The School - Aged Child
Case 4.7 Incontinence
118 The School-Aged Child
a neighborhood of multifamily homes built around 1980. Since the separation, Kara and her siblings have spent 2 weekends with her father and his new girlfriend. Kara ’ s mother works 2 jobs, and the downstairs neighbor helps with caring for the children until she gets home. No public assistance programs are utilized. Kara ’ s school performance has declined since her parents ’ separation. She has not had any disciplinary problems, but her academic performance has suffered.
Medications: Kara takes no medications and has no known allergies. She has not seen her primary care provider or dentist since she was 8 years old.
OBJECTIVE
General: No apparent distress. Cooperative but without direct eye contact with provider.
Vital s igns: Height: 60 inches; weight: 60 lbs; BP: 104/60; HR: 80 bpm; RR: 16 rpm; temperature: 98.6.
HEENT : PERRLA; pearly gray TMs bilaterally. Throat: pink, without exudates or petechiae; tonsils absent.
Neck: No masses; thyroid midline and size within normal limits.
Cardiovascular: RRR, no murmurs; pulses equal at + 2; brisk refi ll.
Chest: CTA throughout. Breast development Tanner I.
Abdomen: + BS × 4; no HSM; soft; no rebound tenderness or masses.
Genitourinary: Within normal limits; Tanner I.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Albumin ___ALT ___AST
___Basic metabolic panel ___BUN
___C - peptide ___Calcium ___CBC w/ Diff
___Comp metabolic panel ___Creatinine
___Fasting plasma glucose ___Free T3
___Free T4 ___HbA1c ___IGF ___Insulin
___Insulin tolerance ___OGTT
___Phosphorus ___Plasma ADH ___Potassium
Incontinence 119
___Random plasma glucose ___Sodium
___T3 ___T4
___T3 uptake ___Total T3 ___TSH
___Two - hour plasma glucose ___Ultrasound, abdominal ___Ultrasound, renal ___Urinalysis ___Urine culture
What is the most likely differential diagnosis and why?
___ Urinary tract infection ( UTI ) ___Diabetes mellitus
___Hyperthyroidism ___Normal urinary function What is the plan of treatment?
Are any referrals needed at this time?
RESOLUTION
Diagnostic t ests: Comp metabolic panel (collected after 12 - hr fast, at 0800 hrs):
Na: 140 mmol/L; K: 3.9 mmol/L; Cl: 100 mmol/L; CO 2 : 24 mmol/L; Gluc: 187 mg/dL; Ca: 9.7 mg/
dL; BUN: 12 mg/dL; Creatinine: 0.6 mg/dL; Total protein: 6.8 g/dL; Alb: 4.1 g/dL; AST: 22 U/L; Alk phos: 205 U/L; Bilirubin, Total: 0.8 mg/dL; ALT: 23 U/L.
HbA1c: 8.4
Urine culture: No growth in 48 hours.
Urine dipstick (clean - catch): pH = 6; Specifi c gravity = 1.015; Protein: neg; Glucose: pos;
Ketones: neg; Nitrites: neg; Leukocyte esterase: neg; Blood: neg; Bilirubin: neg TSH: 2.6 uIU/mL.
Two - hr plasma glucose: 243.
What is the most likely differential diagnosis and why?
Type 1 (insulin - dependent) diabetes mellitus:
Kara ’ s negative urine culture rules out the possibility of a UTI, and her normal TSH level makes it very unlikely that she has hyperthyroidism (Ross, 2008 ). The glucose - positive urine dip, elevated fasting glucose, 2 - hour glucose, and HbA1c all support a diagnosis of diabetes mellitus. Sometimes, children with Type 1 diabetes mellitus are asymptomatic and diagnosed after an incidental fi nding during a physical exam. Other times, a diagnosis may result from the child ’ s presenting to the emer- gency department in diabetic ketoacidosis or after presenting with the classic new - onset symptoms of polyuria, polydypsia, and polyphagia. Appetite is increased initially, but the elevated catabolism and hypovolemia lead to weight loss (Levitsky & Misra, 2010 ).
A urinalysis and a random blood glucose can be done quickly and conveniently in the offi ce. It is important to remember that glucosuria may suggest diabetes but is not diagnostic in and of itself. Other disorders that affect renal function, such as Fanconi syndrome, may cause glucosuria as well (Brazy, 2006 ). The following are criteria for a diabetes diagnosis as set forth by the American Diabetes Association (2010) : 1. HbA1c ≥ 6.5 % OR 2. Fasting plasma glucose ≥ 126 mg/dL OR 3. Two - hr plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test, using a glucose load of 75 g of anhydrous glucose dissolved in water. Any of these three criteria must be confi rmed by a repeat test for confi rmation if no unequivocal hyperglycemia is present. If classic symptoms of hyperglycemia
120 The School-Aged Child
or hyperglycemic crisis are present, then a random plasma glucose ≥ 200 mg/dL is suffi cient for a diagnosis (American Diabetes Association [ADA], 2010 ).
Diabetes in general is a metabolic disorder that results from defective insulin action, insulin secre- tion, or a combination of both (ADA, 2010 ). The hallmark of Type 1 diabetes mellitus is an absolute insulin defi ciency. The autoimmune destruction of pancreatic beta cells prohibits the insulin produc- tion. The difference between Type 1 diabetes and Type 2 is that the insulin defi ciency is relative, rather than absolute, in Type 2. Insulin resistance leads to an initial increase in insulin production. Eventually, the pancreas is unable to keep up with the increased insulin requirements; hence, there is a relative insulin defi ciency (Cooke & Plotnik, 2008 ). In many instances, people with Type 2 diabetes are over- weight because the extra weight, especially increased abdominal girth, plays a major role in insulin resistance. However, the rise of childhood obesity and adult - onset Type 1 diabetes have blurred the defi nitions of “ juvenile diabetes ” and “ adult - onset ” diabetes, which were used synonymously to describe Type 1 and Type 2, respectively. The clinician should be careful to refrain from making assumptions about type based on body habitus or age of presentation. It is also important to consider that both types may exist in the same person (McCulloch, 2009 ).
Diabetes mellitus must be properly typed in order to be effectively managed. After initial testing, additional laboratory assessments may be needed to aid in solidifying a diagnosis. Although the presence of serum antibodies to pancreatic islet cells, glutamic acid decarboxylase ( GAD ), the 40 K fragment of tyrosine phosphatase (IA2), and/or insulin strongly suggests Type 1 diabetes, the absence of such antibodies does not exclude a Type 1 diagnosis (Levitsky & Misra, 2010 ). Measuring C - peptide is helpful since it is secreted along with insulin in a one - to - one molar ratio. Dissimilar to insulin, there is little fi rst - pass liver clearance, but it still indicates a direct relationship to endogenous insulin secretion. C - peptide measurements under standardized conditions are an acceptable assessment of beta - cell function (Palmer et al., 2004 ).
What is the plan of treatment?
Education is key. Glucose monitoring, ketone monitoring, insulin administration, how to operate an insulin pump, and how to recognize signs/symptoms of hypoglycemia are just a few of the instruc- tional points which usually have to be reiterated. It is crucial to also provide appropriate mental health services for the child and the family. Kara ’ s new diagnosis requires lifestyle changes and development of coping and management strategies which affect family function, thereby placing Kara and her mother at increased risk for depression (Jaser, Whittemore, Ambrosino, Lindemann, & Grey, 2008 ).
Are any referrals needed at this time?
Kara was referred from the school - based health center to a diabetes clinic that employs a multidisci- plinary approach to education and management of diabetes. In Kara ’ s case, it is a good idea to refer her for mental health counseling, since she is coping with her parents ’ separation, also. She has addi- tional medical and mental health support at school through the school - based health center, school nurse, and school psychologist. The broader the support base, the better the outcome.
REFERENCES AND RESOURCES
American Diabetes Association ( 2010 ). Diagnosis and classifi cation of diabetes mellitus . Diabetes Care , 33 , S62 – S69 .
Brazy , P. C. ( 2006 ). Fanconi syndrome . Retrieved from http://www.merck.com/mmhe/sec11/ch146/ch146f.
html
Cooke , D. W. , & Plotnik , L. ( 2008 ). Type 1 diabetes mellitus in pediatrics . Pediatrics in Review , 29 , 374 – 385 . Davidson , M. B. ( 2001 ). How do we diagnose diabetes and measure blood glucose control? Diabetes Spectrum ,
14 ( 2 ), 67 – 71 .
Gassner , H. L. , & Gitelman , S. E. ( 2003 ). Case study: Type 1 and type 2, too? Clinical Diabetes , 21 ( 3 ), 140 – 141 . Halvorson , M. , Yasuda , P. , Carpenter , S. , & Kaiserman , K. ( 2005 ). Unique challenges for pediatric patients with
diabetes . Diabetes Spectrum , 18 ( 3 ), 167 – 173 .
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Jaser , S. S. , Whittemore , R. , Ambrosino , J. M. , Lindemann , E. , & Grey , M. ( 2008 ). Mediators of depressive symp- toms in children with type 1 diabetes and their mothers . Journal of Pediatric Psychology , 33 ( 5 ), 509 – 519 . Levitsky , L. L. , & Misra , M. ( 2010 ). Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in
children and adolescents . In UpToDate Online18.1 . Retrieved from http://www.uptodate.com/online/
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McCulloch , D. K. ( 2009 ). Classifi cation of diabetes mellitus and genetic diabetic syndromes . In UpToDate Online 18.1 . Retrieved from http://www.uptodate.com/online/content/topic.do?topicKey=diabetes/24654 & select edTitle=1%7E150 & source=search_result
Murray , R. ( 2002 ). Recognizing the signs of metabolic syndrome and polycystic ovary syndrome in a caucasian adolescent girl: Differentiating type 2 from type 1 diabetes . Diabetes Spectrum , 15 ( 4 ), 227 – 231 .
Palmer , J. P. , Fleming , G. A. , Greenbaum , C. J. , Herold , K. C. , Jansa , L. D. , Kolb , H. , & Steffesu , W. ( 2004 ).
C - Peptide is the appropriate outcome measure for type 1 diabetes clinical trials to preserve β - cell function:
Report of an ADA workshop, 21 – 22 October 2001 . Diabetes , 23 , 250 – 261 .
Roper , S. O. , Call , A. , Leishman , J. , Ratcliffe , G. C. , Mandleco , B. L. , Dyches , T. T. , & Marshal , E. S. ( 2009 ). Type 1 diabetes: Children and adolescents ’ knowledge and questions . Journal of Advanced Nursing , 65 ( 8 ), 1705 – 1714 .
Ross , D. ( 2008 ). Diagnosis of hyperthyroidism . In UpToDate Online 18.1 . Retrieved from http://www.uptodate.
com/online/content/topic.do?topicKey=thyroid/18839 & selectedTitle=1%7E150 & source=search_result