The 10-Year-Old With New Bedwetting and Weight Loss
A 10-year-old girl presents with 2 months of secondary nocturnal enuresis after being dry at night for 4 years. She has also had increased thirst, frequent urination during the day, and 3 kg of weight loss over 3 months despite a good appetite. She is tired at school and has had two episodes of vulvovaginal candidiasis in the past 6 months. Examination: weight 28 kg (previously 31 kg), height 138 cm, BMI 14.7, temperature 36.8°C, HR 96, BP 98/62. She looks thin but is alert. Capillary glucose is 22.4 mmol/L. Urine dipstick shows glucose 4+ and ketones 3+.
1. What is the diagnosis and what is your immediate management?
Read the worked answer
The diagnosis is new-onset type 1 diabetes mellitus with diabetic ketoacidosis (DKA). The combination of polyuria, polydipsia, weight loss, recurrent candidiasis, glucose of 22.4 mmol/L, and heavy glycosuria with ketonuria is diagnostic. The enuresis is a secondary symptom of osmotic diuresis.
Immediate management:
- This is a medical emergency. Admit to a unit with paediatric expertise; if unavailable, stabilise and transfer.
- Fluids: start IV 0.9% saline. In DKA, the child is usually volume-depleted. Give a bolus of 10 mL/kg over 30–60 minutes if there is shock or poor perfusion; otherwise, calculate deficit and replace over 48 hours, avoiding rapid fluid shifts that can cause cerebral oedema. Use isotonic fluids; avoid hypotonic fluids in the first 24–48 hours.
- Insulin: start a continuous IV insulin infusion at 0.05–0.1 units/kg/hour after fluids have been started. Do not give subcutaneous insulin in DKA.
- Potassium: check electrolytes urgently. Total body potassium is depleted even if serum potassium is normal or high. Add potassium to fluids once the serum potassium is below the upper limit of normal and the child is passing urine.
- Monitoring: hourly blood glucose, ketones, and neurological observations. Monitor for signs of cerebral oedema - headache, irritability, drowsiness, bradycardia, hypertension. If suspected, treat urgently with mannitol or hypertonic saline and reduce the fluid rate.
- Bicarbonate: generally not recommended unless the pH is very low and there is haemodynamic instability, and only with senior advice.
- Investigations: blood gas, electrolytes, urea, creatinine, blood glucose, HbA1c, and urine ketones. Consider coeliac and thyroid screening later, as associated autoimmune conditions are common.
Do not send the child home with oral fluids and a glucose meter - DKA requires inpatient management.
2. After recovery, the family asks whether the diabetes could have been prevented and whether the bedwetting will stop. How do you counsel them and what education is needed before discharge?
Read the worked answer
Counselling:
- Explain that type 1 diabetes is an autoimmune condition in which the body's immune system attacks the insulin-producing cells of the pancreas. It is not caused by eating too much sugar or by anything the parents did, and it cannot currently be prevented.
- Explain that the bedwetting was caused by high blood sugar making the kidneys produce large volumes of urine. Once blood sugar is controlled, the bedwetting should stop. If it persists after good control, it should be reviewed.
- Be clear that this is a lifelong condition requiring daily insulin, but that with good control she can live a full and active life.
- Discuss the increased risk of other autoimmune conditions (thyroid disease, coeliac disease) and the need for periodic screening.
Education before discharge:
- Insulin: how to inject, rotate sites, store insulin, and adjust doses. Include a written plan for sick days and for missed doses.
- Blood glucose monitoring: how to check, target ranges, and how to interpret results. Consider continuous glucose monitoring if available.
- Hypoglycaemia: recognise and treat with fast-acting carbohydrate (e.g., 15 g glucose), then a longer-acting snack. Provide glucagon and teach its use.
- DKA prevention: never omit insulin, check ketones when unwell, and seek help early.
- Diet and activity: refer to a dietitian; explain carbohydrate counting and the effect of exercise.
- School: inform the school, provide an individual healthcare plan, and ensure staff know how to recognise and treat hypoglycaemia.
- Psychological support: refer to a paediatric diabetes team and consider psychology input, as the diagnosis is a major adjustment for the child and family.
- Follow-up: arrange review with the diabetes team within 1–2 weeks, and provide contact details for urgent advice.
- Sick-day rules: written instructions for illness, including when to call for help.