Polyuria & Polydipsia in

Children
September 2016

Dr Mostafa Shebani

Objectives
Definition of polyuria, polydipsia and related
symptoms
Causes of polyuria & polydipsia in children
Approach to children with polyuria & polydipsia
Water deprivation test
Cases

Urine synthesis
The amount of urine depends on:
The amount of water ingested
The amount of solute ingested or produced
by metabolism in excess of needs
The ability to concentrate or dilute the urine
The presence of Antidiuretic hormone (ADH)
Ability of kidney to dilute or concentrate the
urine

Definition Of Polydipsia, Polyuria

& Related Symptoms
Frequent Micturition
Frequent voiding of small volumes of urine each time

Enuresis (Nocturnal Incontinence) (bed wetting)

Involuntary voiding of urine while asleep in a child 5
years
Primary enuresis: no period of dryness at night
Secondary enuresis: bed wetting in a child who has
been dry at night for at least 6 months

Nocturia
(Voiding of urine at night while awake)

Definition of Polyuria
Urine output exceeding 2 L / m2 body
surface area / 24 hour
OR

Urine output exceeding 5ml/kg/hour

OR
Pre-school

>1 L / 24 hour

School children

>2 L / 24 hour

Adult

>3 L / 24 hour

Cont.

Polyuria
Water diuresis Urine Osmolality < 250 mOsmol/kg
Excessive water intake as in psychogenic polydepisa

Solute diuresis Urine Osmolality > 250 mOsmol/kg

Glycosuria Diabetes mellitus
Calcium Hyper-calcaemia
Sodium bicarbonate Renal tubular acidosis

Definition of Polydipsia
Drinking of excessive amount of fluid
> 2 L / m2 body surface area / 24 hour

Primary
Habitual drinking (common in toddlers)
Compulsive water drinking (psychogenic polydipsia):
seen in adolescent with psychiatric disorder

Secondary
[secondary to polyuria that leads to
increased thirst]

Differentiating True from

Habitual Polydipsia
True Polydipsia
Desperate for drinks

Habitual Polydipsia
Bottle addiction

Will drink anything offered

Preferences for Juices &

Sweetened drinks
Refuses water

Waking at Night for a drink

Saturated Nappies

Sleeps through the night

Failure to thrive

Thriving

Causes Of Polyuria &

Polydipsia In Children
Diabetes mellitus
Diabetes Insipidus
Central
Nephrogenic

Habitual drinking
(primary polydipsia)
Hypercalcaemia
Hypokalaemia

Renal causes:
Chronic kidney
disease
Obstructive uropathy
(posterior urethral
valve)
Interstitial nephritis
Renal tubular acidosis
Fanconi syndrome
Juvenile

Causes Of Polyuria &

Polydipsia In Children
Bartter Syndrome
Hyperthyroidism
Addisons Disease
Pheochromcytoma

Drugs
Diuretics
Vitamin D
Lithium
Amphotericin B

Assessment of children with

Polyuria & Polydipsia
History
Polyuria
Is it increased volume of urine or just increased
frequency of micturition
Presence of nocturia or enuresis
Is there associated polydipsia

Assessment of children with

Polyuria & Polydipsia
History
Polydipsia
How much the child is drinking
What fluid does the child prefer
Does the child refuse water
Does the child drink day & night or only during the day
Does the child drink from unusual places (drink water
from the sink)

Has either polyuria & polydipsia interfered with the

child normal activities

Assessment of children with

Polyuria & Polydipsia
History
Weight loss or not gaining weight
Past history of:
Neurosurgery, meningitis or head trauma
Chronic kidney disease (CKD), Hypercalcaemia,
urinary tract obstruction

Family history of diabetes mellitus (DM)or

diabetes inspidus (DI)
History of drug use like diuretics, vitamin D,
nephrotoxic drugs, etc.

Assessment of children with

Polyuria & Polydipsia
Examination
Hydration status
Weight

Aim Of Investigating Children

With Polyuria & Polydipsia
The main aim is
To exclude Diabetes Mellitus

Diabetes mellitus is the most common single

cause of polyuria and it is commonly associated
with polydipsia and weight loss
Blood glucose & HbA1c is needed for diagnosis
Investigation

Normal

Fasting BG

< 100 mg

Random BG

< 140 mg

HbA1c

< 6.0%

Pre-diabetes
100-125
mg/dl
140-199
mg/dl
6-6.4%

Diabetes
126 mg/dl
200 mg/dl
6.5%

Investigation Of Children
With Polyuria & Polydipsia
Urea & Electrolyte
Serum Glucose
Serum Calcium
Serum Osmolality
Normal serum osmolality
280-295 mOsmo/kg
Effective serum osmolality
= 2 X [Na + K] + {glucose in mg/dl 18}

Cont.

Investigation Of Children With

Polyuria & Polydipsia (Urine)
Urine for glucose & ketones
Urine Osmolality (use early morning urine
sample if practical)
It ranges from 50-1200 mOsmol/kg (except in
neonates)

Cont.

Investigation Of Children With

Polyuria & Polydipsia (Urine)
Urine specific gravity
Urine specific gravity on urine dipstick is used as a
quick measure of urine osmolality.
A specific gravity of 1.010 is considered to
correlate with urine osmolality of 300-400
mOsmol/kg
The higher the specific gravity, the higher is the
urine osmolality

Cont.

Investigation Of Children With

Polyuria & Polydipsia
If serum osmolality is < 270 mOsmol/kg & urine
osmolality > 600 mOsmol/kg, diabetes insipidus
(DI) is unlikely
If serum osmolality is > 300 mOsmol/kg &
simultaneous urine osmolality is < 300
mOsmol/kg
diagnosis of DI is established
water deprivation test is contraindicated
Need desmopressin test to differentiate between central &
nephrogenic DI

Cont.

Investigation Of Children With

Polyuria & Polydipsia
If serum osmolality is between 270 300
mOsmol/kg in children with significant polyuria &
polydipsia then water deprivation test is needed
to differentiate between DI & primary polydipsia

Water Deprivation test

At base line
Weight the child
Take blood for urea & electrolyte, serum osmolality
Ask patient to empty his/her bladder & send urine for
urine osmolality

Start complete fluid restriction and keep the

child lying down
Every hour repeat the steps done at base line &
check BP, pulse rate & assess for signs of
dehydration

Cont.

Water Deprivation test

The test is terminated if one the following end
points is reached:
Serum osmolality is > 295 mOsmol/kg
Serum Na is > 147 mmol/l
Urine osmolality is > 600
Loss of > 5% of body weight
Signs of dehydration

Cont.

Water Deprivation Test

If serum osmolality is raising > 295 mOsmol/kg
& urine Osmolality is < 600 mOsmol/kg then
DI is likely
If urine osmolality is > 600 mOsmol/kg then
the diagnosis is probably primary polydipsia e.g
Habitual driniking

Cont.

Water Deprivation test

If DI is likely after water deprivation test:
For Desmopressin test to differentiate between
central & nephrogenic DI
Give desmopressin (nasally or subcutaneously)
Continue hourly investigations
If urine osmolality increased to > 600
mOsmol/kg then the diagnosis is central DI
If there is slight rise or no change in urine
osmolality then the diagnosis is nephrogenic DI

Case 1 (3 years old)

History of excessive drinking for several
months
Poor appetite, however weight gain was
satisfactory
He tend to wake once at night to drink
He drink predominantly milk or diluted juice
General & systemic examination is normal
Blood glucose, urea & electrolyte is normal
Urine analysis was normal

Cont.

Case 1 (3 years old)

Following overnight water restriction urine
osmolality is 850 mOsmol/kg
What is the diagnosis?
Habitual Drinking

Case 2 (11 year)

History of polyuria & polydipsia for 8 weeks
Recent history of headache
Na 142 mmol/l, K 3.7 mmol/l, creatinine 0.6
mg/dl, urea 6.5 mg/dl
Blood glucose 112 mg/dl
Serum osmolality 305 mOsmol/kg

Cont.

Case 2 (11 years)

What is the diagnosis?
Diabetes insipidus

What further test need to be done?

Water deprivation test is contraindicated
Desmopressin test

Cont.

Case 2 (11 years)

After Desmopressin test his urine osmolality
increased from 75 mOsmol/kg to 610
mOsmol/kg
What is the diagnosis?
Cranial DI

What other investigation need to be done?

MRI brain
Assessment of pituitary function

Case 3 (15 years old boy)

Polyuria & polydipsia for 6 weeks
His Father & paternal grandfather have T2DM
He is well and not dehydrated
BMI is 22.4 kg/m2 (between 75th & 91st centile)
Blood glucose is 340 mg/dl
Urine showed glycosuria & no ketonuria

Cont.

Case 3 (15 years old boy)

What is the diagnosis?
Diabetes Mellitus

What type of diabetes he might have?

Type 1 DM
Monogenic DM (MODY)
Type 2 DM

Case 4 (21 months old boy)

Referred because of failure to thrive
History of gastro-esophageal reflux diagnosed
at 3 weeks of age
Not gaining in weight from 12 months of age
despite adequate intake
Intermittent episodes of constipation
Normal development
What investigations need to be done?

Cont.

Case 4 (21 months old boy)

Previous investigations:
CBC: normal
Thyroid function: normal
CF & Coeliac screening: negative

Cont.

Case 4 (21 months old boy)

What further questions you need to ask?
Fluid intake: drink 2 2.5 L/day
Is he thirsty: excessive thirsty noted at 6 months of
age
Voiding pattern: 8-10 time/day, incredibly heavy
nappies

Cont.

Case 4 (21 months old boy)

What further investigation you need to
do?
Urea & electrolyte: Na 144, Cl 109
Serum osmolality: 300 mOsmol/kg
Urine osmolality: < 50 mOsmol/kg
Urine specific gravity: 1.005
Urine Electrolyte: Na < 5 mmol/l, K < 20 mmol/l

Cont.

Case 4 (21 months old boy)

What is the diagnosis?
Diabetes insipidus

What further investigations need to be

done?
Water deprivation test is contraindicated
Desmopressin test

Cont.

Case 4 (21 months old boy)

After Desmopressin test his urine osmolality
remained low at 70 mOsmol/kg & urine
specific gravity remained low 1.005
What is the Diagnosis?
Nephrogenic DI

Case 5 (4 years old girl)

History of polyuria & polydipsia for 3 weeks
Drinking 8L of water/day
Passing 9ml/kg/hour of urine
Normal growth & development
No family history of renal disease, polyuria or
DI
What investigations need to be done?

Cont.

Case 5 (4 year old girl)

CBC: normal
Glucose, urea, creatinine: normal
Na 137 mmol/l, K 4.2 mmol/l, calcium normal
Venous blood gas: pH 7.39, bicarbonate 25.3
mmol/l
Serum Osmolality: 275 mOsmol/kg
Urine analysis
Negative for glucose & ketones
Specific gravity: 1.005

Cont.

Case 5 (4 year old girl)

What is the differential diagnosis?
Diabetes Insipidus
Primary polydipsia ??

What further investigations need to

done?
Water deprivation test

Cont.

Case 5 (4 year old girl)

Water deprivation test
Increase in serum osmolality from 283 to 310
mOsmol/kg
Increase in urine osmolality from 149 to 253
mOsmol/kg
Continued passage of diluted urine, urine specific
gravity is 1.005
Weight loss of 3%
Urine output was 4ml/kg/hour

What is the Diagnosis?

Cont.

Case 5 (4 year old girl)

After Desmopressin test
Increased urine osmolality to 784 mOsmol/kg
Increased urine specific gravity to 1.030

What is the diagnosis?

Cranial DI

What further investigations need to be

done?
MRI brain
Assessment of pituitary function

Take Home Message

Polyuria & polydipsia is a common symptoms
during childhood
Differentiate between true polyuria &
frequency of micturition
Differentiate between true polydipsia
(secondary polydipsia) & habitual drinking
Always exclude diabetes mellitus !

Thank You for Listening

Body Surface Area (BSA)