Children with diabetes may present in ketoacidosis. The classic presentation includes weight loss, polyuria, polydypsia, polyphagia, weakness, vomiting, abdominal discomfort, Kussmaul respirations, a fruity acetone breath, and AMS. Patients with diabetic ketoacidosis, as well as many other pediatric disease states associated with a loss of circulating volume, may develop inadequate perfusion. Patients with hypotonic or hypertonic dehydration may develop AMS with and without seizures. Poorly perfused patients or patients with inadequate air exchange have insufficient oxygen delivery to the brain and exhibit insomnia, somnolence, and confusion. Patients who develop hypercapnia as a result of primary lung disease or neurologic dysfunction may also present with AMS. Those with hepatic failure present with nausea, fatigue, and behavioral alterations and may rapidly become obtunded. Patients with inborn errors of metabolism typically present early in life with poor feeding, recurrent vomiting, seizures, metabolic acidosis, lethargy, stupor, and coma.
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