A 4 year old boy is brought into the peds ED for 4 days of profuse vomiting.  The mother reports that he has vomited 10-15 times per day, at first stomach contents but by now empty retching.  No F/C, no diarrhea, no urinary symptoms.  In fact, he seems to be urinating more than usual.  He has had no recent traveling and no sick contacts.  On exam, he looks drowsy and dry but otherwise not in distress.  His abdominal exam shows very mild diffuse tenderness, no guarding or rebound, and the rest of the exam is fairly unremarkable.

What would you be concerned about in a pediatric patient who is clearly dehydrated but still urinating well?  (Scroll down.)

First presentation of T1DM, and possibly DKA.  His fingerstick came back at 634, the anion gap was 22, his pH was 7.2, and his urine showed glucose and ketones.

Hyperglycemia without acidosis is the most common presentation of childhood T1DM, and it manifests with polyuria, polydipsia, and weight loss.  Diabetic ketoacidosis is the second most common form of presentation for T1DM, presenting similarly but also with drowsiness, fruity breath, vomiting, and abdominal pain. The age of presentation of childhood onset T1DM has a bimodal distribution, with one peak at 4 to 6 years of age and a second in early puberty (10 to 14 years of age).  45% of children present before 10 years of age.

Initial treatment of these children can be dangerous – if the glucose is lowered too rapidly via insulin and large NS boluses, CPM may result.  So, make sure to speak with a pediatric endocrinologist to help guide the initial steps beyond a 10 cc/kg NS bolus.