Ketoacidosis at onset of type 1 diabetes mellitus in children--frequency and clinical presentation

Glycemic control in Iranian children with type 1 diabetes mellitus: effect of gender

OBJECTIVES

To evaluate the effect of gender on glycemic control, diabetic complications and associated abnormalities in patients with type 1 diabetes mellitus (T1DM).

METHODS

In the present cross-sectional study, patients with T1DM referred to endocrinology clinic in children's hospital medical center in Tehran from March 2005 through March 2007 were enrolled. For each patient a questionnaire was filled. Finally, effect of gender on glycemic control was analyzed.

RESULTS

Male patients did self monitoring of blood glucose significantly more than female patients. Mean HbA1c which is used as an indicator of glycemic control, insulin dose per kg of body weight and also frequency of diabetic ketoacidosis (DKA), height problems and dyslipidemia were significantly higher in female patients.

CONCLUSIONS

Because of worse glycemic control and higher incidence of DKA, dyslipidemia and height problems in female patients, focus on glycemic control of female patients according to local guidelines on clinical management of T1DM is required.

Reduced prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes in young children participating in longitudinal follow-up

OBJECTIVE

Young children have an unacceptably high prevalence of diabetic ketoacidosis (DKA) at the clinical diagnosis of type 1 diabetes. The aim of this study was to determine whether knowledge of genetic risk and close follow-up for development of islet autoantibodies through participation in The Environmental Determinants of Diabetes in the Young (TEDDY) study results in lower prevalence of DKA at diabetes onset in children aged <2 and <5 years compared with population-based incidence studies and registries.

RESEARCH DESIGN AND METHODS

Symptoms and laboratory data collected on TEDDY participants diagnosed with type 1 diabetes between 2004 and 2010 were compared with data collected during the similar periods from studies and registries in all TEDDY-participating countries (U.S., SEARCH for Diabetes in Youth Study; Sweden, Swediabkids; Finland, Finnish Pediatric Diabetes Register; and Germany, Diabetes Patienten Verlaufsdokumenation [DPV] Register).

RESULTS

A total of 40 children younger than age 2 years and 79 children younger than age 5 years were diagnosed with type 1 diabetes in TEDDY as of December 2010. In children <2 years of age at onset, DKA prevalence in TEDDY participants was significantly lower than in all comparative registries (German DPV Register, P < 0.0001; Swediabkids, P = 0.02; SEARCH, P < 0.0001; Finnish Register, P < 0.0001). The prevalence of DKA in TEDDY children diagnosed at <5 years of age (13.1%) was significantly lower compared with SEARCH (36.4%) (P < 0.0001) and the German DPV Register (32.2%) (P < 0.0001) but not compared with Swediabkids or the Finnish Register.

CONCLUSIONS

Participation in the TEDDY study is associated with reduced risk of DKA at diagnosis of type 1 diabetes in young children.

The relation of age to the severity of Type I diabetes in children

Objective:

To study the relationship between the age and severity of Type 1 diabetes in children 0 - 5 years and more than 5 years of age admitted to Aseer Central Hospital, Southwestern Saudi Arabia over a 7-year period.

Materials and Methods:

A retrospective review of children less than 13 years of age with Type 1 diabetes admitted to the Pediatric Department, between 1st January 2000 to 31st December 2006.

Results:

A total of 181 children with Type1 diabetes were admitted to the hospital during this period. Of these, 27.6% were children 5 years or less, while 72.4% were more than 5 years of age. The duration of symptoms was longer in younger children compared to older patients. Diabetic ketoacidosis was present in 31.4% of the younger children, and in 15.3% of the children more than 5 years old. Hospital stay was also longer in children less than 5 years of age. Most significant differences were in the younger children’s group and affected the biochemical test results.

Conclusion:

The present study showed that more younger children present to the hospital late, and in a state of diabetic ketoacidosis compared to older patients. Efforts should be directed at improving the knowledge and skills of the primary health care personnel to be able to diagnose and refer these cases earlier.

Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review

OBJECTIVE

To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.

DESIGN

Systematic review.

DATA SOURCES

PubMed, EMBASE, Web of Science, Scopus, and Cinahl and article reference lists.

STUDY SELECTION

Cohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication.

RESULTS

46 studies involving more than 24,000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for <2 years old v older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35 (2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection (odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74 (1.10 to 2.77)). Protective factors were having a first degree relative with type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)), higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43 to 0.94) in two studies), and higher background incidence of type 1 diabetes (correlation coefficient -0.715). The mean duration of symptoms was similar between children presenting with or without diabetic ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0) respectively), and up to 38.8% (285/735) of children who presented with diabetic ketoacidosis had been seen at least once by a doctor before diagnosis.

CONCLUSIONS

Multiple factors affect the risk of developing diabetic ketoacidosis at the onset of type 1 diabetes in children and young adults, and there is potential time, scope, and opportunity to intervene between symptom onset and development of diabetic ketoacidosis for both parents and clinicians.

The management of diabetic ketoacidosis in children

The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.

Clinical characteristics at presentation of type 1 diabetes mellitus in children younger than 15 years in Croatia

The aim of the study was to determine the clinical and biochemical characteristics of type 1 diabetes mellitus (DM) at presentation in children younger than 15 years in Croatia during a 9-year period, with special attention to diabetic ketoacidosis (DKA) incidence. The registered data set comprised blood glucose, pH, serum bicarbonate levels, and clinical symptoms at disease manifestation. During the study period, 692 children were diagnosed with type 1 DM. Polydipsia (96.7%), polyuria (96.05%), and weight loss (82.7%) were the most frequent symptoms anticipating disease detection. Enuresis was recorded in 11.55%. A total of 36.41% patients had DKA (pH < 7.3) at disease onset. During the 9-year period, the percentage of children presenting with DKA at time of diagnosis decreased from 41.67% to 33.33% (z = 1.68, p = 0.046). A positive family history of DM, the only factor with an impact on the DKA incidence rate in our population, lowers the probability of the development of ketoacidosis. This study confirms the importance of the detection of the classic symptoms of polyuria, polydipsia, and weight loss in patients with new-onset type 1 DM. The percentage of patients with DKA at diabetes onset decreased during the observed period but is still high and includes one-third of all patients. This is why in every acutely ill child, especially at a younger age, one should evaluate the possibility of type 1 DM to avoid the development of ketoacidosis.

The effect of the length of the prodromal period on the metabolic control within the first 2 years in children with diabetic ketoacidosis manifestation

PURPOSE

We investigated the effects of clinical and laboratory properties at the time of the initial application of patients recently diagnosed and presenting metabolic indicators of diabetic ketoacidosis who were given disease prognoses in years 1 and 2 after discharge.

MATERIALS AND METHODS

A total of 94 patients admitted to Bakirkoy Maternity and Children's Diseases Training and Research Hospital with diabetic ketoacidosis and recently diagnosed with type 1 diabetes mellitus were investigated. Patient files were examined within 2 years following discharge.

FINDINGS

All 94 study patients (53.2% male and 46.8% female) presented acidosis, ketonuria and hyperglycemia. While a moderate correlation was detected between the prodromal period and HbA(1c) values in year 1, only a slight correlation was seen in HbA(1c) values in year 2. In addition, a slight correlation was observed between the prodromal period and the number of hospitalizations due to diabetic ketoacidosis in the first year. Again, while a moderate correlation was observed between HbA(1c) values and the number of hospitalizations due to diabetic ketoacidosis in year 1, only a slight correlation was seen in year 2. The prodromal period was directly proportional to patient age.

RESULTS

Hospital admissions may be reduced through appropriate treatment, follow-up and metabolic control of patients with type 1 diabetes mellitus. In addition, we report a relationship between the prodromal period and HbA(1c) values in type 1 diabetes patients.

The management of diabetic ketoacidosis in children

The object of this review is to provide the definitions, frequency, risk factors, pathophysiology, diagnostic considerations, and management recommendations for diabetic ketoacidosis (DKA) in children and adolescents, and to convey current knowledge of the causes of permanent disability or mortality from complications of DKA or its management, particularly the most common complication, cerebral edema (CE). DKA frequency at the time of diagnosis of pediatric diabetes is 10%-70%, varying with the availability of healthcare and the incidence of type 1 diabetes (T1D) in the community. Recurrent DKA rates are also dependent on medical services and socioeconomic circumstances. Management should be in centers with experience and where vital signs, neurologic status, and biochemistry can be monitored with sufficient frequency to prevent complications or, in the case of CE, to intervene rapidly with mannitol or hypertonic saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours; an initial bolus of 10-20 mL/kg 0.9% saline is followed by 0.45% saline calculated to supply maintenance and replace 5%-10% dehydration. Potassium (K) must be replaced early and sufficiently. Bicarbonate administration is contraindicated. The prevention of DKA at onset of diabetes requires an informed community and high index of suspicion; prevention of recurrent DKA, which is almost always due to insulin omission, necessitates a committed team effort.

Trends in hospitalization for diabetic ketoacidosis in diabetic patients in Taiwan: analysis of national claims data, 1997-2005

BACKGROUND/PURPOSE

Diabetic ketoacidosis (DKA) is a fatal complication of diabetes, and is strongly related to the quality of diabetes care. This study aimed to establish recent secular trends of incidence density (ID) of DKA in patients with diabetes in Taiwan and to explore the effects of age and sex on the risk of a DKA emergency.

METHODS

Using the National Health Insurance claims data, we identified annual diabetic cohorts (around 650,000 diabetic patients annually) from 1997 to 2005, and searched for possible admissions due to DKA emergencies. We performed log-linear regression analysis to assess the trend in ID of DKA and to assess the independent effects of age and sex on the risk of DKA.

RESULTS

Although the annual ID of DKA showed a slight but significant declining trend over the study period, from 6/1000 to 5/1000 person-years, the age/sex-specific analysis indicated that female patients aged ≤ 34 years showed a significantly increasing trend. Multivariate analysis revealed that calendar year and sex had significant but small independent effects on risk of DKA admission. In contrast, age was strongly associated with risk of DKA emergency. Compared with patients aged > 65 years, notably high adjusted rate ratios (ARRs) of DKA were observed in patients aged <15 years (ARR = 48.84) and 15-34 years (ARR =15.21).

CONCLUSION

Although the overall ID of DKA linearly decreased between 1997 and 2005, significant rising trends were still observed in female diabetic patients aged < 35 years. More aggressive diabetic care programs aimed at young female patients should be considered to reduce this emergency and possibly fatal diabetic complications.

Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics

BACKGROUND

Diabetic ketoacidosis (DKA) has significant morbidity and mortality, and is common at diagnosis in children.

OBJECTIVE

Describe the frequency and severity of DKA at diagnosis of type 1 diabetes mellitus (T1DM) in children in Kuwait.

METHODS

Hospital records of 677 diabetic children less than 12 yr of age, diagnosed during the period of 2000-2006 were reviewed. DKA was defined as blood glucose > 11 mmol/L, pH < 7.3, and/or bicarbonate < 15 mmol/L with ketonuria.

RESULTS

Of all patients diagnosed with T1DM, 255 (37.7%) presented with DKA. The frequency of DKA was constant between 2000 and 2002 (42.7-41.5%), but decreased in the following years to 30.7% in 2006 (p < 0.005). The majority had either mild or moderate DKA (74.1%). Fifty-one (36.7%) of all children in the 0-4 yr had severe DKA compared to ten (2.9%) in the 5- to 8-yr-old group, and three (1.5%) in 9- to 12-yr-old patients (p < 0.0001). Moreover, 83% of children with severe DKA were in the 0-4 yr age group. One child (0.15%) died and twenty-seven (4%) needed intensive care unit (ICU) care.

CONCLUSION

Our study provides recent data on Middle Eastern population, for whom data are sparse. Although it has significantly decreased, the frequency of DKA at presentation of T1DM in children in Kuwait is still high, secondary to the high prevalence of diabetes in the community. Young children, especially those less than 2 yr old remain at high risk. Increasing the general awareness of the public as well as of pediatricians to the disease may lead to early diagnosis before the development of acidosis.

Diabetic ketoacidosis at diagnosis in Austrian children in 1989-2008: a population-based analysis

AIM

The aim of the study was to analyse the prevalence of diabetic onset ketoacidosis (DKA) during a period of 20 years (1989-2008) on a population basis in the whole of Austria.

METHODS

A prospective population-based incidence study (1989-2008) was performed. The registered data set comprised blood glucose, pH, ketonuria and clinical symptoms of DKA at manifestation. DKA was defined as pH < 7.3 and severe DKA as pH < 7.1. Time trends were estimated using linear regression models.

RESULTS

During the study period, 3331 children <15 years of age (1,797 boys and 1,534 girls) were registered with newly diagnosed type 1 diabetes. Of these, 1,238 (37.2%) presented with DKA, 855 (25.7%) had a mild and 383 (11.5%) a severe form, and one patient died at onset. DKA frequency was negatively associated with age at onset (p < 0.0001). In children <2 years the prevalence was 60%, with a higher risk for girls (70% vs 54% for boys, p < 0.05). Despite a significant increase in diabetes incidence in Austria during the observation period from 8.4 to 18.4/100,000 (p < 0.0001), no significant change in the prevalence of DKA at manifestation was observed.

CONCLUSIONS

The overall frequency of DKA in children with newly diagnosed type 1 diabetes in Austria is high and has not changed during the last 20 years despite a clear increase in the manifestation rate. In particular, children less than 2 years of age have a high risk of DKA at onset.

Initial insulin therapy in children and adolescents with type 1 diabetes mellitus

OBJECTIVE

The aim of the study was to define parameters that influence the initial insulin dosage in young subjects with type 1 diabetes regarding the amount of daily insulin, the ratios of basal and prandial insulin, and the insulin/carbohydrate ratios.

STUDY DESIGN

We used a computer-based registry (with prospectively collected data) in Germany and Austria, a software for the management and data documentation of diabetic patients (DPV), to analyze the initial insulin therapy in 2247 children with newly diagnosed type 1 diabetes to identify factors that influence diabetes therapy within the first 10 d.

RESULTS

For both genders, glucosylated hemoglobin A1c (HbA1c), blood pH at diabetes onset, and pubertal status are the major factors determining the initial insulin dosage calculated as the amount of daily insulin per kilogram body weight (kg), the basal and prandial insulin dose per kilogram, and day and the insulin/carbohydrate ratios for meals. The frequency of hypoglycemia correlated with increasing quotient of applied to calculated insulin dosage.

CONCLUSION

The predictive factors of insulin requirement may exert beneficial effects on the assessment and adjustment of insulin therapy in young diabetic subjects at disease onset. On the basis of a multiple, linear regression, we suggest a formula to calculate the initial insulin therapy.

Clinical features at the onset of childhood type 1 diabetes mellitus in Shenyang, China

AIM

To describe the clinical picture and laboratory features of Chinese children with newly diagnosed type 1 diabetes mellitus.

METHODS

The clinical and laboratory data of a total of 203 children who presented with newly diagnosed type 1 diabetes mellitus during a 5-year period (2004-2008) were retrospectively analysed based on hospital records.

RESULTS

There were 88 boys (43.3%) and 115 girls (56.7%) with a median age of 8.3 years. The age distribution was categorised as 0-4 years: 52 (25.6%), 5-9 years: 57 (28.1%) and 10-14 years: 94 (46.3%). We found a peak incidence rate in the older age group. No significant seasonality was observed. The most common symptoms were polydipsia, polyuria and weight loss. Eighty-five (41.9%) of all patients presented with diabetic ketoacidosis (DKA). The average duration of presenting symptoms before the hospital encounter was 24.5 days. Young age group children had shorter duration (17.1 days, P = 0.03) and significantly lower levels of C-peptide (P = 0.003) and haemoglobin A1c (P = 0.049) than the other groups. Children with DKA had a higher incidence of preceding infections (P = 0.032), lower free triiodothyronine and free thyroxine levels (P= 0.035, 0.046), and higher white blood cell counts (P = 0.000) than the non-DKA group.

CONCLUSION

The duration between the onset of the symptoms and diagnosis was long, and the proportion of DKA in children with newly diagnosed diabetes mellitus was high. These findings call for a collaborative effort for the early recognition of symptoms by patients and physicians in order to avoid more severe types of presentation.

Is diabetic ketoacidosis at disease onset a result of missed diagnosis?

OBJECTIVE

To determine the frequency of medical encounters before diagnosis of diabetes in children in Ontario, Canada; to determine risk factors for diabetic ketoacidosis (DKA).

RESEARCH DESIGN

All medical encounters within 4 weeks before date of diagnosis for all new cases of diabetes in children <18 years were identified from April 1994 to March 2000 by use of administrative databases. The main outcome measure was the frequency of medical encounters before diagnosis in children presenting with and without DKA.

RESULTS

A total of 3947 new cases of diabetes were identified, 735 (18.6%) with DKA. DKA rates were 39.7% for children < or =3 years and 16.3% for children >3 years (P < .001). During the week before diagnosis, 285 children with DKA (38.8%) and 1104 children with diabetes without DKA (34.4%; P = .026) had at least 1 medical visit. Children with diabetes overall had more medical encounters before diagnosis than control subjects. Children with DKA were less likely to have had relevant laboratory testing before diagnosis than children with diabetes without DKA.

CONCLUSIONS

Children with diabetes presenting with DKA more frequently had a medical encounter before diagnosis compared with children with diabetes without DKA. These data have important implications for enhancing public and physician awareness of diabetes in children.

Difficulties or mistakes in diagnosing type 1 diabetes in children?--demographic factors influencing delayed diagnosis

BACKGROUND

Diabetic ketoacidosis (DKA) development in children with new-onset type 1 diabetes (T1DM) is often the main consequence of delayed diagnosis. The aim of the study was to estimate the frequency of difficulties in T1DM diagnosis and to investigate if and how the demographic factors (gender, patient's age at presentation, family history of T1DM, level of maternal education, place of residence, and health service unit the patient called at) have any influence on diagnostic delays.

SUBJECTS AND METHODS

Retrospective analysis of 474 children (243 boys-51.27% and 231 girls -48.73%) with new-onset T1DM aged below 17 yr and living in the Pomeranian region of Poland was carried out. The delay in diagnosis was recognized if the patient was not diagnosed on the first visit because of omission, wrong interpretation of main diabetic symptoms, exclusive treatment of additional signs, or concomitant diseases.

RESULTS

Difficulties in diagnosing T1DM were found in 67 cases (14.13%) and they are the main cause of DKA development in these children (p = 0.00). Among the examined demographic factors, mainly the patient's age at presentation has a significant influence on diagnostic delays (p = 0.01), especially in children below 2 yr (p = 0.00). Most frequently family doctors were responsible for wrong preliminary diagnosis.

CONCLUSIONS

Difficulties in diagnosing T1DM are a significant cause of DKA development in children with new-onset disease. Patient's age at presentation is the main risk factor of delayed diagnosis, especially in children below 2 yr. The increase in awareness among pediatricians concerning the possibility of T1DM development in children is needed.

Ketoacidosis at diabetes onset is still frequent in children and adolescents: a multicenter analysis of 14,664 patients from 106 institutions

OBJECTIVE

We aimed at analyzing the frequency, clinical characteristics, and trends associated with the occurrence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes on the basis of long-term follow-up data.

RESEARCH DESIGN AND METHODS

A total of 106 pediatric diabetes centers in Germany and Austria participated in this study. Data from 14,664 patients with type 1 diabetes collected between 1995 and 2007 were suitable for evaluation. DKA was defined and classified according to the International Society for Pediatric and Adolescent Diabetes consensus guidelines.

RESULTS

DKA was observed in 21.1% of patients. The frequency of DKA, including the severe form, remained unchanged throughout the 13-year observation period. The frequency of DKA was particularly striking among children <5 years of age (26.5%).

CONCLUSIONS

Ketoacidosis occurring at diabetes onset continues to be a difficult problem. Our data show no significant change in the frequency and magnitude of DKA over the last 13 years.

Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study

OBJECTIVE

The purpose of this work was to determine the prevalence and predictors of diabetic ketoacidosis at the diagnosis of diabetes in a large sample of youth from the US population.

PATIENTS AND METHODS

The Search for Diabetes in Youth Study, a multicenter, population-based registry of diabetes with diagnosis before 20 years of age, identified 3666 patients with new onset of diabetes in the study areas in 2002-2004. Medical charts were reviewed in 2824 (77%) of the patients in a standard manner to abstract the results of laboratory tests and to ascertain diabetic ketoacidosis at the time of diagnosis. Diabetic ketoacidosis was defined by blood bicarbonate <15 mmol/L and/or venous pH < 7.25 (arterial/capillary pH < 7.30), International Classification of Diseases, Ninth Revision, code 250.1, or listing of diabetic ketoacidosis in the medical chart.

RESULTS

More than half (54%) of the patients were hospitalized at diagnosis, including 93% of those with diabetic ketoacidosis and 41% without diabetic ketoacidosis. The prevalence of diabetic ketoacidosis at the diagnosis was 25.5%. The prevalence decreased with age from 37.3% in children aged 0 to 4 years to 14.7% in those aged 15 to 19 years. Diabetic ketoacidosis prevalence was significantly higher in patients with type 1 (29.4%) rather than in those with type 2 diabetes (9.7%). After adjusting for the effects of center, age, gender, race or ethnicity, diabetes type, and family history of diabetes, diabetic ketoacidosis at diagnosis was associated with lower family income, less desirable health insurance coverage, and lower parental education.

CONCLUSION

At the time of diagnosis, 1 in 4 youth presents with diabetic ketoacidosis. Those with diabetic ketoacidosis were more likely to be hospitalized. Diabetic ketoacidosis was a presenting feature of <10% of youth with type 2. Young and poor children are disproportionately affected.

Diabetic ketoacidosis and cerebral oedema in Sweden--a 2-year paediatric population study

AIM

The aim of this study was to investigate diabetic ketoacidosis (DKA) and cerebral oedema in the Swedish paediatric diabetes population, and to measure laboratory parameters during treatment.

METHODS

The Swedish National Paediatric Diabetes Registry (SWEDIABKIDS) indicates that 16% of patients < 18 years during 2000 to 2004 had DKA at onset of diabetes. Data from 1999 and 2000 was collected retrospectively from all of Sweden by questionnaire.

RESULTS

We identified 292 cases of DKA (pH < 7.30) in 265 children (149 at diabetes onset), aged 0.8-19.9 years. The incidence of DKA in patients with previously diagnosed diabetes was 1.4/100 patient years in 1999 and 1.7/100 in 2000. Two patients, both 11 years old with newly diagnosed diabetes, had overt symptoms of cerebral oedema and one developed neurological sequelae. This corresponds to an incidence of 0.68% (2/292) with no mortality. Symptoms of subclinical cerebral oedema after admission (headache, vomiting, lethargy) were recorded in a further 16 cases. In two of these mannitol was given, and both recovered within 1-2 h. Laboratory data was available from 253/292 episodes. During treatment for DKA, hypokalaemia (< 3.5 mmol/l) was significantly more common at onset of diabetes than in patients with established diabetes (65 vs. 28%, P < 0.001; initial prescription of potassium was 20 mmol/l).

CONCLUSIONS

We conclude that 16% of children with new-onset diabetes presented with DKA at diagnosis and that the incidence of DKA in children with established diabetes was 1.6/100 patient years. Cerebral oedema occurred in 0.68% of the DKA episodes.

Ketoacidosis at diagnosis of type 1 diabetes in children in northern Finland: temporal changes over 20 years

OBJECTIVE

To study the frequency of diabetic ketoacidosis (DKA) over a 20-year period among children diagnosed with type 1 diabetes in northern Finland.

RESEARCH DESIGN AND METHODS

The study population comprised 585 patients (328 boys) diagnosed with type 1 diabetes aged <15 years in the Department of Pediatrics, Oulu University Hospital, between 1 January 1982 and 31 December 2001. The data for clinical characteristics were collected retrospectively from the patients' case records. The earlier 10-year period (1982-1991) was compared with the later 10-year period (1992-2001). Two definitions for DKA were used: DKA(i) pH <7.30 or DKA(ii) pH <7.30 and/or bicarbonate <15 mmol/l.

RESULTS

During the later 10-year period, children less often had DKA at diagnosis [DKA(i) 15.2 vs. 22.4%, P = 0.028, and DKA(ii) 18.9 vs. 29.5%, P = 0.003]. The proportion of young children aged <5 years at diagnosis increased over time, but the frequency of DKA also was lower in this age-group during 1992-2001 compared with the earlier 10-year period [DKA(i) 17.7 vs. 32.1%, P = 0.052, and DKA(ii) 20.3 vs. 42.6%, P = 0.005]. In children aged <2 years at diagnosis, the frequency of DKA remained high during 1992-2001 [DKA(i) 39.1% and DKA(ii) 47.8%].

CONCLUSIONS

The overall frequency of DKA in children with newly diagnosed type 1 diabetes decreased over a 20-year period in northern Finland. However, children aged <2 years are still at high risk for DKA at diagnosis.

Children diagnosed with diabetes during infancy have unique clinical characteristics

OBJECTIVE

Characterizing clinical and biochemical features of children diagnosed with diabetes mellitus between the ages of 6-24 months.

DESIGN AND METHODS

Medical records of 42 children diagnosed with diabetes mellitus at age of 6-24 months were reviewed for gender, ethnic origin, family medical history, clinical and biochemical features at onset of diabetes compared with 60 diabetic patients diagnosed at age 5-16 years.

RESULTS

Children diagnosed at 6-24 months had at onset more symptoms of apathy, restlessness, hyperglycemia during acute illness and a lower rate of remission than those diagnosed at older age (p < 0.001), significantly more episodes of diabetic ketoacidosis (83% vs. 40%, p < 0.001), lower HbA1c levels (mean 11.6 +/- 3.4 vs. 13.75 +/- 3.4%, p < 0.05) and a higher rate of celiac disease (12% vs. 3%, p = 0.046). There were no significant differences as to other autoimmune diseases.

CONCLUSIONS

Patients with diabetes presenting at 6-24 months might be associated with a different clinical pattern and higher rate of celiac disease than diabetes presenting later in life. Understanding the nature and course of diabetes in this age group is crucial for planning interventional and preventive programs.

Blood ketone bodies in patients with recent-onset type 1 diabetes (a multicenter study)

BACKGROUND

Insulin deficiency with glucagon excess leads to the release of ketone bodies (KBs) by the liver and excretion in the urine. So far, only KB monitoring in urine has been used during assessment of children with diabetes. Currently used nitroprusside strips for urine KB detection react only with acetoacetate (AcAc) and not with the most prevalent KB moiety - 3beta-hydroxybutyrate (3HB) - that is in equilibrium with AcAc (up to 10:1 ratio).

AIM

To verify the significance of 3HB in the blood compared to that of AcAc in the urine in recently diagnosed type 1 diabetic subjects independent of the presence of diabetic ketoacidosis (DKA).

METHODS

A total of 118 consecutive newly diagnosed subjects with type 1 diabetes from different centers in Italy underwent intensive insulin therapy and hydration when necessary (38/118 = 32% with DKA). Hourly urine and capillary blood samples were used to monitor KBs until metabolic control was achieved.

RESULTS

Although DKA was present in 32% of patients, blood 3HB was significantly increased (3.56 +/- 1.7 mmol/L) in 83% of the patients and correlated with blood glucose (r = 0.39; p < 0.01) according to a bimodal model. The strongest association was found between 3HB and venous pH (r =-0.56; p < 0.0001). Time required for blood 3HB normalization depended strongly on the starting blood KB values (r = 0.44; p < 0.0001) and was significantly lower than that required for disappearance of KB from urine (17.4 +/- 13.6 h, range 1-69 h vs. 19.7 +/- 17.8 h, range 1-120 h; p = 0.004). However, urine KBs disappeared before blood 3HB normalization in 23% of the patients.

CONCLUSIONS

Blood 3HB evaluation is a better indicator of metabolic control compared to urine KB detection and is useful to predict the time required for blood KB clearing. Further studies are needed to assess its use in the early detection and management of DKA.

Characteristics at diagnosis of type 1 diabetes in children younger than 6 years

OBJECTIVE

To characterize the prodrome, presentation, family history, and biochemical status at diagnosis of type 1 diabetes mellitus (T1D) in children under age 6 years.

STUDY DESIGN

This was a retrospective chart review of patients hospitalized at diagnosis with T1D from 1990 to 1999 in a children's hospital.

RESULTS

A total of 247 children were hospitalized, 44% of whom presented in diabetic ketoacidosis (DKA). When stratified by 2-year age intervals, only total carbon dioxide (tCO(2)) was significantly lower in the youngest children (P = .02), and the duration of candidiasis was significantly longer in those children presenting in DKA (P = .004). Parents were more likely to recognize symptomatic hyperglycemia in children older than 2 years (P < .0001). Most parents sought care for their child suspecting that the child had diabetes; the other children were diagnosed when presenting with another concern. Only gender and tCO(2) were significantly correlated with hemoglobin A1c (HbA1c); age-adjusted HbA1c was 0.64% higher in girls compared with boys (P = .045), and each 1-mmol/L decrement in tCO(2) increased the age- and gender-adjusted HbA1c by 0.086% (P < .001).

CONCLUSIONS

A high proportion of children under age 6 years present critically ill at the diagnosis of T1D. When any of the classic symptoms of diabetes or a yeast infection is present, a serum glucose level should be measured.

Relationship between skin acetone and blood beta-hydroxybutyrate concentrations in diabetes

BACKGROUND

Acetone is emitted from the skin and acetone concentrations correlate with blood beta-hydroxybutyrate.

METHODS

Skin acetone concentrations of 63 patients with diabetes and 32 control subjects were measured by cold trapping followed by gas chromatography.

RESULTS

Skin acetone concentrations of patients with diabetes (188+/-17 ppb; mean+/-SE) were significantly higher than those of the control subjects (87+/-10 ppb, p<0.01). There was no significant difference in skin acetone concentrations among patients with diabetes with regard to mode of treatment. Skin acetone concentrations were correlated with blood beta-hydroxybutyrate (r=0.669, p<0.01), blood glucose (r=0.608, p<0.01), and HbA1c (r=0.292, p<0.05) in patients with diabetes. Skin acetone concentration was high (940 ppb) in a patient with diabetic ketoacidosis, and it fell to 80 ppb after insulin therapy.

CONCLUSION

Measurement of skin acetone can be used as a screening test for ketoacidosis provided the analytical methods and tools become simpler. Moreover, it could become a marker of diabetic control and of ketone production in diabetes and other ketogenic conditions.

Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis

OBJECTIVE

To look for technical simplification and economic efficiency in the treatment of pediatric diabetic ketoacidosis (DKA) with subcutaneous use of the fast-acting insulin analog (lispro) and compare its use with regular intravenous insulin treatment.

RESEARCH DESIGN AND METHODS

In this controlled clinical trial from June 2001 to June 2003, we randomized 60 episodes of DKA with a blood glucose level > or = 16.6 mmol/l (300 mg/dl), venous pH <7.3 and/or bicarbonate <15 mmol/l, or ketonuria greater than + +. Of the 60 episodes, 30 were treated with subcutaneous lispro (0.15 units/kg) given every 2 h (lispro group) and the other 30 cases received continuous intravenous regular insulin (0.1 unit x kg(-1) x h(-1); CIRI group). Volume deficit was repaired with 10-ml/kg aliquots of 0.9% sodium chloride. Laboratory monitoring included hourly bedside capillary glucose, venous blood gas, beta-hydroxybutyrate, and electrolytes. Plasma blood glucose levels were measured on admission, 2 h after admission, when capillary blood glucose reached < or = 13.8 mmol/l (250 mg/dl), and 6, 12, and 24 h thereafter.

RESULTS

Capillary glucose levels decreased by 2.9 and 2.6 mmol x l(-1) x h(-1) in the lispro and CIRI groups, respectively, but blood glucose fluctuated at different time intervals. In the CIRI group, metabolic acidosis and ketosis resolved in the first 6-h period after capillary glucose reached 13.8 mmol/l, whereas in the lispro group, they resolved in the next 6-h interval; however, both groups met DKA recovery criteria without complications.

CONCLUSIONS

DKA treatment with a subcutaneous fast-acting insulin analog represents a cost-effective and technically simplified procedure that precludes intensive care unit admission.

Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus

OBJECTIVES

(a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM).

RESEARCH DESIGN AND METHODS

Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained.

RESULTS

Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old.

CONCLUSIONS

At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.

Incidencia y características clínicas al manifestarse la diabetes mellitus tipo 1 en niños de Galicia (España, 2001-2002)

OBJECTIVE

To determine the epidemiology, clinical manifestations and laboratory results at onset of type 1 diabetes mellitus in children aged 0-14 years from January 2001 to December 2002.

PATIENTS AND METHODS

All children younger than 14 years old living in Galicia (Spain) and admitted to one of the hospitals of the Galician health service with a diagnosis of type 1 diabetes mellitus from 2001-2002 were included. A questionnaire was administered to collect data on age, sex, place of residence, associated autoimmune disorders, family history, clinical manifestations before onset and their duration, and biochemical parameters at diagnosis (glycemia, HbA1c, pH and bicarbonate).

RESULTS

A total of 109 children were diagnosed (48 girls and 61 boys). The annual incidence (per 100,000 pediatric inhabitants) was 17.6. A higher frequency was found in winter (33 %) and spring (26 %) than in autumn (21.3 %) and summer (20.3 %). Admissions were most frequent among 5-9 year-olds (40.3 %), followed by 10-14 year-olds (33 %) and 0-4 year-olds (26.6 %). The most frequent clinical manifestations were polyuria and polydipsia (95.8 %). Nycturia or enuresis and weight loss were also described. The mean duration of these symptoms was 25.4 days in the group of children aged between 10-14 years old, 21.7 days in those aged 5-9 years old and 13.6 days in those younger than 4 years old. In one-third of the patients, the initial presentation was ketoacidosis.

CONCLUSIONS

The incidence of type 1 diabetes mellitus among Galician children is high. The interval between the onset of the first symptoms and diagnosis is long. In 31.7 % of the patients, the initial event was ketoacidosis.