If the child appears to be well or is only modestly dehydrated, non-glucose-containing fluids may be given orally if the child is referred promptly to the pediatric diabetes team. If the child is vomiting or severely dehydrated or obtunded, he or she should be taken to the nearest emergency department by emergency medical services.

The key is prompt referral to the pediatric diabetes team. Occasionally such a team is unavailable and the pediatrician must treat an acutely ill patient in the office. In this setting, the most appropriate response is to establish intravenous access and to administer a modest 10 to 20 mL/kg bolus of normal saline until the child can be transported to an urgent care facility.

Insulin therapy should not be attempted outside a controlled hospital setting. If the child is ill, he will require close monitoring. If the patient is well, therapy can safely be delayed several hours until he is seen by the diabetes team.