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

Treatment Outcome and Associated Factors among Type 1 Diabetic Children Admitted with DKA in Bahir Dar City Public Referral Hospital, Northwest, Ethiopia: A Cross-sectional Study

Background. Outcomes that should be measured during diabetic ketoacidosis management is crucial. However, data associated to this was limited in Ethiopia. Methods. A cross-sectional study was conducted among children with diabetic keto acidosis between 2016 and 2021.Data were stored in Epi-data version 4.6 and exported into STATA 14.0 software for analysis. The association between independent variables and length of hospital stay was assessed using binary logistic regression. Finally, variables with P-value <.05 were considered statistically significant. Result. Median length of hospital stay was 8 ± 6.2 days. Majority of patients (97.5%) improved and discharged. Factors that affected longer hospital stay were Residence(aOR = 4.31;95% CI = 1.25-14.80),family history of diabetes (aOR = 0.12; 95% CI = 0.02-0.64), glycemia at admission (aOR = 1.01; 95% CI = 1.00-1.02),insulin skipping (aOR = 0.08; 95% CI = 0.01-0.98), abdominal pain (aOR = 4.28; 95% CI = 1.11-15.52) and time in which the patient get out of diabetic ketoacidosis(aOR = 6.39; 95% CI = 1.09-37.50). Conclusion. Majority of patients showed improvement and discharged to homes after a long hospital stay. Majority of patients resolved from diabetic ketoacidosis between 24 and 48 hours.

Predictors of the clinical severity of T1DM presentation at diagnosis in children and adolescents with type 1 diabetes mellitus (T1DM)

PURPOSE

We aimed to assess factors associated with the presence and severity of ketoacidosis (DKA) at pediatric type 1 diabetes (T1DM) diagnosis, in relation to pancreatic, associated and familial autoimmunity.

METHODS

Antibodies against pancreatic beta-cells, organ specific autoantibodies (thyroid, celiac, and parietal) and family history of autoimmunity were retrospectively evaluated in 116 T1DM patients aged 11.9 ± 4.6 (mean ± SD) years, with disease duration 7.62 ± 3.67 years (mean ± SD).

RESULTS

Most patients (67.2%) presented with DKA at diagnosis. Younger children (< 2 years) had tenfold risk of DKA, compared to older children (12.1-15 years) (OR = 10.8, 95% CI: 1.0-116.9, P = 0.05). Fasting c-peptide levels were lower in the DKA group (OR = 0.26, 95% CI = 0.07-0.89, P = 0.033). The number of anti-pancreatic antibodies at disease onset did not show any significant correlations with the presence (p = 0.889) or severity of DKA (p = 0.863). All patients with multiple autoimmunity (> 2 autoimmune diseases plus T1DM) presented with DKA. Familial autoimmunity acted protectively against DKA manifestation (OR = 0.40, 95% CI = 0.16-1.0, P = 0.051).

CONCLUSIONS

Among newly diagnosed T1DM patients, 67.2% presented with DKA. Younger age, lower c-peptide and the presence of associated autoimmunity were predictive factors of the presence and severity of DKA at diagnosis. High degree of suspicion, due to family history, may prevent DKA development and severity.

Disordered eating behaviours in adolescents with type 1 diabetes can be influenced by their weight at diagnosis and rapid weight gain subsequently

AIMS

To assess the prevalence and disease-related risk factors for disordered eating behaviours among adolescents with type 1 diabetes and also to search for risk factors at disease diagnosis that can predict the development of disordered eating behaviours.

METHODS

A retrospective observational study of 291 adolescents aged 15-19 years with type 1 diabetes who completed the Diabetes Eating Problem Survey-Revised (DEPS-R) as is routine in our diabetes clinic. The prevalence of disordered eating behaviours and risk factors for their development was assessed.

RESULTS

In 84 (28.9%) adolescents, disordered eating behaviours were found. Disordered eating behaviours were positively associated with female sex (β = 3.01 [SE = 0.97], p = 0.002), higher BMI-Z score (β = 2.08 [SE = 0.49], p < 0.001), higher HbA1c (β = 0.19 [SE = 0.03], p < 0.001) and treatment with multiple daily injections of insulin (β = 2.19 [SE = 1.02], p = 0.032). At type 1 diabetes diagnosis, higher BMI-Z score (β = 1.54 [SE = 0.63], p = 0.016) for those diagnosed before age 13 years and increased weight gain at 3 months post-diagnosis (β = 0.88 [SE = 0.25], p = 0.001) in females diagnosed at age 13 years or older were found to be risk factors for disordered eating behaviours.

CONCLUSIONS

Disordered eating behaviours are common among adolescents with type 1 diabetes and are associated with various parameters, including BMI at diagnosis and the rate of weight gain at 3 months post-diagnosis in females. Our findings highlight the need for early preventive efforts for disordered eating behaviours and interventions to avoid late diabetes complications.

The role of anion gap normalization time in the management of pediatric diabetic ketoacidosis

Introduction

Our aims were to determine whether anion gap normalization time (AGNT) correlates with risk factors related to the severity of diabetic ketoacidosis (DKA) in children, and to characterize AGNT as a criterion for DKA resolution in children admitted with moderate or severe disease.

Methods

A ten-year retrospective cohort study of children admitted to the intensive care unit with DKA. We used a survival analysis approach to determine changes in serum glucose, bicarbonate, pH, and anion gap following admission. Using multivariate analysis, we examined associations between patients' demographic and laboratory characteristics with delayed normalization of the anion gap.

Results

A total of 95 patients were analyzed. The median AGNT was 8 h. Delayed AGNT (>8 h) correlated with pH < 7.1 and serum glucose >500 mg/dL. In multivariate analysis, glucose >500 mg/dL was associated with an increased risk for delayed AGNT, by 3.41 fold. Each 25 mg/dL elevation in glucose was associated with a 10% increment in risk for delayed AGNT. Median AGNT preceded median PICU discharge by 15 h (8 vs. 23 h).

Discussion

AGNT represents a return to normal glucose-based physiology and an improvement in dehydration. The correlation observed between delayed AGNT and markers of DKA severity supports the usefulness of AGNT for assessing DKA recovery.

Increased HLA class II risk is associated with a more aggressive presentation of clinical type 1 diabetes

AIM

To determine the association of HLA class II risk with the demographic and clinical characteristics of type 1 diabetes at diagnosis.

METHODS

We conducted a register-based retrospective cohort study of 4993 Finnish children (2169 girls) - diagnosed with type 1 diabetes under the age of 15 years in 2003-2016. The participants were divided into six risk groups based on their HLA DR/DQ genotype. Demographic characteristics, family history of type 1 diabetes and metabolic markers at the time of diagnosis were compared between the groups.

RESULTS

In total, 4056/4993 children (81.2%) carried an HLA genotype associated with an increased risk of type 1 diabetes (risk groups 3-5), whereas 937/4993 children (18.8%) carried a HLA genotype conferring no or decreased disease risk. Children with higher HLA risk were younger at diagnosis (p < 0.001) and had a shorter duration of classical symptoms before diagnosis (p = 0.016). Subjects in the high-risk group were more likely to have a family member affected by type 1 diabetes when compared to those in the neutral risk group (11.5% vs. 8.8%, p = 0.05).

CONCLUSION

Children with stronger HLA disease susceptibility are younger at their disease manifestation and have a shorter period of symptoms before diagnosis, suggesting that the HLA class II genes are associated with a more aggressive disease presentation.

Clinical Incidence and Characteristics of Newly Diagnosed Type 1 Diabetes in Chinese Children and Adolescents: A Nationwide Registry Study of 34 Medical Centers

Objective

To investigate the clinical incidence and characteristics of type 1 diabetes mellitus (T1DM) of children and adolescents at the time of initial diagnosis in China.

Methods

Data on all pediatric patients with newly diagnosed T1DM were retrospectively collected from 34 medical centers in 25 major cities in China from January 2015 to January 2020. Patients were classified into three age groups: <5 years, 5 to <10 years, and ≥10 years of age. The same patient population was also categorized into diabetic ketoacidosis (DKA) and non-DKA groups based on clinical criteria.

Results

The mean annual clinical incidence of T1DM was 3.16/100,000 from the years 2015 to 2019. A total of 6,544 patients with newly diagnosed T1DM aged 0-16 years (median 7.84 ± 3.8) were studied [ages <5 years (29.3%), 5 to <10 years (38.7%), and ≥10 years (32%)], 52.4% of them were women. In total, 90.5% of the cases were occurred in individuals without a family history. Patients had lower C-peptide (CP) and body mass index (BMI) z scores when compared with healthy children, 41.8% of them had measurable T1DM-related antibodies and 52.7% had DKA. Among all three age groups, the <5 years group had the lowest BMI z score, CP, and glycated hemoglobin (HbA1c) on average, while it had the highest incidence rate of DKA (56.9%). Compared to the non-DKA group, the DKA group was significantly younger, with a lower BMI z score and CP, higher antibody positive rate, HbA1c, and the rate of insulin pump therapy.

Conclusion

The clinical incidence of T1DM in children and adolescents in China was 3.16/100,000. Patients with DKA at the first diagnosis of T1DM have a worse β-cell function. Public health measures for the prevention and treatment of T1DM should focus on preschoolers (aged <5 years) in particular, considering the severity and the highest frequency of DKA in this age group. More efforts should be dedicated to early screening and diagnosis of the T1DM.

Familial autoimmunity in pediatric patients with type 1 diabetes (T1D) and its associations with the severity of clinical presentation at diabetes diagnosis and with coexisting autoimmunity

PURPOSE

The aim was to evaluate the impact of familial autoimmunity on the age and severity of type 1 diabetes (T1D) presentation and on the coexistence of other autoimmune diseases.

METHODS

We retrospectively evaluated the medical records of 121 children/adolescents (male: 63) followed in our Diabetic Clinic from 2002 to 2016.

RESULTS

Seventy-six patients (62.8%) had at least one relative with an autoimmune disease, Hashimoto's thyroiditis (49.5%) and T1D (22.3%) being the commonest. Children with familial autoimmunity were younger at T1D diagnosis (mean age ± SD) (6.766 ± 3.75). Median fasting c-peptide levels at presentation were not related to familial autoimmunity. Patients with familial autoimmunity more often exhibited GADA autoantibody positivity at diagnosis. The larger the number of the patient's relatives diagnosed with an autoimmune disease, the higher were the patient's GADA levels (Spearman's rho test = 0.19, p = 0.049). Children with a first-degree relative with autoimmunity had a coexisting autoimmune disorder at a significantly higher percentage (p = 0.016). Family history of autoimmunity was negatively associated with the presence of diabetic ketoacidosis (DKA) (p = 0.024). Patients with a relative with T1D less frequently exhibited DKA at diagnosis (12.8 vs. 87.2%, p = 0.003). The presence of DKA was associated with younger age (p = 0.05) and lower c-peptide levels (p = 0.033).

CONCLUSIONS

Familial autoimmunity was present in 62.8% of children with T1D, autoimmune thyroiditis and T1D being the two most frequent familial autoimmune diseases. Familial autoimmunity reduced the risk of DKA at diagnosis, but these patients were younger and had higher levels of pancreatic autoantibodies and a greater risk of developing additional autoimmune diseases.

Diabetes ketoacidosis recovery in youth with newly diagnosed and established type 1 diabetes

BACKGROUND

The objective of this study was to describe the differences in metabolic parameters and in time to recovery from diabetes ketoacidosis (DKA), between children and adolescents with newly diagnosed diabetes compared with established type 1 diabetes (T1DM).

METHODS

This was a single-center, retrospective study. The cohort consists of 356 children and adolescents with T1DM who had DKA during 2008-2018. Data were obtained from the patients' medical files. Recovery of DKA was defined as the resolution of acidosis (pH >7.3 and bicarbonate >15 meq/L).

RESULTS

The mean time to recovery from DKA was significantly longer in patients with newly diagnosed diabetes than in those with established diabetes (13± versus 8.5± h) (p < 0.001). This difference was maintained in an analysis according to DKA severity: mild, moderate, and severe. pH at presentation did not differ between the groups, but bicarbonate at presentation was significantly lower in patients with newly diagnosed diabetes than in those with established diabetes, 9.9± versus 12± mmol/L (p < 0.001). Potassium and phosphorus levels were lower, and sodium and chloride levels were higher in patients with newly diagnosed diabetes than in those with established diabetes (p < 0.001).

CONCLUSIONS

DKA is associated with a shorter recovery time in patients with established diabetes compared to newly diagnosed diabetes. This may have implications on the treatment of people with established diabetes.

IMPACT

DKA is associated with a shorter recovery time in patients with established diabetes compared with newly diagnosed diabetes. Shorter recovery time in a patient with established diabetes compared with newly diagnosed diabetes was observed in any DKA severity. The time to recovery from DKA did not differ significantly between patients treated with an insulin pump and those treated with multiple daily injections. Triggers for DKA among patients with established diabetes were poor compliance with treatment, infection, pump dysfunction, and dehydration.

Epidemiological trends in the presentation of diabetic ketoacidosis in children newly diagnosed with type 1 diabetes from 2011 to 2017 in Kuwait

BACKGROUND

Monitoring the trends in the presentation of T1D over decades cannot be underestimated as it provides a rich source of information on diabetes-related complications like DKA. DKA represents a medical emergency, with potentially fatal outcome, and thus the prevention of DKA is a priority in diabetes care. The aim of this study is to report on trends in the presentation of DKA in children newly diagnosed with T1D in Kuwait.

MATERIAL AND METHODS

This study is based on a retrospective review of children newly diagnosed with T1D aged 14 years or less at three Governmental Hospitals representing three health sectors out of the total six health sectors in the country during the period 2011-2017.

RESULTS

A total of 799 children (376 males and 423 females) were newly diagnosed with T1D. 287 children presented with DKA (35.9%) with only 73 children (9.1%) classified as severe. During the years 2011 to 2017, we note that the percentage of children older than 6 years of age presenting with severe DKA has decreased significantly (p=0.022). Unfortunately, this has not been replicated in children younger than 6 years.

CONCLUSION

This study highlights the importance of continued monitoring of clinical characteristics of children at diagnosis of T1D specifically presenting with DKA to enable diabetes care professionals to appreciate the multifaceted aspects of T1D, in particular the importance of raising awareness of the early signs of the onset of T1D with special attention to DKA and its severe consequences.

Good glycemic control at puberty in boys with type 1 diabetes is important for final height

BACKGROUND

Poor glycemic control in children with type 1 diabetes (T1D) may hinder sexual development and the associated growth spurt. This study aims to identify factors that may affect the timing of puberty, total pubertal growth (TPG), and final height (F-Ht) in boys with T1D.

METHODS

This was a retrospective longitudinal study of 68 boys diagnosed with T1D during 1996 to 2009, who were prepubertal at diagnosis and had completed puberty at the time of data collection. Data were accessed regarding anthropometric measurements, Tanner stage, and glycosylated hemoglobin (HbA1c) levels from diagnosis to F-Ht. F-Ht was compared to parental height and Israeli National Health Survey data.

RESULTS

The mean F-Ht standard deviation score (F-Ht-SDS) was lower than the mean Ht-SDS at diagnosis (P < .006) but similar to the mean target height SDS (P = .3) and to values from the national survey (P = .12). Mean HbA1c levels in the year preceding pubertal onset were associated with the age at onset of puberty (R = 0.33, P = .009) and inversely with TPG (R = -0.3, P = .03). Mean HbA1c levels during puberty were inversely associated with TPG (R = -0.26, P = .035) and F-Ht (R = -0.28, P = .02). Boys who presented with diabetic ketoacidosis at diagnosis were shorter than those who did not throughout the follow-up.

CONCLUSIONS

We found associations of age of pubertal onset, pubertal growth spurt, and F-Ht with target height and glycemic control before and during puberty. Targeted interventions to achieve optimal metabolic control during these time periods are needed for normal, timely puberty and for achieving optimal adult height within the genetic target height.

Delayed referral is common even when new-onset diabetes is suspected in children. A Swedish prospective observational study of diabetic ketoacidosis at onset of Type 1 diabetes

OBJECTIVE

Delayed treatment for new-onset diabetes Type 1 (T1D) can lead to diabetic ketoacidosis (DKA) with potentially devastating consequences. This prospective observational study aimed to characterize pediatric patients with DKA at hospital admission, regarding parental awareness of diabetes-related symptoms and delayed referrals from primary health care providers to pediatric emergency wards.

RESEARCH DESIGN AND METHODS

Patients 0-18 years admitted to hospital with new-onset T1D and DKA between 2015 and 2017 were invited to participate. Questionnaires were filled out separately by the caregivers and by the attending hospital staff. Data from the Swedish National Diabetes Registry (SWEDIABKIDS) were used for comparison. Delayed referral was defined as a primary healthcare contact due to diabetes-related symptoms 0-4 weeks before hospital admission without immediate referral, or registered elevated glucose levels at primary healthcare centers without immediate referral.

RESULTS

The study included 237 patients, among which parental suspicion of new-onset diabetes before healthcare contacts was reported in 39%. Parental suspicion of diabetes was associated with higher pH values at diagnosis. Patients in contact with primary health care providers before hospital admission had a delayed referral in 43% of the cases. Delayed referral was associated with lower pH values at hospital admission. Symptoms leading to primary healthcare contacts were similar regardless of whether delay occurred or not.

CONCLUSIONS

Parental suspicion of diabetes was associated with milder DKA at hospital admission. Delayed referral was seen in a considerable proportion of children with primary healthcare contacts for symptoms associated with diabetes. Increased awareness of diabetes symptoms is of paramount importance.

Increase in Prevalence of Diabetic Ketoacidosis at Diagnosis Among Youth With Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

We previously reported a high (˜30%) but stable prevalence of diabetic ketoacidosis (DKA) at youth-onset diagnosis of type 1 diabetes (2002 and 2010). Given the changing demographics of youth-onset type 1 diabetes, we sought to evaluate temporal trends in the prevalence of DKA at diagnosis of type 1 diabetes from 2010 to 2016 among youth <20 years of age and evaluate whether any change observed was associated with changes in sociodemographic distribution of those recently diagnosed.

RESEARCH DESIGN AND METHODS

We calculated prevalence of DKA within 1 month of type 1 diabetes diagnosis by year and evaluated trends over time (2010-2016) (n = 7,612 incident diabetes cases; mean [SD] age 10.1 [4.5] at diagnosis). To assess whether trends observed were attributable to the changing distribution of sociodemographic factors among youth with incident type 1 diabetes, we estimated an adjusted relative risk (RR) of DKA in relation to calendar year, adjusting for age, sex, race/ethnicity, income, education, health insurance status, language, season of diagnosis, and SEARCH for Diabetes in Youth Study site.

RESULTS

DKA prevalence increased from 35.3% (95% CI 32.2, 38.4) in 2010 to 40.6% (95% CI 37.8, 43.4) in 2016 (P _trend = 0.01). Adjustment for sociodemographic factors did not substantively change the observed trends. We observed a 2% annual increase in prevalence of DKA at or near diagnosis of type 1 diabetes (crude RR 1.02 [95% CI 1.01, 1.04] and adjusted RR 1.02 [95% CI 1.01, 1.04]; P = 0.01 for both).

CONCLUSIONS

Prevalence of DKA at or near type 1 diabetes diagnosis has increased from 2010 to 2016, following the high but stable prevalence observed from 2002 to 2010. This increase does not seem to be attributable to the changes in distribution of sociodemographic factors over time.

"Puddles on the Road": Hurdles in the Pathway from Symptoms to Diagnosis and Treatment in Children with Type 1 Diabetes

INTRODUCTION

This study was conducted to investigate the pathway from first symptoms to initiation of insulin regimen in children with new-onset Type 1 Diabetes Mellitus (T1DM) and explore the reasons behind diabetes ketoacidosis (DKA) at onset among children with T1DM.

MATERIALS AND METHODS

An exploratory study was conducted using a pretested questionnaire, among parents of children diagnosed with T1DM within preceding 3 months.

RESULTS

Out of the total 105 children, 56.1% were males. The median age was 7 years. The commonest reported symptoms were polydipsia (97.8%), polyuria (75.2%), and nocturia (75.2%). The mean time taken by parents from onset of symptoms to decide to visit the physician (appraisal gap) was 7.85 ± 7.95 days. The help-seeking gap (from decision-making to visiting a physician) was 3.01 ± 8.31 days, diagnostic gap (from first visit to diagnosis) was 4.19 ± 6.72 days, and the treatment gap (from diagnosis to the start of insulin) was 2.12 ± 6.87 days. The DKA at onset (was present in 39 out of 105 children 37.1%) and was higher among children with lower per-capita income (P-0.017), lack of previous experience among parents (P-0.017), longer appraisal (P-0.023), and treatment gap (P-0.009).

CONCLUSION

Increasing awareness about the diabetes among children among the public and primary healthcare workers can help prevent DKA at onset.

Level of awareness of diabetic ketoacidosis among diabetes mellitus patients in Riyadh

Background:

Diabetic ketoacidosis (DKA) is considered to be a serious acute life-menacing complication of diabetes type (1) and type (2). The study aims to assess the level of awareness regarding DKA among diabetic patients in the Riyadh population.

Methodology:

The study is an institution-based cross-sectional study with a sample size of 150 participants. The participants are chosen through systemic random sampling, who have type (1) or type (2) diabetes mellitus patients and are 18–35 years of age. The medical personnel were excluded from the study. A self-administered, precoded, and pretested questionnaire was developed especially for this study after consulting literature and epidemiologists containing data about the risk factor, management, and complication. Data were analyzed using (SPSS). A P value of less than 0.05 was considered significant.

Results:

38.67% (58) participants have poor awareness regarding complications, 67.34% (101) have poor knowledge regarding management, and 6% (9) participants have a good knowledge, 38% (57) participants have poor knowledge regarding risk factors and 30% (45) of the participants have good awareness. The relation between having a first degree relative with diabetes and awareness regarding management is significant with a P value of 0.022; 73% (110) of the participants had no relatives with diabetes mellitus and 71% (79) had a poor level of awareness regarding the management of DKA. However, 55% (22) of respondents who had relatives with diabetes mellitus also had a poor level of awareness regarding treatment.

Conclusion:

The majority of the participants had a poor level of awareness. There is a relationship between having a first-degree relative with diabetic mellitus and the level of awareness regarding DKA.

Characteristics of diabetes diagnosis and control in toddlers and preschoolers from families with limited resources: A single center experience

AIM

To describe the characteristics of diabetes diagnosis, insulin therapy regarding type, dose and frequency also the degree of glycemic control achieved in toddlers and preschoolers coming from families with limited resources.

METHODS

Over one year, 69 toddlers and preschoolers clinically diagnosed as type 1 diabetes were included. Data related to presentation at diagnosis, insulin therapy and glycemic control was reviewed from patients' care givers and medical records.

RESULTS

Diabetic ketoacidosis (DKA) was recorded in 71% of the children at initial diagnosis. The mean time since diabetes diagnosis was 2 ± 1 years. Most of children (65/69, 94%) were on basal-bolus regimen while four (6%) were on basal insulin only. NPH and long acting analogues were used as basal insulin in (74%) and (26%). Regular insulin and rapid acting analogues were used as bolus insulin (27%) and (73%).The mean frequency of daily self monitoring of blood glucose was (2.9 ± 1). The arithmetic mean of HbA1c done over past 6 months to one year before inclusion in the study was 8.2 ± 1.5% (66 ± 12 mmol/mol) with 65% having HbA1c ≥ 7.5% (≥58 mmol/mol).

CONCLUSION

Toddlers and preschoolers with diabetes coming from families with limited resources frequently present with DKA at diagnosis and have suboptimal self-monitoring of blood glucose and glycemic control. NPH is more commonly used in this age group, combined with postprandial rapid analogues and less commonly preprandial regular insulin and that yields more favorable HbA1c but with a greater risk of hypoglycemia. The most common cause of hospital readmission was ketoacidosis and uncontrolled hyperglycemia.

DIABETIC KETOACIDOSIS AS THE INITIAL PRESENTATION OF TYPE 1 DIABETES IN CHILDREN AND ADOLESCENTS: EPIDEMIOLOGICAL STUDY IN SOUTHERN BRAZIL

Objective:

To analyze the variables associated with the presence of diabetic ketoacidosis in type 1 diabetes mellitus (T1DM) diagnosis and its impact on the progression of the disease.

Methods:

We reviewed the records of 274 children and adolescents under 15 years, followed in a Pediatric Endocrinology clinic of a university hospital in Curitiba-PR. They had their first appointment between January 2005 and April 2015.

Results:

Most patients received their T1DM diagnosis during a diabetic ketoacidosis episode. The associated factors were: lower age and greater number of visits to a physician’s office prior to diagnosis; diabetic ketoacidosis was less frequent in patients who had siblings with T1DM and those diagnosed at the first appointment. Nausea and vomiting, abdominal pain, tachydyspnea, and altered level of consciousness were more common in the diabetic ketoacidosis group. There was no association with socioeconomic status, duration of symptoms before diagnosis, and length of the honeymoon period.

Conclusions:

Prospective studies are necessary to better define the impact of these factors on diagnosis and disease control. Campaigns to raise awareness among health professionals and the general population are essential to promote early diagnosis and proper treatment of diabetes mellitus in children and adolescents.

Characteristics of Children with Diabetic Ketoacidosis Treated in Pediatric Intensive Care Unit: Two-Center Cross-Sectional Study in Croatia

Background and objective: There is an increasing risk of type 1 diabetes mellitus (T1D) among children in Croatia. Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with T1D, with cerebral edema as the most severe complication. Since early recognition of cerebral edema leads to a better outcome, it is important that patients with moderate or severe DKA are closely monitored and treated in pediatric intensive care units (PICUs). The aim of this study is to investigate clinical and laboratory parameters, as well as complications in children treated in PICUs because of DKA. Materials and methods: Patients treated due to DKA in the PICU of the University Hospitals of Split and Osijek from 2013 to 2017 were included in this study. Retrospectively collected data included age, gender, clinical signs and symptoms, and various laboratory parameters. After dividing subjects into two groups: Newly diagnosed with T1D (NT1D) and previously diagnosed with T1D (PT1D), collected data were compared between the two groups. Results: A total of 82 patients were enrolled. Those with NT1D were more often treated in the PICU, with two of them developing cerebral edema. Dehydration was the most frequent clinical sign, found in 95% of patients at admission. Decreased consciousness level was found in 41.5% of patients, with majority of them being somnolent. No difference was found between NT1D and PT1D. Additionally, there was no significant difference regarding laboratory data at admission. Conclusions: More children with NT1D required treatment in the PICU due to DKA with two of them developing cerebral edema. Since cerebral edema is a life-threatening condition, treatment of patients with moderate or severe DKA in PICUs will provide necessary monitoring enabling early recognition, treatment, and better treatment outcome. To minimize the incidence of DKA among patients with NT1D, it is important to continuously carry out public health education programs aimed at early identification of signs and symptoms of T1D.

Ketoacidosis at diagnosis of type 1 diabetes: Effect of prospective studies with newborn genetic screening and follow up of risk children

We studied the frequency of diabetic ketoacidosis (DKA) in children at diagnosis of type 1 diabetes (T1D) in a region where newborn infants have since 1995 been recruited for genetic screening for human leukocyte antigen (HLA)-conferred disease susceptibility and prospective follow up. The aim was to study whether participation in newborn screening and follow up affected the frequency of DKA, and to follow the time trends in DKA frequency. We first included children born in Oulu University Hospital since 1995 when the prospective studies have been ongoing and diagnosed with T1D <15 years by 2015 (study cohort 1, n = 517). Secondly, we included all children diagnosed with T1D <15 years in this center during 2002-2014 (study cohort 2, n = 579). Children who had an increased genetic risk for T1D and participated in prospective follow up had low frequency of DKA at diagnosis (5.0%). DKA was present in 22.7% of patients not screened for genetic risk, 26.7% of those who were screened but had not an increased risk and 23.4% of children with increased genetic risk but who were not followed up. In study cohort 2 the overall frequency of DKA was 18.5% (13.0% in children <5 years, 14.0% in children 5-10 years and 28.6% in children ≥10 years at diagnosis; P<.001). In children <2 years the frequency of DKA was 17.1%. Participation in prospective follow-up studies reduces the frequency of DKA in children at diagnosis of T1D, but genetic screening alone does not decrease DKA risk.

Ketoacidosis at onset of type 1 diabetes is a predictor of long-term glycemic control

BACKGROUND

Few studies have evaluated the impact of diabetic ketoacidosis (DKA) at diabetes onset on long-term glycemic control in patients with type 1 diabetes (T1D).

OBJECTIVE

We aimed to determine any differences in long-term glycemic control between children/adolescents with T1D presenting with DKA at diabetes onset and those without.

METHODS

This retrospective study comprised 335 patients diagnosed with T1D from September 2007 to December 2012, among which 132 (39.4%) presented with DKA. Variables compared between patients with DKA at onset and those without: yearly hemoglobin A1c (HbA1c) levels, daily insulin dose, yearly rates of severe hypoglycemia and DKA, percent of patients achieving target HbA1c levels.

RESULTS

After the first year of diabetes, the mean daily insulin dose and HbA1c level were significantly higher in the group with DKA at onset (0.74 ± 0.26 vs 0.69 ± 0.27 units/kg/d, P = .049, and 7.85 ± 1.13% vs 7.49 ± 0.94%, P = .01, respectively), despite similarity of therapy (multiple daily injections or continuous subcutaneous insulin infusion), with a similar but not statistically significant trend subsequently. Mean HbA1c since onset was significantly higher in the DKA group (8.08 ± 0.95% vs 7.86 ± 0.95%, P = .025). A significantly higher percentage of patients in the group without DKA at onset achieved a mean level of HbA1c since onset within glycemic targets (32% vs 20.5%, P = .02). In the DKA group, the frequency of subsequent DKA episodes per diabetes years was significantly higher (P = .042).

CONCLUSIONS

DKA at diagnosis was associated with less favorable long-term glycemic control as assessed by HbA1c and the rate of DKA episodes. T1D patients presenting with DKA may therefore need stricter treatment and tight follow-up.

Clinical characteristics of patients with diabetic ketoacidosis at the Intensive Care Unit of a University Hospital

Objectives:

The aims of this study were assessing the frequency of clinical characteristics of patients with severe Diabetic ketoacidosis (DKA) who were admitted to the intensive care unit (ICU) and investigating the relationship between paraclinical (glucose, anion gap, and serum bicarbonate) and clinical parameters in patients with severe DKA.

Method:

A retrospective chart review of all adult patients with DKA who were admitted to the ICU at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2012 and December 2013. The data collected include the demographic data, clinical presentation, precipitating factors, duration of hospital stay and mortality rate. The data were analyzed using STAT software.

Results:

A total of 60 patients were included. Of these, 50 were men (83.3%). The median age was 23 years (ranging 18-29 years). Newly diagnosed diabetics accounted for 15 (25%) of the cases; the remainder were previously known patients of type1 diabetes on treatment. The main precipitating factors of DKA were insulin treatment cessation (87.5%) and infection/sepsis (39.6%). Serum blood glucose, serum bicarbonate level, and the calculated anion gap did not significantly correlate with clinical parameters of severe DKA.

Conclusion:

Most patients with severe DKA who were admitted to the ICU of our institution presented with gastrointestinal symptoms. Non-compliance to insulin therapy was the main precipitating factor of DKA.

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.

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.

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.