Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review

[An investigation of ketoacidosis in children with newly diagnosed type 1 diabetes]

OBJECTIVE

To investigate the incidence of diabetic ketoacidosis (DKA) in children with newly diagnosed type 1 diabetes.

METHODS

A retrospective analysis was performed for the clinical data of 224 children with newly diagnosed type 1 diabetes, and according to the presence or absence of DKA, these children were divided into DKA group and non-DKA group, with 112 children in each group. The DKA group was further divided into ≥5-year group (65 children) and <5-year group (47 children), and according to the blood gas parameters, this group was divided into mild group (26 children), moderate group (29 children), and severe group (57 children). The factors influencing the development of DKA were analyzed, as well as the clinical and laboratory features of DKA children with different ages.

RESULTS

The most common symptoms in these 224 children with type 1 diabetes were polydipsia (86.2%), polyuria (78.6%), and weight loss (57.1%). Compared with the non-DKA group, the DKA group had a significantly higher percentage of children who were aged <5 years, who had low family income, or whose parents had an educational level of senior high school or below. The DKA group had significantly higher levels of random blood glucose and HbA1C and significantly lower levels of pH, HCO3^-, and C-peptide than the non-DKA group (P<0.05). There was no significant difference in the percentage of children with severe DKA between the ≥5-year group and the <5-year group (P>0.05). Compared with the <5-year group, the ≥5-year group sufferred from symptoms for a significantly prolonged period, and had a significantly lower level of random blood glucose and significantly higher levels of HbA1C and C-peptide (P<0.05).

CONCLUSIONS

DKA has a high incidence rate in children with type 1 diabetes, and the development of DKA is associated with age, parents' educational level, and family income.

Spontaneous Dissemination in Neighboring Provinces of DKA Prevention Campaign Successfully Launched in Nineties in Parma's Province

Aim: to investigate how much effectiveness of the historical campaign of DKA prevention at T1D diagnosis has survived in Parma’s province where this was launched in Nineties, and how much it has spontaneously spread in the neighboring provinces. Method: children aged 6-14 years with newly diagnosed TID coming from province of Parma (Group 1) and from two other nearby provinces (Group 2) were investigated. Clinical and laboratory data were retrospectively collected from medical files of each patient and included age, gender, capillary pH, serum bicarbonate, 3-beta-hydroxybutyrate (3HB), glycated hemoglobin (HbAlc) at the time of admittance from 1st January 2012 and 31 December 2016. Results: no DKA condition was globally found in 25/36 patients (69.4%): 16/17 and 9/19 patients belonged to Group 1 and 2 respectively (p=0.002). Mild or moderate DKA was reported in 5.9% patients of Group 1 and in 47.31% (p=0.005) patients from Group 2. Severe DKA was observed in only 1 child from Group 2. Normal 3-beta-hydroxybutyrate (3HB) serum levels was reported in the 25 patients without DKA at diabetes diagnosis. Duration of hyperglycemia-related symptoms before overt T1D diagnosis was shorter (4.6±2.5 days) in patients with 3HB levels <1 mmol/dl than in those with 3HB levels exceeding 1 mmol/dl (9.6±4.2 days, p<0.0001). HbA1c values were on overage lower in patients without DKA (9.9±1.2%) than in patients with DKA at diabetes diagnosis (13.60±1.3%; p<0,001). Conclusion: 1) the campaign for DKA prevention, launched in Nineties and renewed at beginning of Twenties in Parma’s province, continues to be effective in the same province after several years; 2) in the two control provinces despite no information campaign being officially promoted in loco, an unexpected decrease in severe DKA incidence as well a shorter latency before overt T1D diagnosis were observed in the same period. (www.actabiomedica.it)

Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review

OBJECTIVES

To summarise incidence and prevalence of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D) for the overall patient population and different subgroups (age, sex, geographical region, ethnicity and type of insulin administration).

DESIGN

Systematic literature review (SLR).

DATA SOURCES

Medline (via PubMed) and Embase (1 January 2000 to 23 June 2016).

STUDY SELECTION

Peer-reviewed observational studies with reported data on the incidence or prevalence of DKA in T1D adults were included. A single reviewer completed the study screening and selection process and a second reviewer performed an additional screening of approximately 20% of the publications; two reviewers independently conducted the quality assessment; the results were narratively synthesised.

RESULTS

Out of 1082 articles, 19 met the inclusion and exclusion criteria, with two additional studies identified that did not specify the patient age range and are therefore not included in the SLR. Overall, eight studies reported incidence with a range of 0-56 per 1000 person-years (PYs), with one outlying study reporting an incidence of 263 per 1000 PYs. Eleven studies reported prevalence with a range of 0-128 per 1000 people. Prevalence of DKA decreased with increasing age. Subgroup analyses were performed using data from no more than two studies per subgroup. There was a higher prevalence of DKA reported in women, non-whites and patients treated with insulin injections compared with men, whites and patients using continuous subcutaneous insulin infusion pumps, respectively.

CONCLUSIONS

To our knowledge, this is the first SLR on the epidemiology of DKA in T1D adults. Despite an increasing prevalence of T1D in recent years, DKA in adults has been poorly characterised. In an era when the benefit-risk profiles of new antidiabetic therapies are being evaluated, including the potential risk of DKA, there is a clear need to better elucidate the expected rate of DKA among T1D adults.

Recognizing type 1 diabetes mellitus in children & adolescents

The common chief complaint of abdominal pain, nausea, and vomiting should prompt a broad differential diagnosis list. When a 17-year-old previously healthy male presented to a primary care clinic with these symptoms, it provoked a detailed workup and found a startling diagnosis of type 1 diabetes mellitus (T1DM). This article provides an overview of recognizing T1DM in children and adolescents with a thorough and diagnostic evaluation.

Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids

BACKGROUND

Pediatric diabetic ketoacidosis (DKA) is a disease associated with several complications that can be severe. One complication includes cerebral edema (CE), and patients may experience significant morbidity with this disease.

OBJECTIVE

This review evaluates the myths concerning CE in pediatric DKA including mechanism, presentation of edema, clinical assessment of dehydration, and association with intravenous (i.v.) fluids.

DISCUSSION

Multiple complications may occur in pediatric DKA. CE occurs in < 1% of pediatric DKA cases, though morbidity and mortality are severe without treatment. Several myths surround this disease. Subclinical CE is likely present in many patients with pediatric DKA, though severe disease is rare. A multitude of mechanisms likely account for development of CE, including vasogenic and cytotoxic causes. Clinical dehydration is difficult to assess. Literature has evaluated the association of fluid infusion with the development of CE, but most studies are retrospective, with no comparator groups. The few studies with comparisons suggest fluid infusion is not associated with DKA. Rather, the severity of DKA with higher blood urea nitrogen and greater acidosis contribute to CE. Multiple strategies for fluid replacement exist. A bolus of 10 mL/kg of i.v. fluid is likely safe, which can be repeated if hemodynamic status does not improve.

CONCLUSIONS

Pediatric CE in DKA is rare but severe. Multiple mechanisms result in this disease, and many patients experience subclinical CE. Intravenous fluids are likely not associated with development of CE, and 10-mL/kg or 20-mL/kg i.v. bolus is safe.

Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) remains a common medical emergency. Over the last few years, new national guidelines have changed the focus in managing the condition from being glucose-centered to ketone-centered. With the advent of advancing technology and the increasing use of hand-held, point-of-care ketone meters, greater emphasis is placed on making treatment decisions based on these readings. Furthermore, recent warnings about euglycemic DKA occurring in people with diabetes using sodium-glucose co-transporter 2 (SGLT-2) inhibitors urge clinicians to inform their patients of this condition and possible testing options. This review describes the reasons for a change in treating DKA, and outlines the benefits and limitations of using ketone readings, in particular highlighting the difference between urine and capillary readings.

Substantial reduction in hospital stay of children and adolescents with diabetic ketoacidosis after implementation of Clinical Practice Guidelines in a university hospital in Saudi Arabia

RATIONALE, AIMS AND OBJECTIVES

We aimed to determine the effect of Clinical Practice Guideline (CPG) implementation on length of hospital stay of children and adolescents with diabetic ketoacidosis (DKA).

METHODS

This was a 6-year (2008-2014) case-control retrospective study conducted at King Khalid University Hospital, Riyadh, that compared patients with DKA managed using CPG with those treated before CPG implementation.

RESULTS

There were 63 episodes of DKA in 41 patients managed using CPG compared with 40 episodes in 33 patients treated before implementation of CPG. Baseline characteristics of the 2 groups were similar (age, sex, newly diagnosed patients, recurrent DKA, DKA severity, and mean glycosylated hemoglobin). The mean length of hospital stay (±SD) was 68.6 ± 53.1 hours after implementation of CPG compared with 107.4 ± 65.6 hours before implementation (P < .001). The reduction in length of hospital stay equals to 1700 bed days saved per year per 1000 patients.

CONCLUSIONS

Implementation of CPG for DKA decreased the length of hospital stay.

Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most serious acute complications of type 1 diabetes (T1D) and the leading cause of morbidity and mortality in children with T1D. This study was aimed at assessing the prevalence and associated factors of DKA in children with newly diagnosed T1D in Addis Ababa.

METHODS

A hospital based cross-sectional study was conducted in selected hospitals in Addis Ababa. Children below the age of 12 years with DKA who were admitted to the pediatric ward in the selected hospitals between January 2009 and December 2014 and the residence of Addis Ababa were included. DKA was defined as children below the age of 12 years who have blood glucose level ≥250mg/dl, ketonuria, and ketonemia and diagnosed being T1D patient for the first time. Descriptive statistics was performed using frequency distribution, mean, median, tables, and graphs. Logistic regression analysis was used to identify independent factors associated with the prevalence of DKA in children with newly diagnosed T1D.

RESULTS

Of 395 DKA patients who were hospitalized during the five-year period, 142(35.8%) presented with DKA at first diagnosis of diabetes. On the other hand 253 (64.2%) children with DKA had longstanding T1D. Independent factors associated with DKA include: Age category 2-4.49years, 7-9.49 years and ≥9.5years (Adjusted odd ratio (AOR) = 3.14[1.21,8.06]), 3.44(1.39,8.49) and 4.02(1.68,9.60), respectively); parents' knowledge on the sign and symptoms of DKA (AOR = 0.51[0.27, 0.95]); sign and symptoms of DKA before the onset of DKA (AOR = 0.35[0.21, 0.59]) and infection prior to DKA onset (AOR = 3.45[1.97, 6.04]).

CONCLUSIONS

The overall proportion of children diagnosed with DKA and new onset of T1D in Addis Ababa was high. In particular, children between 9-12 years of age and children whose parents did not know the sign and symptoms of DKA had a high risk of DKA at primary diagnosis of T1D.

Optic Nerve and Cerebral Edema in the Course of Diabetic Ketoacidosis

In the recent years we have been observing an increased incidence of type 1 diabetes in children and adolescents. This leads to a more frequent acute complication of type 1 diabetes among children with hyperglycemia. The most common of these is diabetic ketoacidosis (DKA), while cerebral edema is the most dangerous. In children with DKA, cerebral edema most often presents with clinical symptoms but may also appear in the so-called "subclinical" form. That is why the search continues for new methods of assessing and monitoring cerebral edema in the course of DKA treatment. Ultrasonographic optic nerve sheath diameter (US ONSD) assessment is performed in various clinical scenarios when cerebral edema is suspected. It is most often performed in adult patients but increasingly often in children. US ONSD assessment is useful in the treatment of DKA in children with type 1 diabetes. This manuscript provides an overview of research results available in PubMed and other available databases on the course of treatment of DKA in children with type 1 diabetes.

High frequency of diabetic ketoacidosis at diagnosis of type 1 diabetes in Italian children: a nationwide longitudinal study, 2004-2013

This longitudinal population-based study analyses the frequency of diabetic ketoacidosis (DKA) at type 1 diabetes diagnosis in Italian children under 15 years of age, during 2004-2013. DKA was defined as absent (pH ≥ 7.30), mild/moderate (7.1 ≤ pH < 7.30) and severe (pH < 7.1). Two multiple logistic regression models were used to evaluate the time trend of DKA frequency considered as present versus absent and severe versus absent, adjusted for gender, age group and geographical area of residence at diagnosis. Overall, 9,040 cases were ascertained. DKA frequency was 40.3% (95%CI: 39.3-41.4%), with 29.1% and 11.2% for mild/moderate and severe DKA, respectively. Severe DKA increased significantly during the period (OR = 1.03, 95%CI: 1.003-1.05). Younger-age children and children living in Southern Italy compared to Central Italy were at significantly higher risk of DKA and severe DKA. Family history of type 1 diabetes and residence in Sardinia compared to Central Italy were significantly associated with a lower probability of DKA and severe DKA. The high frequency of ketoacidosis in Italy over time and high variability among age groups and geographical area of residence, strongly suggests a continuing need for nationwide healthcare strategies to increase awareness of early detection of diabetes.

Clinical presentation and memory function in youth with type 1 diabetes

OBJECTIVE

While cerebral edema and diabetic ketoacidosis (DKA) in type 1 diabetes (T1DM) have well-described acute effects on cognition, little is known about the impact of clinical presentation on longer term cognitive outcomes. We hypothesized that clinical factors (degree of hyperglycemia exposure and DKA) at the time of diagnosis would relate to cognition within 3.5 months later in children with T1DM.

METHODS

Cognitive testing was performed on children 7-17 years old with T1DM (n = 66) within 3.5 months of diagnosis and siblings without T1DM (n = 33). Overall intelligence, processing speed, and memory (including a sensitive long-delay spatial memory test; spatial delayed response or SDR) were assessed. Medical records were reviewed for hemoglobin A1c (HbA1c), DKA status, and other clinical factors at diagnosis.

RESULTS

Within the group with T1DM, 17 children presented in DKA and 49 did not. After adjusting for age, gender, and socioeconomic status, the subgroup with T1DM and DKA at diagnosis performed worse on the long-delay SDR task compared to sibling controls (p = 0.006). In addition, within the group with T1DM, higher HbA1c at diagnosis was associated with worse performance on the long-delay SDR task (p = 0.027). Performance on the other cognitive tasks was not different across groups or subgroups.

CONCLUSIONS

DKA and degree of hyperglycemia exposure at diagnosis have implications for long-delay spatial memory function within 3.5 months of diagnosis. These findings suggest that early detection of T1DM, which decreases risk for prolonged exposure to hyperglycemia and DKA, may avoid negative effects on memory function.

Ketoacidosis at first presentation of type 1 diabetes mellitus among children: a study from Kuwait

We examined the frequency and severity of diabetic ketoacidosis (DKA) in 679 children and adolescents (0-14 years) at diagnosis of Type 1 Diabetes Mellitus (T1DM) in Kuwait. Between 1(st) January 2011 and 31(st) December 2013, all newly diagnosed children with diabetes were registered prospectively in a population-based electronic register. DKA was diagnosed using standard criteria based on the levels of venous pH and serum bicarbonate. At the time of diagnosis, mild/moderate DKA was present in 24.8% of the children, while severe DKA was present in 8.8%. Incidence of ketoacidosis was significantly higher in young children less than 2 (60.7% vs 32.4% p = <0.005) compared to children 2-14 years old, and a higher proportion presented with severe DKA (21.4% vs 8.3% p = <0.05). No association was seen with gender. Significant differences were found in the incidence of DKA between Kuwaiti and non-Kuwaiti children (31.1% vs 39.8%; p < 0.05). Family history of diabetes had a protective effect on the occurrence of DKA (OR = 0.44; 95% CI = 0.27-0.71). Incidence of DKA in children at presentation of T1DM remains high at 33.6%. Prevention campaigns are needed to increase public awareness among health care providers, parents and school teachers in Kuwait.

Epidemiology of diabetic ketoacidosis in Arab patients with type 1 diabetes: a systematic review

AIMS

Diabetic ketoacidosis (DKA) is an acute and risky complication of type 1 diabetes. The aim of this study is to build the overall rate of DKA in Arab patients with type 1 diabetes in the 22 Arab nations. This is expected to tailor the healthcare approaches in Arab countries where attention is needed to save lives from the devastating consequences of DKA.

METHODS

The study here is a quantitative analysis of the articles indexed in four different scientific literature databases: Web of Science, PubMed, Science Direct and Scopus, from inception to June 2015. Arab patients with type 1 diabetes who presented with DKA have been captured. Key information was possible to extract for patients belong to only 12 Arab countries out of the 22 Arab patients.

RESULTS

Twenty-nine studies in 12 different Arab countries captured 4,688 type 1 diabetes patients with overall rates of 46.7% patients presented with DKA, ranging from a low of 17% in Egypt to a high of 100% in Morocco, Algeria and Tunisia.

CONCLUSION

This is the first descriptive quantitative study to determine the overall DKA rate in 46 years of studies in the Arab world of patients with type 1 diabetes; DKA rates were found to range from 17% to 100% with overall rate of 46.7%.

High Frequency of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes

AIM

The aim of this study was to evaluate the incidence of diabetic ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes in 2006-2007 and 2013-2014.

METHOD

The study group consisted of 426 children aged 0-18 years with type 1 diabetes onset admitted to our hospital in 2006-2007 (group A) and 2013-2014 (group B). The study comprised the analysis of medical and laboratory records from patients' medical charts and the electronic database.

RESULTS

There was no difference between groups A and B in the percentage of children admitted with diabetic ketoacidosis (25% versus 28%, resp., P = 0.499). Among children with diabetic ketoacidosis, severe metabolic decompensation (pH < 7.1) appeared in similar frequency in groups A and B (28% versus 30%, resp., P = 0.110). In group B, children with diabetic ketoacidosis were statistically younger compared to patients without ketoacidosis (P = 0.015) and had higher HbA1c levels (P = 0.006). In both groups, a 2-fold increase in diabetic ketoacidosis was noted in children under the age of 3, compared to overall frequency.

CONCLUSION

No decrease in diabetic ketoacidosis has been noted in the recent years. Although the prevalence and severity of diabetic ketoacidosis remain stable, they are unacceptably high. The youngest children are especially prone to ketoacidosis.

A Multicenter Retrospective Survey regarding Diabetic Ketoacidosis Management in Italian Children with Type 1 Diabetes

We conducted a retrospective survey in pediatric centers belonging to the Italian Society for Pediatric Diabetology and Endocrinology. The following data were collected for all new-onset diabetes patients aged 0–18 years: DKA (pH < 7.30), severe DKA (pH < 7.1), DKA in preschool children, DKA treatment according to ISPAD protocol, type of rehydrating solution used, bicarbonates use, and amount of insulin infused. Records (n = 2453) of children with newly diagnosed diabetes were collected from 68/77 centers (87%), 39 of which are tertiary referral centers, the majority of whom (n = 1536, 89.4%) were diagnosed in the tertiary referral centers. DKA was observed in 38.5% and severe DKA in 10.3%. Considering preschool children, DKA was observed in 72%, and severe DKA in 16.7%. Cerebral edema following DKA treatment was observed in 5 (0.5%). DKA treatment according to ISPAD guidelines was adopted in 68% of the centers. In the first 2 hours, rehydration was started with normal saline in all centers, but with different amount. Bicarbonate was quite never been used. Insulin was infused starting from third hour at the rate of 0.05–0.1 U/kg/h in 72% of centers. Despite prevention campaign, DKA is still observed in Italian children at onset, with significant variability in DKA treatment, underlying the need to share guidelines among centers.

Type 1 Diabetes Among East African Immigrant and Nonimmigrant Black Youth in the U.S

Type 1 diabetes has not previously been described in East African immigrant youth in the United States. The purpose of this study was to compare East African immigrant and nonimmigrant Black youth with type 1 diabetes. Among other clinical and demographic differences, estimated prevalence of type 1 diabetes was nearly four times higher among East African youth in King County, Washington (6.20/1000, 95% confidence interval (CI) [4.49, 7.91] vs. 1.56/1000, 95% CI [1.03, 2.09]) compared to nonimmigrant Black youth. These observations are lost within the Black/African American race classification and additional work is needed to confirm and further explore these findings.

Preventing Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a major cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). This article examines the factors associated with DKA in children with T1DM, both at first presentation and in recurrent cases. The challenge for future research is to find effective ways to improve primary care physician and general community awareness of T1DM to reduce DKA at presentation and develop practical, cost-effective programs to reduce recurrent DKA.

Care of diabetes in children and adolescents: controversies, changes, and consensus

Diabetes is one of the most common chronic medical disorders in children. The management of diabetes remains a substantial burden on children with diabetes and their families, despite improvements in treatment and rates of morbidity and mortality. Although most children with diabetes have type 1 diabetes, the increasing recognition of type 2 diabetes and genetic forms of diabetes in the paediatric population has important treatment implications. Diabetes therapy focuses strongly on targets for good metabolic control to reduce the risk of long-term complications. A parallel goal is to minimise short-term complications of hypoglycaemia and diabetic ketoacidosis. Technology offers opportunity for improvement in care, but has not yet fully lived up to its potential. New insights into the pathogenesis of diabetes and the development of new therapies have led to clinical trials aimed at the prevention of diabetes.

15-year incidence of diabetic ketoacidosis at onset of type 1 diabetes in children from a regional setting (Auckland, New Zealand)

We assessed the incidence of diabetic ketoacidosis (DKA) in children aged <15 years with newly diagnosed type 1 diabetes mellitus (T1DM) in the Auckland Region (New Zealand) in 1999–2013, in a retrospective review of a complete regional cohort. DKA and its severity were classified according to ISPAD 2014 guidelines. Of 730 children presenting with new-onset T1DM over the 15-year time period, 195 cases had DKA of any severity (27%). There was no change in the incidence of DKA or the proportion of children with severe DKA at presentation. The incidence of DKA among children aged <2.0 years (n = 40) was 53% compared to 25% for those aged 2–14 years (n = 690; p = 0.005). In children aged 2–14 years, increasing age at diagnosis was associated with greater likelihood of DKA at presentation (p = 0.025), with the odds of DKA increasing 1.06 times with each year increase in age. Non-Europeans were more likely to present in DKA than New Zealand Europeans (OR 1.52; p = 0.048). Despite a consistent secular trend of increasing incidence of T1DM, there was no reduction in the incidence of DKA in new-onset T1DM in the Auckland Region over time. Thus, it is important to explore ways to reduce DKA risk.

Increased risk of severe diabetic ketoacidosis among Jewish ultra-orthodox children

AIMS

Diabetic ketoacidosis (DKA) at diabetes diagnosis is a dangerous yet potentially preventable condition. Young age, low socioeconomic status, and low parental education have been found to be associated with increased risk of DKA. We aimed to evaluate the impact of religious affiliation on presentation with DKA at type 1 diabetes mellitus (T1DM) diagnosis in Jewish children.

METHODS

The study comprised an analysis of medical records of all consecutive patients with new-onset T1DM who were admitted to one tertiary medical center from January 2007 to January 2014. DKA was defined as venous pH <7.3 or HCO3(-) < 15 mmol/l, and severe DKA as pH <7.1 or HCO3(-) < 5 mmol/l.

RESULTS

Of 81 patients with new-onset T1DM (38 females, mean ± SD age at diagnosis 9.9 ± 4.2 years), 34 (42 %) presented with DKA: 21 of 60 (35 %) of patients from secular families and 13 of 21 (62 %) from ultra-orthodox families. Children from ultra-orthodox families had a 3.5-fold increased risk of presenting with DKA than children from secular families (95 % CI 1.2-10.1, p = 0.02) and a 3.8-fold risk to be admitted with severe DKA (95 % CI 1.1-12.6, p = 0.02). Other factors that were found to be associated with an increased risk of DKA were younger age, an absence of maternal academic education, and residence in an area of low socioeconomic status.

CONCLUSIONS

DKA and severe DKA at diabetes diagnosis were more common among religious ultra-orthodox than among secular Jewish children. Awareness of the symptoms and dangers of DKA in new-onset T1DM should be directed to particularly high-risk population groups.

The pathway to diagnosis of type 1 diabetes in children: a questionnaire study

OBJECTIVE

To explore the pathway to diagnosis of type 1 diabetes (T1D) in children.

DESIGN

Questionnaire completed by parents.

PARTICIPANTS

Parents of children aged 1 month to 16 years diagnosed with T1D within the previous 3 months.

SETTING

Children and parents from 11 hospitals within the East of England.

RESULTS

88/164 (54%) invited families returned the questionnaire. Children had mean±SD age of 9.41±4.5 years. 35 (39.8%) presented with diabetic ketoacidosis at diagnosis. The most common symptoms were polydipsia (97.7%), polyuria (83.9%), tiredness (75.9%), nocturia (73.6%) and weight loss (64.4%) and all children presented with at least one of those symptoms. The time from symptom onset to diagnosis ranged from 2 to 315 days (median 25 days). Most of this was the appraisal interval from symptom onset until perceiving the need to seek medical advice. Access to healthcare was good but one in five children presenting to primary care were not diagnosed at first encounter, most commonly due to waiting for fasting blood tests or alternative diagnoses. Children diagnosed at first consultation had a shorter duration of symptoms (p=0.022) and children whose parents suspected the diagnosis were 1.3 times more likely (relative risk (RR) 1.3, 95% CI 1.02 to 1.67) to be diagnosed at first consultation.

CONCLUSIONS

Children present with the known symptoms of T1D but there is considerable scope to improve the diagnostic pathway. Future interventions targeted at parents need to address the tendency of parents to find alternative explanations for symptoms and the perceived barriers to access, in addition to symptom awareness.

[Diabetic ketoacidosis in children: hospital experience. A 15-year retrospective study]

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the major complications of diabetes mellitus (DM). The objective of this report was to highlight the clinical and laboratory importance in the treatment of patients with DKA during a 15-year period treated at the Hospital Infantil del Estado de Sonora (HIES).

METHODS

We retrospectively reviewed 140 patients with episodes of DKA to report clinical and laboratory features, mortality, and treatment with HIES protocol.

RESULTS

Mortality was 0%. Using descriptive statistics we observed minimal complications without neurologic sequelae in three patients with cerebral edema.

CONCLUSIONS

The HIES protocol is a practical and effective electrolyte and acid-base treatment for DKA.

Frequency and associated risk factors of recurrent diabetic ketoacidosis among Saudi adolescents with type 1 diabetes mellitus

OBJECTIVES

To explore the frequency and associated risk factors of recurrent diabetic ketoacidosis (RDKA) among Saudi adolescents with type 1 diabetes mellitus (T1DM).

METHODS

A cross-sectional study was conducted among 103 T1DM adolescents (aged 13-18 years, 57 males) who were hospitalized for diabetic ketoacidosis (DKA) between January 2013 and May 2014 at Prince Sultan Military Medical City (PSMMC), Riyadh, Kingdom of Saudi Arabia. The respondents were purposively, conveniently selected, and interviewed using a structured Arabic questionnaire including clinical information and demographics.

RESULTS

Fifty-six participants had experienced one episode of DKA, 41 had 2 episodes, and 6 had ≥3 episodes. Compared with adolescents who had hemoglobin A1c (HbA1c) ≤9, mean difference in RDKA was found among adolescents with &gt;9 HbA1c. Similarly, adolescents who stopped insulin and those with lipodystrophy at the injection site had a higher frequency of RDKA. Discontinuing insulin (67%) was the major reason for RDKA followed by infection (31%). Among adolescents who discontinued insulin treatment, 31 (46.3%) gave no reason for stopping, 25 (37.3%) reported feeling sick, 7 (10.4%) gave a combination of reasons, and 4 (6%) reported a lack of supplies or other reasons. Regression analysis revealed that a higher HbA1c level and the presence of lipodystrophy were independent risk factors for RDKA.

CONCLUSION

The frequency of RDKA was significantly greater in the T1DM adolescents with a higher HbA1c level, lipodystrophy, and those who had discontinued insulin treatment. Comprehensive multidisciplinary diabetes education should be offered to control modifiable risk factors in these patients.

Precipitating factors, outcomes, and recurrence of diabetic ketoacidosis at a university hospital in Damascus

AIMS

To study precipitating factors, outcomes, and recurrence of diabetic ketoacidosis (DKA) at a University hospital at Damascus, the capital of Syria.

PATIENTS AND METHODS

Medical records between 2006 and 2012 were reviewed. One hundred and fifteen admissions for 100 patients with DKA were included. All fulfilled the American Diabetic Association DKA diagnostic criteria.

RESULTS

Of 115 admissions of DKA, there were 92 single admission and 23 recurrent admissions (eight patients). The order of precipitating factors of recurrent DKA or single admissions were the same with different percentage. The first and second factors were infection (74% and 48%) and treatment problems (17% and 24%), respectively. Complications rate was significantly higher in the intensive care unit (41.6%), compared to the ward admissions (14.2%). Overall in-hospital mortality rate was 11.3%. The severity of medical conditions that provoke DKA with aging, not the metabolic complications of hyperglycemia or ketoacidosis, were behind this high mortality rate. Patients who died were significantly (P = 0.004) older than patients who were discharged alive.

CONCLUSION

Results concerning precipitating factor were similar to the results of many other studies. However, mortality rate was higher which might be explained by the severity of underlying precipitating illness.

Future challenges for pediatric diabetes management in developing countries: lessons from Africa

In this review, we describe the epidemiology of diabetes mellitus in children and adolescents in Africa, noting that there is a paucity of data with regard to the burden of disease, prevalence of undiagnosed diabetes, healthcare and acute and chronic complications. Furthermore, access to care remains an issue of great concern. Our view is that in the next 5 years, more research will be undertaken on the burden of the disease and on interventions to provide better access to care. While the majority of African countries still have a low incidence of diabetes in children, it is predicted that the incidence will increase and it is therefore essential that governments develop sustainable policies to deal with such increases.

Identifying targets to reduce the incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes in the UK

BACKGROUND

Diabetic ketoacidosis (DKA) is the leading cause of mortality in childhood diabetes, and at diagnosis might represent delayed presentation. The extent and reasons for delays are unclear, but identifying and targeting factors associated with DKA could reduce this incidence.

OBJECTIVE

To compare the patient pathway before diagnosis of type 1 diabetes mellitus (T1DM) in children presenting with DKA and non-acidotic hyperglycaemia.

DESIGN, SETTING AND PATIENTS

Over a 3-month period, children newly diagnosed with T1DM were identified on admission to UK hospitals. Parents and medical teams completed a questionnaire about events before diagnosis.

RESULTS

Data were available for 261 children (54% male), median age 10.3y (range 0.8-16.6 y). 25% presented with DKA, but more commonly in children <2y (80% vs 23%, p<0.001). Fewer children with DKA reported polyuria (76% vs 86%) or polydipsia (86% vs 94%) (both p<0.05), but more reported fatigue (74% vs 52%) and weight loss (75% vs 54%) (both p<0.01). 24% of children had multiple healthcare professional (HCP) contacts, and these children had lower pH on admission. 46% of children with a delayed presentation to secondary care had non-urgent investigations. 64% of parents had considered a diagnosis of diabetes, and these children were less likely to present with DKA (13% vs 47%, p<0.001).

CONCLUSIONS

Multiple HCP contacts increased risk of presentation in DKA, whereas, parental awareness of diabetes was protective. Improved public and health professional education targeting non-classical symptoms, awareness of diabetes in under 2 y, and point-of-care testing could reduce DKA at diagnosis of diabetes.

Demographic and clinical characteristics of type 1 diabetes mellitus in omani children - single center experience

OBJECTIVES

To describe the demographic characteristics and clinical presentation of Omani children with type 1 diabetes mellitus at Sultan Qaboos University Hospital, Muscat, Oman.

METHODS

A retrospective analysis of all children with type 1 diabetes mellitus attending the Pediatric Endocrine Unit at Sultan Qaboos University Hospital, Oman from June 2006 to May 2013.

RESULTS

One hundred and forty-four patients were included in the study. The mean±SD of age at diagnosis was 6.7 ± 3.7 years. The median duration of symptoms was 10 days (IQR; 5-14). The most commonly reported presenting symptoms were polyuria (94%), polydipsia (82%), and weight loss (59%). Diabetic ketoacidosis at initial presentation was diagnosed in 31% of the patients. Different insulin regimens were prescribed: multiple daily injections in 109 (76%) patients, twice daily insulin regimen in 23 (16%) patients, and insulin pump therapy in 12 (8%) patients. Family history of type 1 diabetes mellitus was present in 31 (22%) patients. There were no significant differences in presenting complaints (polyuria, p=0.182; polydipsia, p=0.848), duration of symptoms (p=0.331), reported weight loss (p=0.753), or diabetic ketoacidosis at presentation (p=0.608) between patients with and without family history of type 1 diabetes mellitus.

CONCLUSION

Polyuria, polydipsia and weight loss are the most common presenting symptoms. Family history of type 1 diabetes mellitus is highly prevalent among the studied patients. Diabetic ketoacidosis was found to be less common in Oman compared to other diabetes centers in the Middle East.

Diabetes in North America and the Caribbean: an update

The North America and Caribbean (NAC) Region faces a high burden of diabetes. In 2013, the number of children (aged 0-14 years) with type 1 diabetes was 108,600, with 16.7 new cases diagnosed per 100,000 children. Furthermore, there were 36,755,500 individuals with diabetes (mostly type 2 diabetes) in adults (20-79 years), and an additional 44,277,700 individuals had impaired glucose tolerance. The age-adjusted prevalence of diabetes in adults was 9.6%; the second highest among the seven Regions of the International Diabetes Federation. This estimate is expected to grow to 9.9% by 2035. There was some heterogeneity in the estimates within the Region with the age-adjusted prevalence for the USA estimated at 9.2%, 7.9% for Canada, 12.6% for Mexico, and 9.6% for the Caribbean islands. Mortality due to diabetes in the NAC Region is not limited to older age groups, with 37.6% of deaths occurring in people under the age of 60. The economic impact was also enormous, with healthcare expenditure due to diabetes estimated at 263.2 billion USD for 2013 - the highest of all IDF Regions. Diabetes threatens the public health and economies of countries in the NAC Region, and efforts in prevention and management must be intensified in order to surmount this growing problem.

Incidence of and mortality from Type I diabetes in Taiwan from 1999 through 2010: a nationwide cohort study

Objective

To evaluate the secular trend in incidence of and mortality from Type 1 diabetes mellitus (T1DM) in Taiwan, 1999–2010.

Methods

All 7,225 incident cases of T1DM were retrospectively retrieved from Taiwan's National Health Insurance Research Database from 1999 to 2010. Trend of bi-annual age- and sex-specific incidence rates of T1DM was calculated and tested with Poisson regression model. Standardized mortality ratios (SMRs) were calculated, using age-, sex-, and calendar years-specific mortality rates of the general population as the reference, to estimate the relative mortality risk of T1DM.

Results

The number of male and female T1DM was 3,471 (48%) and 3,754 (52%), respectively. The annual number of incident T1DM increased from 543 in 1999 to 737 in 2010. The overall bi-annual incidence rate rose from 1999–00 to 2003–04 and mildly declined thereafter rose to 2009–10, with an insignificant trend (P = 0.489) over the study period. Regardless of gender, the higher age-specific incidence rate was noted in the younger groups (<30 years) and highest at <15 years. The incidence rates in younger groups were constantly higher in female population than in male one. The SMR from all causes was significantly increased at 3.00 (95% Confidence Interval (CI) 2.83–3.16) in patients with T1DM. The sex-specific SMR was 2.66 (95% CI 2.46–2.85) and 3.58 (95% CI 3.28–3.87) for male and female patients, respectively. For both sexes, the age-specific SMR peaked at 15–29 years.

Conclusions

Among T1DM patients in Taiwan, there were significant increasing trends in males and female aged <15 years. We also noted a significantly increased overall and sex-specific SMR from all causes in patients with TIDM which suggests a need for improvements in treatment and care of patients with T1DM.

'Looking for the needle in the haystack': a qualitative study of the pathway to diagnosis of type 1 diabetes in children

OBJECTIVE

To explore the pathway to diagnosis of type 1 diabetes (T1D) in children from the perspective of the child, family and general practitioner (GP).

DESIGN

Qualitative interview study.

PARTICIPANTS

Parents of children aged 1 month to 16 years diagnosed with new onset T1D within the previous 3 months, children over 6 years diagnosed with new onset T1D within the previous 3 months and GPs who saw those children prior to diagnosis.

SETTING

Children and parents were identified and recruited from two hospitals within the East of England.

RESULTS

The parents of 16 children (2-16 years) were interviewed. The total interval from onset of symptoms to diagnosis ranged from 6 to 127 days. The appraisal interval was the longest for almost all children and the diagnostic interval the shortest. Even with some knowledge of T1D, it took many parents several weeks of a complex cyclical and iterative decision-making process and often a physical trigger, such as weight loss, to decide to consult a healthcare professional. By that stage, many had already made or suspected the diagnosis of T1D themselves. Five GPs were interviewed. They felt that the main challenges to diagnosing T1D in children were the rarity of the condition coupled with how well most of the children appeared, and the difficulty in obtaining urine or blood samples from children.

CONCLUSIONS

This study highlights the difficulties for parents and GPs in recognising the early symptoms of T1D. It suggests that future interventions should be targeted at parents in the appraisal interval and include the importance of timely presentation to a healthcare professional and the differences between types 1 and 2 diabetes. Primary care physicians should also take parental concerns seriously and do urine dipstick tests during the consultation for children with symptoms of T1D.

Ketoacidosis at presentation of type 1 diabetes mellitus in children: a retrospective 20-year experience from a tertiary care hospital in Serbia

Diabetic ketoacidosis (DKA) has significant morbidity and mortality and is common at diagnosis in children. The aim of this study was to determine the frequency and clinical characteristics of DKA over a 20-year period among children diagnosed with type 1 diabetes mellitus (T1DM) at University children's hospital in Belgrade, Serbia. The study population comprised of 720 patients (366 boys) diagnosed with type 1 diabetes aged <18 years between January 1992 and December 2011. Of all patients diagnosed with T1DM, 237 (32.9 %) presented with DKA. The majority had either mild (69.6 %) or moderate (22.8 %) DKA. Sixty (55.0 %) of all children under 5 years had DKA compared to sixty-two (20.9 %) in the 5- to 10-year-old group and one hundred fifteen (36.6 %) in the 11- to 18-year-old patients (p<0.01), while 2.5 % of the entire DKA cohort were in real coma. During the later 10-year period, children less often had DKA at diagnosis compared with the earlier 10-year period (28.0 vs. 37.4 %) (p<0.01), but the frequency of severe DKA was higher in the age group <5 year and in the age group >11 year during 2002-2011, compared with the earlier 10-year period (12.9 vs. 3.4 %, p<0.01 and 17.1 vs. 3.8 %, p<0.01).

CONCLUSION

The overall frequency of DKA in children with newly diagnosed type 1 diabetes decreased over a 20-year period at our hospital. However, children aged <5 years and adolescents are still at high risk for DKA at diagnosis.

Diabetic ketoacidosis at diagnosis in Austrian children: a population-based analysis, 1989-2011

OBJECTIVE

To analyze the effect of a community-based, poster-focused prevention program on the frequency of diabetic ketoacidosis (DKA) at diabetes onset in Austria.

STUDY DESIGN

All newly diagnosed patients with diabetes ≤ 15 years of age were registered prospectively by the Austrian Diabetes Incidence Study Group. Registered data included initial blood glucose, pH, and ketonuria. DKA was defined as pH < 7.3 and severe DKA as pH < 7.1. Data between 1989 and 2011 were available. In autumn, 2009, a community-based prevention program similar to the Parma Campaign, in which posters were dispensed broadly, was initiated. The frequency of DKA at the onset of diabetes in the years 2005-2009 and 2010-2011 was compared.

RESULTS

During the study period, 4038 children were registered. A total of 37.2% presented with DKA; 26% had a mild and 11.2% a severe form. The frequency of DKA was negatively associated with age at onset. In the years before the intervention program, 26% had mild DKA compared with 27% after the intervention (not significant). The prevalence of severe DKA in the years before the campaign was 12% compared with 9.5% thereafter (not significant). No significant change in the DKA rate at onset by the prevention program could be found when we compared age groups <5, 5 to <10, and 10 to <15 years, neither for mild nor for severe DKA.

CONCLUSION

The frequency of DKA in children with newly diagnosed type 1 diabetes in Austria is high and did not change despite the efforts of a community-based information program.

Factors associated with diabetic ketoacidosis at onset of Type 1 diabetes in children and adolescents

AIMS

To identify risk factors for diabetic ketoacidosis at diagnosis of Type 1 diabetes in children and adolescents.

METHODS

In three time periods (1986-1987, 1996-1997 and 2006-2007) 75, 86 and 245 patients, respectively, aged < 20 years were newly diagnosed with Type 1 diabetes in one tertiary care centre. In this retrospective comparative study, data of clinical characteristics, laboratory evaluation at diagnosis, as well as demographic data were retrieved from the patients' files. Comparative analyses were performed between patients presenting with or without diabetic ketoacidosis and between the three time periods.

RESULTS

Patients presenting with diabetic ketoacidosis were younger (9.2 ± 4.7 vs. 10.4 ± 4.7 years; P < 0.02), thinner (weight standard deviation score -0.59 ± 1.2 vs. -0.25 ± 1.1; P = 0.002) and less frequently had a first- and/or second-degree relative with Type 1 diabetes compared with those without diabetic ketoacidosis at presentation (16.0 vs. 31.2%, respectively; P = 0.001). Children with diabetic ketoacidosis were less likely to have had relevant testing before diagnosis than children without diabetic ketoacidosis. Children aged < 2 years presented more often with diabetic ketoacidosis than the older children (85 vs. 32%; P < 0.001). Children of Ethiopian origin had a higher rate of diabetic ketoacidosis at diagnosis than the rest of the cohort (57.8 vs. 33%; P = 0.04).

CONCLUSIONS

Factors affecting the risk of developing diabetic ketoacidosis at diagnosis of Type 1 diabetes may be related to the degree of awareness of symptoms of diabetes among parents and primary care physicians. Prevention programmes should aim at increasing awareness and consider the application of special measures to avoid diabetic ketoacidosis in children aged < 2 years and high-risk ethnic groups.

Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial

Treatment protocols for pediatric diabetic ketoacidosis (DKA) vary considerably among centers in the USA and worldwide. The optimal protocol for intravenous (IV) fluid administration is an area of particular controversy, mainly in regard to possible associations between rates of IV fluid infusion and the development of cerebral edema (CE), the most common and the most feared complication of DKA in children. Theoretical concerns about associations between osmotic fluid shifts and CE have prompted recommendations for conservative fluid infusion during DKA. However, recent data suggest that cerebral hypoperfusion may play a role in cerebral injury associated with DKA. Currently, there are no existing data from prospective clinical trials to determine the optimal fluid treatment protocol for pediatric DKA. The Pediatric Emergency Care Applied Research Network FLUID (FLuid therapies Under Investigation in DKA) study is the first prospective randomized trial to evaluate fluid regimens for pediatric DKA. This 13-center nationwide factorial design study will evaluate the effects of rehydration rate and fluid sodium content on neurological status during DKA treatment, the frequency of clinically overt CE and long-term neurocognitive outcomes following DKA.

Diabetic ketoacidosis in the pediatric emergency department

Despite many advances, the incidence of pediatric-onset diabetes and diabetic ketoacidosis (DKA) is increasing. Diabetes mellitus is 1 of the most common chronic pediatric illnesses and, along with DKA, is associated with significant cost and morbidity. DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment involves fluid resuscitation with insulin and electrolyte replacement under constant monitoring for cerebral edema. When DKA is recognized and treated immediately, the prognosis is excellent. However, when a patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral edema, the results can be devastating.