In the ED, hyperglycemia is likely to be seen in several different situations First, the child may be known to have diabetes and present with an intercurrent illness or traumatic injury Both illness and injury result in increased counterregulatory hormones, which may lead to relative insulin resistance and hyperglycemia The second presentation is the child for whom diabetes is suspected because of classical symptoms of polyuria, polydipsia, and polyphagia accompanied by weight loss Almost half of children with new-onset diabetes mellitus present to their pediatrician or to the ED in this way Third, some medical conditions are associated with persistent hyperglycemia, such as recurrent urinary tract infections and vaginal yeast infections Furthermore, type diabetes is increasingly being reported in minority adolescents; in many, hyperpigmentation of the posterior neck and axilla (acanthosis nigricans) may be noted Fourth, a laboratory panel obtained for some other reason (e.g., abdominal pain) may reveal hyperglycemia If a child is severely ill and has concomitant hyperglycemia, close attention should be paid to the underlying illness Severity of hyperglycemia in the setting of critical illness is correlated with mortality, and it can be thought of as a general index of illness severity in this nondiabetes setting Management/Diagnostic Testing Children who are mildly dehydrated (5%) with slight acidosis will benefit from an IV fluid bolus (10 to 20 mL/kg of isotonic crystalloid); furthermore, this bolus may be given while awaiting laboratory test results Insulin therapy can be initiated subcutaneously, at a total daily dose of 0.25 to 0.5 Unit/kg/day for the prepubertal child and 0.5 to 0.75 Unit/kg/day for the adolescent Using the basal-bolus approach, one-half of the total daily dose is administered as insulin glargine or detemir, two 24-hour–acting analogs, and rapid-acting insulin (lispro, aspart) is dosed as a combination of coverage for ingested carbohydrates and as a correction for the degree of hyperglycemia above a chosen target—these initial dosages should be calculated along with the help of a consulting diabetes specialist Hyperglycemia associated with critical illness, in a patient without diabetes, should be managed in the context of the underlying illness Specific therapy for hyperglycemia should generally not be initiated in the ED, but can generally wait until the patient arrives in the ICU Clinical Indications for Discharge or Admission Some children with new-onset diabetes may also have hyperglycemia without ketoacidosis or with only mild acidosis Generally, these patients are engaged in a 1- to 2-day program of intensive diabetes education to teach the family and stabilize the insulin dosage; these educational programs require multidisciplinary input from professional diabetes educators, nutritionists, and social workers, and can take place in the inpatient or outpatient setting Children with known diabetes often develop hyperglycemia and ketosis without significant acidosis (venous pH greater than 7.3 or bicarbonate greater than 15 mEq/L) during the course of intercurrent illness, especially gastroenteritis, or secondary to omission of insulin doses Once the laboratory results are available, the physician must decide whether to hospitalize the child, continue treatment in the ED, or send the child home Several factors must be considered before sending a child home