What is the best initial approach for a young girl presenting with enuresis, polydipsia (excessive thirst) or polyuria (frequent urination), and weight loss?

Initial Diagnostic Approach

Perform random blood glucose testing immediately as the first-line investigation for this child presenting with enuresis, polydipsia/polyuria, and weight loss. This triad of symptoms strongly suggests diabetes mellitus, which requires urgent diagnosis to prevent progression to diabetic ketoacidosis 1, 2.

Rationale for Random Blood Glucose First

The clinical presentation described—enuresis combined with polydipsia/polyuria and weight loss—represents classic symptoms of diabetes mellitus in children 3, 2. These symptoms reflect osmotic diuresis from hyperglycemia, and the weight loss indicates a catabolic state from insulin deficiency 2.

The International Children's Continence Society guidelines explicitly state that glycosuria on urine dipstick means diabetes mellitus must be immediately excluded 1. However, waiting for urinalysis delays the critical diagnosis when a random blood glucose can provide immediate confirmation at the point of care.

Why Blood Glucose Takes Priority:

• Immediate diagnosis: A random blood glucose ≥200 mg/dL with classic symptoms confirms diabetes mellitus instantly, allowing urgent treatment initiation 2
• Prevents life-threatening complications: Approximately 50% of children present in diabetic ketoacidosis at diagnosis when the condition is not recognized early 2
• Point-of-care testing: Capillary blood glucose measurement can be performed immediately in the office, providing results within seconds 2
• Guides urgent management: Hyperglycemia with weight loss indicates severe insulin deficiency requiring immediate hospital admission and insulin therapy 4, 2

Role of Urinalysis

While urinalysis is valuable, it serves as a secondary confirmatory test rather than the initial diagnostic step in this clinical scenario:

• Urine dipstick showing glycosuria and ketonuria supports the diabetes diagnosis but still requires blood glucose confirmation 1, 2
• The presence of ketonuria indicates metabolic decompensation and increased urgency for treatment 1, 2
• Urine culture is not indicated unless there are specific signs of urinary tract infection beyond the polyuria from hyperglycemia 1

Common Pitfall to Avoid:

Do not attribute enuresis with polyuria to a primary bladder problem when accompanied by polydipsia and weight loss 1. The enuresis guideline specifically warns that childcare providers unfamiliar with diabetes may not realize polyuria represents hyperglycemia requiring insulin, and may inadvertently worsen the condition by giving juice 1.

Clinical Algorithm:

1. Perform random blood glucose immediately (capillary or venous) 2
2. If glucose ≥200 mg/dL with classic symptoms → Confirm diabetes mellitus diagnosis 2
3. Simultaneously obtain urine dipstick for glycosuria and ketonuria 1, 2
4. Admit to hospital urgently for insulin initiation and metabolic stabilization 2
5. Check HbA1c to assess duration of hyperglycemia 5, 4

Additional Considerations:

The differential diagnosis for polyuria-polydipsia in children includes diabetes insipidus and psychogenic polydipsia 6, 7, 8, but the presence of weight loss distinguishes diabetes mellitus from these conditions, as diabetes insipidus and primary polydipsia do not cause weight loss 8. The weight loss reflects catabolism from insulin deficiency, making diabetes mellitus the most urgent diagnosis to exclude 3, 2.

Answer: A. Random Blood Glucose should be performed first, followed by urinalysis for confirmation and assessment of ketones.