Pediatric Metabolic Acidosis Clinical Presentation
- Author: Lennox H Huang, MD, FAAP; Chief Editor: Timothy E Corden, MD more...
The etiology of a metabolic acidosis is often apparent from the patient’s history and physical examination. The following factors are assessed in a complete investigation of the patient's history:
- Anorexia, nausea, vomiting, or diarrhea - In pediatric patients, diarrhea is the most common cause of a metabolic acidosis
- Metabolic acidosis associated with seizures, a depressed sensorium, or both in a neonate - This warrants consideration of an inborn error of metabolism, or neonatal sepsis
- History of depressed mental status, lethargy, and poor feeding in a neonate - Left-sided, obstructive cardiac lesions should be considered (eg, aortic coarctation or hypoplastic left heart syndrome)
- Failure to thrive suggestive of chronic metabolic acidosis - This can be seen in renal insufficiency or RTA
- New onset of polyuria, polydipsia, and weight loss - This could signify undiagnosed diabetes mellitus and diabetic ketoacidosis in a child
- Possible ingestion of a toxin or other form of intoxication - Inquire as to what medications are in the home; suspect a poisoning in a healthy child who quickly develops a metabolic acidosis; possible agents are ethanol, ethylene glycol, salicylates, and methanol
- History of trauma, hives, or fever
- History of states associated with a lactic acidosis secondary to shock from hypovolemia, sepsis, cardiac failure, anaphylaxis, or spinal shock
- Chronic medical or surgical issue - Examples to be concerned with include chronic renal failure, presence of a ureterosigmoidostomy, or diabetes mellitus
Clinical findings generally depend on the etiology and severity of the metabolic acidosis.
Hyperventilation or Kussmaul breathing may often be the first sign of a metabolic acidosis in a child. Breath sounds are often clear to auscultation (“quiet tachypnea”).
Patients with metabolic acidosis secondary to shock may have signs reflective of single- or multiple-organ dysfunction, as follows:
- CNS manifestations may include lethargy, coma, and seizures
- Respiratory manifestations may include tachypnea, respiratory distress, and hypoxemia
- Cardiovascular signs may include poor perfusion, weak pulses, tachycardia, hypotension, murmurs, or a gallop
- Nonspecific abdominal symptoms and signs may be present such as nausea, pain, vomiting, and altered appetite
- Signs of dehydration may include tachycardia, dry mucous membranes, and delayed capillary refill
- Patients with diabetic ketoacidosis may present with fruity odor to their breath
Kraut JA, Madias NE. Metabolic acidosis: pathophysiology, diagnosis and management. Nat Rev Nephrol. 2010 May. 6(5):274-85. [Medline].
Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001 Jan 25. 344(4):264-9. [Medline].
Hodson E. Metabolic acidosis and growth in children. Nephrology. Dec 2005. 10(S5):S221-2. [Full Text].
Randolph DA, Nolen TL, Ambalavanan N, Carlo WA, Peralta-Carcelen M, Das A, et al. Outcomes of extremely low birthweight infants with acidosis at birth. Arch Dis Child Fetal Neonatal Ed. 2014 Feb 19. [Medline].
Dabelea D, Rewers A, Stafford JM, et al. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics. 2014 Apr. 133(4):e938-45. [Medline]. [Full Text].
Nallasamy K, Jayashree M, Singhi S, et al. Low-dose vs standard-dose insulin in pediatric diabetic ketoacidosis: a randomized clinical trial. JAMA Pediatr. 2014 Nov. 168(11):999-1005. [Medline].
Koves IH, Leu MG, Spencer S, et al. Improving care for pediatric diabetic ketoacidosis. Pediatrics. 2014 Sep. 134(3):e848-56. [Medline].
Han JJ, Yim HE, Lee JH, Kim YK, Jang GY, Choi BM, et al. Albumin versus normal saline for dehydrated term infants with metabolic acidosis due to acute diarrhea. J Perinatol. 2009 Jun. 29(6):444-7. [Medline].
Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest. 2000 Jan. 117(1):260-7. [Medline].
Manthous CA. Lactic acidosis in status asthmaticus : three cases and review of the literature. Chest. 2001 May. 119(5):1599-602. [Medline].
Parker MJ, Parshuram CS. Sodium bicarbonate use in shock and cardiac arrest: attitudes of pediatric acute care physicians. Crit Care Med. 2013 Sep. 41(9):2188-95. [Medline].
Agarwal B, Kovari F, Saha R, Shaw S, Davenport A. Do Bicarbonate-Based Solutions for Continuous Renal Replacement Therapy Offer Better Control of Metabolic Acidosis than Lactate-Containing Fluids. Nephron Clin Pract. 2011 Feb 23. 118(4):c392-c398. [Medline].