We recommend consideration of HHNK in comatose pediatric patients and advocate the prompt institution of fluid therapy. Insulin is not required during the initial course of treatment and potentially can have adverse effects. Compared to adults, pediatric patients appear to be at a greater risk of developing potentially fatal cerebral during the course of treatment. In order to prevent complications associated with the rapid decrease in serum tonicity the initial management should consist of fluid therapy directed toward repleting the intravascular volume, correcting electrolyte abnormalities, and slowly returning serum tonicity to normal.