Study Describes Treatment Strategies for Pediatric Diabetes Complication..::The Health News::..

Physicians treating ill children who are hyperglycemic and dehydrated should include hyperglycemic hyperosmolar syndrome (HHS) in their suspicions, according to a case report.

HHS, a life-threatening complication of type 2 diabetes, has increased more than tenfold in the U.S. pediatric population over the last decade. HHS is well described in the adult literature and has a 10%-50% mortality rate. The investigators noted that this is the first discussion of pediatric HHS treatment strategies.

"We believe that HHS will become more common in the pediatric population because of the recent epidemic of obesity in children," said lead author, Rebecca M. Carchman, MD, from the department of critical care at the University of North Carolina Hospital in Chapel Hill. "Obesity is a major risk factor for type 2 diabetes. HHS may be the first presentation of pediatric type 2 diabetes, as it was in our patients."

The authors of the case report described four obese adolescents with hyperglycemic hyperosmolar syndrome associated with type 2 diabetes. The patients were treated with isotonic fluid resuscitation and insulin. Two of the four patients died. The first presumably died due to hypovolemic shock and the second developed rhabdomyolysis and multisystem organ failure. None of the patients had cerebral edema. The report appeared in Pediatric Critical Care Medicine.

"Because of the high mortality rate and complication risk associated with HHS, it is essential that pediatricians, emergency physicians and pediatric intensivists are aware of the disease," said Carchman. "It is also important that they recognize the degree of dehydration in HHS patients and treat aggressively. The risk of cerebral edema associated with aggressive fluid resuscitation in HHS is unknown."

The typical presenting triad of HHS is severe hyperglycemia (blood glucose >600 mg/dL), hyperosmolality (>320 mosm/L) and a mild metabolic acidosis (pH >7.3) with no ketosis.

Patients with HHS are extremely dehydrated - it is estimated that they have 15%-20% total body water loss," Carchman explained. "Most patients, however, do not present with the typical laboratory values, and may have metabolic acidosis and ketosis due to longstanding dehydration. Because of this, the diagnosis of HHS may be confused with diabetic ketoacidosis (DKA)."

Guidelines for treatment of pediatric DKA emphasize conservative fluid resuscitation in order to avoid cerebral edema. The researchers recommended that children with HHS should not be treated like those in DKA. HHS should be treated with rapid and aggressive fluid resuscitation because the risk of hypovolemic shock is greater than that of cerebral edema in this disease. Another complication of HHS is rhabdomyolysis, which should be suspected and treated to avoid renal failure.

The evidence for the initial treatment and management of pediatric HHS is limited to extrapolations from the adult literature and pediatric case reports. Nevertheless, the investigators believe that pediatric patients require more rapid fluid administration than in DKA because of the risk of hypovolemic shock associated with severe dehydration. The risk of cerebral edema in HHS is unknown.

"Pediatric patients with HHS have a high mortality rate and may experience multiple complications such as rhabdomyolysis and hypovolemic shock," the researchers concluded. "Treatment strategies to reduce mortality are unclear and warrant further investigation."

In an accompanying editorial, Dr. Sunit C. Singhi, MD, professor of pediatrics and head of the pediatric emergency and intensive care units at the Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research in Chandigarh, India, discussed the high mortality associated with HHS and the problems coupled with proper diagnosis and effective treatment.

"In adolescents with extreme obesity and [type 2 diabetes], life-threatening hyperglycemic hyperosmolar syndrome appears be on rise," he said. "Population-based data are needed to estimate the magnitude of the problem in view of increasing incidence of obesity and type 2 [diabetes] in younger age groups in certain ethnic groups. Prospective trials are needed to resolve controversy surrounding composition of the resuscitations and rehydration fluids and the rate of fluid infusion."

"Although this is a case study, practitioners need to pay close attention to presentation and treatment of HHS in the pediatric population," said PCCM editor Patrick M. Kochanek, MD, FCCM. "This syndrome looms large in the future. Trials should be performed to define treatment." This article was prepared by Biotech Week editors from staff and other reports. Copyright 2005, Biotech Week via NewsRx.com & NewsRx.net.

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