eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Diabetes Mellitus, Type 1: Differential Diagnoses & Workup

Author: William H Lamb, MBBS, MD, FRCP(Edin), FRCP, Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK
Contributor Information and Disclosures

Updated: Jul 2, 2009

Differential Diagnoses

Diabetes Insipidus
Hyperthyroidism
Pheochromocytoma
Renal Glucosuria
Toxicity, Salicylate

Other Problems to Be Considered

Type 2 diabetes (non–insulin-dependent diabetes mellitus [NIDDM])
Maturity onset diabetes of the young (MODY)
Psychogenic polydipsia
Nephrogenic diabetes insipidus
High-output renal failure
Transient hyperglycemia with illness and other stress
Steroid therapy
Factitious illness (Münchhausen syndrome by proxy)

Workup

Laboratory Studies

The need for and extent of laboratory studies vary, depending on the general state of the child's health. For most children, only urine testing for glucose and blood glucose measurement are required for a diagnosis of diabetes. Other conditions associated with diabetes require several tests at diagnosis and at later review. (See Diabetic Ketoacidosis for information on laboratory studies needed to manage cases of diabetic ketoacidosis [DKA].)

  • Urine glucose
    • A positive urine glucose test suggests but is not diagnostic for type 1 diabetes mellitus (T1DM). Diagnosis must be confirmed by test results showing elevated blood glucose levels.
    • Test urine of ambulatory patients for ketones at the time of diagnosis.
  • Urine ketones
    • Ketones in the urine confirm lipolysis and gluconeogenesis, which are normal during periods of starvation.
    • With hyperglycemia and heavy glycosuria, ketonuria is a marker of insulin deficiency and potential DKA.
  • Blood glucose
    • Apart from transient illness-induced or stress-induced hyperglycemia, a random whole-blood glucose concentration of more than 200 mg/dL (11 mmol/L) is diagnostic for diabetes, as is a fasting whole-blood glucose concentration that exceeds 120 mg/dL (7 mmol/L). In the absence of symptoms, the physician must confirm these results on a different day. Most children with diabetes detected because of symptoms have a blood glucose level of at least 250 mg/dL (14 mmol/L).
    • Blood glucose tests using capillary blood samples, reagent sticks, and blood glucose meters are the usual methods for monitoring day-to-day diabetes control.
  • Glycated hemoglobin
    • Glycosylated hemoglobin derivatives (HbA1a, HbA1b, HbA1c) are the result of a nonenzymatic reaction between glucose and hemoglobin. A strong correlation exists between average blood-glucose concentrations over an 8-week to 10-week period and the proportion of glycated hemoglobin. The percentage of HbA1c is more commonly measured. Normal values vary according to the laboratory method used, but nondiabetic children generally have values in the low-normal range. At diagnosis, diabetic children unmistakably have results above the upper limit of the reference range.
    • Measurement of HbA1c levels is the best method for medium-term to long-term diabetic control monitoring. The Diabetes Control and Complications Trial (DCCT) has demonstrated that patients with HbA1c levels around 7% had the best outcomes relative to long-term complications. Check HbA1c levels every 3 months. Most clinicians aim for HbA1c values of 7-9%. Values less than 7% are associated with an increased risk of severe hypoglycemia; values more than 9% carry an increased risk of long-term complications.
    • An international expert committee composed of appointed representatives of the American Diabetes Association, the European Association for the Study of Diabetes, and others recommend HbA1c assay for diagnosing diabetes mellitus.16 The committee’s recommendation to diagnosis diabetes is an HbA1c level of 6.5% or higher, with confirmation from repeat testing (unless clinical symptoms are present and glucose level is >200 mg/dL). Glucose measurement should remain the choice for diagnosing pregnant women or if HbA1c assay is unavailable. The advantages of HbA1c listed by the committee cite the following advantages over glucose measurement:
      • Captures long-term glucose exposure
      • Has less biologic variability
      • Does not require fasting or timed samples
      • Is currently used to guide management decisions
  • Renal function tests: If the child is otherwise healthy, renal function tests are typically not required.
  • Islet cell antibodies
    • Islet cell antibodies may be present at diagnosis but are not needed to diagnose insulin-dependent diabetes mellitus (IDDM).
    • Islet cell antibodies are nonspecific markers of autoimmune disease of the pancreas and have been found in as many as 5% of unaffected children. Other autoantibody markers of type 1 diabetes are known, including insulin antibodies. More antibodies against islet cells are known (eg, those against glutamate decarboxylase [GAD antibodies]), but these are generally unavailable for routine testing.
  • Thyroid function tests
    • Because early hypothyroidism has few easily identifiable clinical signs in children, children with type 1 diabetes mellitus may have undiagnosed thyroid disease.
    • Untreated thyroid disease may interfere with diabetes management. Check thyroid function regularly (every 2-5 years or annually if thyroid antibodies are present).
  • Antithyroid antibodies: This test indicates risk of present or potential thyroid disease.
  • Antigliadin antibodies
    • Some children with IDDM may have or develop celiac disease. Positive antigliadin antibodies, especially specific antibodies (eg, antiendomysial, antitransglutaminase) are important risk markers.
    • If antibody tests are positive, a jejunal biopsy is required to confirm or refute a diagnosis of celiac disease.

Imaging Studies

  • No routine imaging studies are required.

Other Tests

  • Oral glucose tolerance test (OGTT)
    • Although unnecessary in diagnosing type 1 diabetes mellitus, an OGTT can exclude the diagnosis of diabetes when hyperglycemia or glycosuria are recognized in the absence of typical causes (eg, intercurrent illness, steroid therapy) or when the patient's condition includes renal glucosuria.
    • Obtain a fasting blood sugar level, then administer an oral glucose load (2 g/kg for children aged <3 y, 1.75 g/kg for children aged 3-10 y [max 50 g], or 75 g for children aged >10 y). Check the blood glucose concentration again after 2 hours. A fasting whole-blood glucose level higher than 120 mg/dL (6.7 mmol/L) or a 2-hour value higher than 200 mg/dL (11 mmol/L) indicates diabetes. However, mild elevations may not indicate diabetes when the patient has no symptoms and no diabetes-related antibodies.
    • A modified OGTT can also be used to identify cases of maturity onset diabetes of the young (MODY) that often present as type 1 diabetes, if, in addition to blood glucose levels, insulin or c-peptide (insulin precursor) levels are measured at fasting, 30 minutes, and 2 hours. Type 1 diabetes mellitus cannot produce more than tiny amounts of insulin. People with MODY or type 2 diabetes mellitus show variable and substantial insulin production in the presence of hyperglycemia.
  • Lipid profile
    • Lipid profiles are usually abnormal at diagnosis because of increased circulating triglycerides caused by gluconeogenesis.
    • Apart from hypertriglyceridemia, primary lipid disorders rarely result in diabetes.
    • Hyperlipidemia with poor metabolic control is common.
  • Urinary albumin: Beginning at age 12 years, perform an annual urinalysis to test for a slightly increased albumin excretion rate (AER), referred to as microalbuminuria, which is an indicator of risk for diabetic nephropathy.

More on Diabetes Mellitus, Type 1

Overview: Diabetes Mellitus, Type 1
Differential Diagnoses & Workup: Diabetes Mellitus, Type 1
Treatment & Medication: Diabetes Mellitus, Type 1
Follow-up: Diabetes Mellitus, Type 1
Multimedia: Diabetes Mellitus, Type 1
References
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References

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Further Reading

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Keywords

diabetes mellitus type 1, insulin-dependent diabetes, IDM, insulin-dependent diabetes mellitus, IDDM, growth-onset diabetes, type I diabetes, type 1 diabetes, DM, diabetes, type 1 DM, T1DM, childhood diabetes, childhood diabetes mellitus, childhood-onset diabetes, childhood-onset diabetes mellitus, diabetes in childhood, diabetes mellitus in childhood, juvenile-onset diabetes, juvenile-onset diabetes mellitus, ketosis-prone diabetes, autoimmune diabetes mellitus, brittle diabetes mellitus, diabetic ketoacidosis, DKA, maturity-onset diabetes of the young, MODY, chamber-pot dropsy, thirst disease, sugar disease, sugar sickness

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Contributor Information and Disclosures

Author

William H Lamb, MBBS, MD, FRCP(Edin), FRCP, Clinical Lecturer, Department of Child Health, The General Hospital, Bishop Auckland, UK
William H Lamb, MBBS, MD, FRCP(Edin), FRCP is a member of the following medical societies: British Medical Association, Royal College of Paediatrics and Child Health, and Royal College of Physicians
Disclosure: Medtronic UK Honoraria Speaking and teaching

Medical Editor

Arlan L Rosenbloom, MD, Adjunct Distinguished Service Professor Emeritus of Pediatrics, University of Florida; Fellow of the American Academy of Pediatrics; Fellow of the American College of Epidemiology
Arlan L Rosenbloom, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Epidemiology, American Pediatric Society, Endocrine Society, Florida Pediatric Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London), Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece
George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD, Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and Arkansas Children's Hospital
Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Genentech, Inc. Honoraria Speaking and teaching; Pfizer, Inc. Honoraria Consulting

 
 
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