Causes of death in children with insulin dependent diabetes 1990-96

Diabetic ketoacidosis in youth with diabetes mellitus during the COVID-19 pandemic

OBJECTIVES

We sought to determine if the early months of the coronavirus disease 2019 (COVID-19) pandemic influenced pediatric diabetic ketoacidosis (DKA) hospitalization characteristics.

METHODS

This is a cross-sectional study of youth with laboratory-confirmed DKA admitted to a large tertiary children's hospital in the USA. Data were collected from admissions in March through July 2019 and March through July 2020, respectively. We evaluated the clinical characteristics of hospitalization, including demographic data and DKA severity. We used univariable ordinal logistic regression followed by multiple ordinal logistic regression to adjust for potential confounders.

RESULTS

We included 137 children with diabetes admitted for DKA in the relevant period in 2019 and 173 patients admitted for DKA in the same period in 2020. Hemoglobin A1C (HbA1c) upon admission was higher in 2020 (median=12.2 %) than in 2019 (11.5 %, p=0.018). Children who were admitted with DKA in 2020 were less likely to be autoantibody positive than those in 2019 (83 vs. 91 %, p=0.028). In the univariable model, being admitted in 2020 was significantly associated with more severe DKA (p=0.038), as was HbA1c (p=0.001). After adjusting for HbA1c upon admission, admission year was no longer significantly associated with more severe DKA.

CONCLUSIONS

In this study of pediatric diabetes of any type and duration of diabetes, youth admitted for DKA at the start of the COVID-19 pandemic, compared with those admitted during the year before, were more likely to have autoantibody-negative diabetes and had significantly higher HbA1c. Additionally, higher HbA1c seemed to mediate more severe DKA during the pandemic.

Low dose insulin infusion versus the standard dose in children with diabetic ketoacidosis: a meta-analysis

Aim: This systematic review aims to consolidate findings from current clinical trials that compare the effectiveness of insulin infusion at 0.05 IU/kg/h versus 0.1 IU/kg/h in managing pediatric diabetic ketoacidosis. Methods: We searched several databases, including PubMed, Embase, Scopus, Cochrane Central and Web of Science. Our primary outcomes were time to reach blood glucose ≤250 mg/dl and time to resolution of acidosis. Secondary outcomes included rate of blood glucose decrease per hour, incidence of hypoglycemia, hypokalemia, treatment failure, and cerebral edema. Results & conclusion: The present study establishes that a low insulin dose exhibits comparable efficacy to the standard dosage for managing pediatric patients suffering from diabetic ketoacidosis, with a lower incidence of complications.

In vitro and functional investigation reveals the curative effect of thymoquinone from black cumin-loaded chitosan nanoparticles on streptozotocin induced paediatric diabetes

Diabetic ketoacidosis (DKA) is regarded to be a communal complication of both type 1 and type 2 diabetes mellitus in children and adolescents. Successful therapy of DKA in children requires prompt diagnosis, strict monitoring of medical indicators, and prompt action. Thymoquinone (Tq) from black cumin loaded chitosan nanoparticles (ChNPs) intend to assess an effective agent to overcome this problem. XRD, FTIR, SEM, and TEM were used in the physicochemical analysis. Enzymatic activity of α-amylase and α-glucosidase was used in in vitro tests of anti-diabetic efficacy. Protecting insulin against enzyme breakdown is a crucial part of the insulin delivery mechanism. In the STZ-induced diabetes RIN-5F cell line, the anti-apoptotic capability of Tq-ChNPs was demonstrated through the NF-κB mediated apoptotic pathway. The combination of thymoquinone and chitosan NPs demonstrated that a wide variety of incredibly effective substances to elevate their curative effects, thus contributing to the growth of clinical and pharmaceutical fields.

Have interventions aimed at assisting general practitioners in facilitating earlier diagnosis of type 1 diabetes in children been successful? A systematic review protocol

BACKGROUND

Early diagnosis of type 1 diabetes in children is critical to prevent deterioration to diabetic ketoacidosis (DKA), a state where the body's insulin levels are critically low resulting in the use of fat for fuel and the accumulation of ketones. DKA is a life-threatening emergency where dehydration and cerebral oedema can quickly develop and lead to death. Despite treatment, DKA also has harmful impacts on cognition and brain development. Most children admitted to a hospital with DKA see their general practitioner in the week leading up to their admission. A delay in referral from general practice can result in delays in commencing lifesaving insulin therapy. Prior systematic reviews have explored publicity campaign interventions aimed at recognising type 1 diabetes earlier; however, no reviews have explored these interventions targeted at reducing the delay after presentation to the general practitioner. This systematic review aims to summarise interventions that target the diagnostic delay emerging from general practice and to evaluate their effectiveness in reducing DKA admissions.

METHODS

Six databases (Ovid (MEDLINE), Web of Science, EMBASE, CINAHL, Evidence-Based Medicine Reviews (EBMR) and Google Scholar) will be searched to identify studies exploring interventions to reduce diagnostic delay in children with type 1 diabetes, and hence DKA, in general practice. The primary outcome will be the number of DKA admissions to a hospital following a delay in general practice. The secondary outcome will be the behaviour of general practitioners with respect to urgent referral of children with type 1 diabetes. Title, abstract and full-text screening for exclusion and inclusion of publications will be completed by two independent reviewers. Any risks of bias within individual studies will be assessed by two independent reviewers, using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Our confidence in the overall body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

The systematic review will be disseminated via publication and potentially in conference presentations. Ethics is not required for a systematic review of secondary data.

PROSPERO REGISTRATION NUMBER

CRD42023412504.

Correlation between Neutrophil-to-Lymphocyte Ratio and Cerebral Edema in Children with Severe Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA), a common onset modality of type 1 diabetes mellitus (T1DM), can lead, in rare instances, to the development of cerebral edema, which is the leading cause of mortality in T1DM. Aside from the identification of several demographic and clinical risk factors for cerebral edema, attention has also been drawn to the possible link between systemic inflammation and neuroinflammation. This single-center retrospective study of 98 children with severe DKA aimed to investigate the possible relationship between neutrophil-to-lymphocyte ratio NLR) levels and the presence of cerebral edema. Patients were classified into three groups: alert (n = 28), subclinical cerebral edema (n = 59), and overt cerebral edema (n = 11). Lower blood pH and elevated NLR and blood urea were correlated with the presence of cerebral edema (p < 0.001). After a multivariable risk adjustment for possible confounding factors, such as age, pH, corrected sodium, and BUN, the NLR remained positively associated with cerebral edema (p = 0.045). As such, NLR may be an additional instrument to help practitioners target patients with a higher risk of severe cerebral edema. These patients would benefit from more rigorous neurologic surveillance, enabling the prompt identification of early signs of cerebral edema.

Qualitative study exploring the perspectives of emerging adults with type 1 diabetes after transfer to adult care from a paediatric diabetes centre in Montreal, Canada

INTRODUCTION

Among youth living with type 1 diabetes (T1D), the increasing demands to diabetes self-care and medical follow-up during the transition from paediatric to adult care has been associated with greater morbidity and mortality. Inadequate healthcare support for youth during the transition care period could exacerbate psychosocial risks and difficulties that are common during emerging adulthood. The current investigation sought to explore the post-transfer perceptions of emerging adults living with T1D relating to their transition to adult care.

RESEARCH DESIGN AND METHODS

Thirty-three emerging adults living with T1D were recruited during paediatric care and contacted for a semistructured interview post-transfer to adult care (16.2±4.2 months post-transfer) in Montreal, Canada. We analysed data using thematic analysis.

RESULTS

We identified four key themes: (1) varied perceptions of the transition process from being quick and abrupt with minimal advice or information from paediatric healthcare providers (HCP) to more positive including a greater motivation for self-management and the transition being concurrent with the developmental period; (2) facilitators to the transition process included informational and tangible social support from HCPs and family or friends, a positive relationship with adult HCP and a greater ease in communicating with the adult care clinic or adult HCP; (3) barriers to adequate transition included lack of advice or information from paediatric HCPs, loss of support from HCPs and friends or family, the separation of healthcare services and greater difficulty in making appointments with adult clinic or HCP and (4) participants recommendations for improving the transition included increasing the length and frequency of appointments in adult care, having access to educational information, and better transition preparation from paediatric HCPs.

CONCLUSIONS

The experiences and perceptions of emerging adults are invaluable to guide the ongoing development and improvement of transition programmes for childhood-onset chronic illnesses.

Incidence and predictors of mortality in children with diabetic ketoacidosis in the comprehensive specialized referral hospitals of West Amhara Region, Northwest Ethiopia: a retrospective follow-up study

Background

Diabetic ketoacidosis is one of the major life-threatening conditions associated with acute metabolic complications. It remains a major public health problem in developing countries such as Ethiopia.

Objective

To assess the incidence and prediction of mortality in children with diabetic ketoacidosis in West Amhara Region Comprehensive Specialized Referral Hospitals, Northwest Ethiopia, in 2022.

Methods

An institution-based retrospective follow-up study was conducted among 423 study participants with a confirmed diagnosis of diabetic ketoacidosis from 01/01/2017 to 31/12/2021. Data were entered, coded, cleaned, and checked using Epi-Data version 4.6 and exported to Stata version 14 for data analysis.

Results

A total of 401 child records were included in the final analysis and were followed for 3781 days during the study period. The overall mortality of children with diabetic ketoacidosis was 10.6 per 1000 person-days observed (95% CI: 7.8-14.4) during the entire follow-up period. Hypoglycemia (AHR=4.6; 95% CI: 2.13-10.1), rural residence (AHR=2.9; 95% CI=1.01-8.11), age younger than five (AHR=4.4; 95% CI=1.4-13.7) or between five and 10 (AHR=3.1; 95% CI=1.1-8.8), and female gender (AHR=2.6; 95% CI=1.1-5.8) were significant predictors of mortality.

Conclusions

The incidence rate of mortality in children with diabetic ketoacidosis was relatively high. Age, rural residence, female gender, and hypoglycemia were significantly predictive of mortality. Community education or mass campaigns about the signs and symptoms of diabetic ketoacidosis may reduce the mortality rate in children.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care.

METHODS

We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity.

RESULTS

One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted β=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted β=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted β=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted β=-0.01; 95% CI, -0.03 to -0.00).

CONCLUSION

Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.

The Impact of a Multifaceted Simulation Education and Feedback Program for Community Emergency Departments on Pediatric Diabetic Ketoacidosis Management

OBJECTIVES

We sought to determine if general emergency departments (GEDs) were managing pediatric diabetic ketoacidosis (DKA) correctly and if management could be improved using a multilayered educational initiative. We hypothesized that a multifaceted program of in situ simulation education and formal feedback on actual patient management would improve community GED management of pediatric DKA.

METHODS

This study combined a prospective simulation-based performance evaluation and a retrospective chart review. A community outreach simulation education initiative was developed followed by a formal patient feedback process.

RESULTS

Fifteen hospitals participated in simulation sessions and the feedback process. All hospitals were scored for readiness to provide care for critically ill pediatric patients using the Emergency Medical Services for Children (EMSC) Pediatric Readiness Assessment. Six of the 15 have had a second hospital visit that included a DKA scenario with an average performance score of 60.3%. A total of 158 pediatric patients with DKA were included in the chart review. The GEDs with higher patient volumes provided best practice DKA management more often (63%) than those with lower patient volumes (40%). Participating in a DKA simulated scenario showed a trend toward improved care, with 47.2% before participation and 68.2% after participation ( P = 0.091). Participating in the formal feedback process improved best practice management provided to 68.6%. Best practice management was further improved to 70.3% if the GED participated in both a DKA simulation and the feedback process ( P = 0.04).

CONCLUSIONS

A multifaceted program of in situ simulation education and formal feedback on patient management can improve community GED management of pediatric patients with DKA.

Les recommandations en vigueur pour la prise en charge de l'acidocétose diabétique pédiatrique

Pour traiter l'acidocétose diabétique pédiatrique, il faut porter une attention particulière aux liquides et aux électrolytes pour limiter le risque de complications, telles qu'une lésion cérébrale, associée à une morbidité et une mortalité élevées. L'incidence d'œdème cérébral en cas d'acidocétose diabétique n'a pas diminué malgré les protocoles visant la limitation des liquides qui s'appuient sur la restriction de la réanimation liquidienne initiale. Selon de nouvelles données probantes, l'administration précoce de liquides isotoniques n'entraîne pas de risque supplémentaire et peut améliorer les résultats cliniques chez certains patients. Les protocoles et les directives cliniques sont adaptés et axés particulièrement sur la surveillance et le remplacement initiaux et continus des liquides et des électrolytes. Il est maintenant recommandé de commencer par une réanimation à l'aide de liquides isotoniques chez tous les patients dans les 20 à 30 minutes suivant leur arrivée à l'hôpital, suivie par la réplétion du déficit volumique sur une période de 36 heures, en association avec une perfusion d'insuline et des suppléments d'électrolytes, ainsi qu'avec la surveillance et la prise en charge attentives d'une éventuelle lésion cérébrale.

Current recommendations for management of paediatric diabetic ketoacidosis

Treatment of paediatric diabetic ketoacidosis (DKA) includes careful attention to fluids and electrolytes to minimize the risk of complications such as cerebral injury (CI), which is associated with high morbidity and mortality. The incidence of cerebral edema in paediatric DKA has not decreased despite the use of fluid-limiting protocols based on restricting early fluid resuscitation. New evidence suggests that early isotonic fluid therapy does not confer additional risk and may improve outcomes in some patients. Protocols and clinical practice guidelines are being adjusted, with a particular focus on recommendations for initial and ongoing fluids and electrolyte monitoring and replacement. Initial isotonic fluid resuscitation is now recommended for all patients in the first 20 to 30 minutes after presentation, followed by repletion of volume deficit over 36 hours in association with an insulin infusion, electrolyte supplementation, and careful monitoring for and management of potential CI.

A Pediatric Patient With Type 1 Diabetes Mellitus With Poor Glycemic Control, Medication-Resistant Hypertension, and New-Onset Headache Diagnosed With Adrenocorticotropic Hormone (ACTH)-Secreting Pituitary Macroadenoma

The most well-known cause of hyperglycemia is diabetes mellitus, a condition that affects the body's ability to either use (type 2 diabetes mellitus - T2DM) or produce (type 1 diabetes mellitus - T1DM) insulin. Exogenous insulin is the mainstay therapy to achieve optimal glucose control in T1DM, though glucose hemostasis is affected by several factors. Following the initiation of insulin therapy, symptoms of polyuria, polydipsia, and weight loss are reversed. Diabetes mellitus is associated with several complications, including but not limited to, renal disease (hypertension, microalbuminuria), peripheral neuropathy, delayed growth, and delayed puberty. Hyperglycemia can also be caused by acute illness, surgery, trauma, infection, parenteral nutrition, obesity, or other medical conditions such as Cushing syndrome and polycystic ovarian syndrome. While refractory hyperglycemia is often attributed to poor adherence to medications, other organic etiologies should also be considered, especially in the setting of early-onset complications of diabetes mellitus. In this report, we present a case of a pediatric patient with T1DM with refractory hyperglycemia and medication-resistant hypertension who was lost to follow-up. When he returned to the endocrinology clinic, he had Cushingoid features and a headache. After multiple admissions for hypertension, the patient was discovered to have a pituitary macroadenoma. Following the removal of the adenoma, the patient's insulin requirement decreased substantially and his blood pressure returned to normal, allowing all blood pressure medications to be discontinued.

Reducing Diabetic Ketoacidosis Readmissions with a Hospital-School-Based Improvement Partnership

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in pediatric type 1 diabetes mellitus (T1D). Baseline data showed 139 of 182 DKA readmissions (76.4%) were due to missed basal insulin dosing. The team used quality improvement tools to implement a process change around basal insulin. The project utilized insulin degludec and school-based nurses when missed basal insulin was noted as a main driver for readmission. The DKA readmission rate averaged 5.25 per month from January 2017 to April 2019. The rate decreased to 3.64 per month during the intervention from May 2019 to March 2020, a 31% reduction over 11 months. This standardized approach for patients with T1D readmitted with DKA, using a school-based intervention and insulin degludec, reduced the number of DKA readmissions. This method is safe and effective for lowering DKA readmissions due to missed basal insulin in areas with reliable school nursing.

Frequency, Clinical Characteristics and Predictors of Ketoacidosis at Diagnosis of Type One Diabetes Mellitus in Children and Adolescents from Jordan

OBJECTIVE

Data regarding diabetic ketoacidosis (DKA) at diagnosis of type one diabetes (T1D) in developing countries are scarce. The aim of this study was to describe the frequency of DKA at the onset of T1D in children and adolescents in Jordan and to compare the clinical and biochemical characteristics between the group that presented with DKA and the group that did not.

METHODS

The records of 341 children and adolescents, less than sixteen years of age, who were diagnosed with T1D between 2015 and 2019 were evaluated retrospectively.

RESULTS

Of all the children diagnosed with T1D, 108 (31.7%) presented with DKA. The majority had mild or moderate DKA (38% and 33.3% respectively). Higher paternal education levels were associated with a lower probability of presenting with DKA (p=0.043). A family history of T1D had a protective effect on the occurrence of DKA (Odds ratio=2.138; 95% confidence interval=1.167-3.917, p=0.014). Patients with celiac disease and higher HbA1c levels were more likely to experience recurrent episodes of DKA, (p=0.004 and 0.011, respectively).

CONCLUSION

In Jordan, the rate of DKA at presentation of T1D remains high. Prevention campaigns are needed to increase diabetes awareness among the public and healthcare providers.

Outcomes of children with severe diabetic ketoacidosis managed outside of a pediatric intensive care unit

OBJECTIVES

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes. Our objective was to determine if children with severe DKA without alteration in mental status can be managed safely on a general children's medical unit.

METHODS

Single center retrospective study of 191 patient encounters among 168 children admitted to the children's medical unit (CMU) at Primary Children's Hospital between 2007 and 2017 with severe DKA (pH <7.1 and/or bicarbonate <5 mmol/L). Chart review identified complications including death, transfer to the intensive care unit (ICU), incidence of cerebral edema, and hypoglycemia. We compared patients requiring ICU transfer with those who did not with respect to demographics, laboratory findings at presentation, therapeutic interventions, length of stay, and cost.

RESULTS

Of 191 patient encounters, there were 0 deaths (0%, 95% CI 0-2.4%), 22 episodes of alteration of mental status concerning for developing cerebral edema (11.5%, 95% CI 7.7-16.9%), 19 ICU transfers (10%, 95% CI 6.4-15.1%), and 7 episodes of hypoglycemia (3.7%, 95% CI 1.6-7.5%). ICU transfer was associated lower initial pH (7.03 ± 0.06 vs. 7.07 ± 0.07, p<0.05), increased length of stay (3.0 ± 0.8 vs. 2.2 ± 0.9 days, p<0.05), and increased cost of hospitalization (mean ± SD $8,073 ± 2,042 vs. $5,217 ± 1,697, p<0.05).

CONCLUSIONS

The majority of children with severe DKA without alteration in mental status can be managed safely on a medical unit. Implementing a pH cutoff may identify high-risk patients that require ICU level of care.

Diabetes Related Deaths in a Tertiary Pediatric Referral Institution in England: The Value of Biochemical Analyses in Post-Mortem Samples

OBJECTIVES

To establish the incidence of "diabetes-related death" (DRD) in children with known and unknown Diabetes Mellitus (DM) dying unexpectedly, and describe post-mortem (PM) biochemistry findings.

PATIENTS AND METHODS

PM reports from the previous 16-year period were reviewed. Cases of DRD were extracted. All available demographic, clinical, and autopsy data including laboratory analyses was retrieved.

RESULTS

9/1376 (0.7%) DRD cases were identified. This was attributed to Diabetic Ketoacidosis in 7 and to Death in Bed Syndrome in 2. 4/9 cases were known diabetic and on insulin; whilst in 5/9 cases the diagnosis of DM was at PM. The mean age was 11.6 years (range 2.5-15). At PM, 4 cases were undernourished. The histology demonstrated pancreatic changes in keeping with DM in 3/9 and unremarkable pancreatic findings in 6/9. 3 cases also had autoimmune thyroiditis (1 also had myocarditis and Armanni-Ebstein nephropathy). Toxicological and biochemical analysis showed raised: β-hydroxybutyrate in 6, ketone bodies in 5 cases and raised HbA1c in 3c.

CONCLUSION

Type 1 DM is an infrequent but yet potentially preventable cause of death in children. Our findings highlight the value of routine biochemical and toxicological analysis in all PM examinations of infants and children dying suddenly and unexpectedly.

Risk factors, outcomes, and predictors of resolution of acute kidney injury in children with diabetic ketoacidosis

BACKGROUND

Acute kidney injury (AKI) is a common complication in patients with diabetic ketoacidosis (DKA) (incidence 35-77%). AKI evolution during DKA treatment/recovery is poorly understood. Our aim was to assess children with DKA for prevalence, short-term kidney outcomes, severity, and predictors of AKI development and resolution.

METHODS

This retrospective cohort study included children aged 2-14 years admitted with DKA between January 2016 and May 2020 in a Saudi tertiary care hospital. We defined AKI as an increase in serum creatinine of > 1.5 times baseline or > 3 mg/dL (26 mmol/L) within 48 h.

RESULTS

Of 213 patients admitted with DKA, 172 (80.75%) developed AKI: stage 1 in 83 (38.96%), stage 2 in 86 (40.37%), and stage 3 in 3 (1.4%). No patient required dialysis. Multivariate analysis showed an increased risk of developing AKI with male gender (OR = 2.85) and lower serum bicarbonate (OR = 0.83) when adjusted for initial heart rate, hematocrit, new onset diabetes, and recurrent AKI. The mean time to AKI resolution was 13.21 ± 6.78 h. Factors leading to prolonged recovery from AKI in linear regression analysis were older age (B coefficient = 0.44, p = 0.01), recurrent DKA episodes (B coefficient = 3.70, p value 0.003), increased acidosis severity (B coefficient =  - 0.44, p = 0.04), increased time to anion gap normalization (B coefficient = 0.44, p = 0.019), and increased initial glucose (B coefficient = 0.01, p = 0.011).

CONCLUSION

In our cohort, AKI is a common, but mostly transient complication in children presenting with DKA, and its severity is associated with longer intensive care stays and time for acidosis resolution. AKI was associated with male gender, and lower serum bicarbonate. Proper consideration of such risk factors is needed for AKI assessment and management in future DKA clinical practice guidelines. A higher resolution version of the Graphical abstract is available as Supplementary information.

Clinical characteristics of 683 children and adolescents, aged 0-18 years, newly diagnosed with type 1 diabetes mellitus in Henan Province: a single-center study

BACKGROUND

Type 1 diabetes mellitus (T1DM) is a common chronic systemic disease that threatens the health of children worldwide. Diabetic ketoacidosis (DKA) is the most severe acute complication of diabetes and can lead to death. This study aimed to explore the epidemiological features, clinical manifestations, and risk factors for DKA in children and adolescents newly diagnosed with T1DM in the Department of Endocrinology of the Children's Hospital of Henan Province.

METHODS

Medical records of 683 children and adolescents newly diagnosed with T1DM in our center from March 2014 to November 2021 were retrospectively analyzed. The data included the general condition, laboratory indexes, and clinical symptoms. The patients were divided into three groups according to age: Group I, 0-3 years; Group II, 4-9 years; and Group III, 10-18 years.

RESULTS

The incidence of DKA was 62.96% and was highest in Group I. Group I had the lowest C-peptide and hemoglobin A1c, but the highest blood glucose at first diagnosis, and 25-hydroxyvitamin D3 levels, hospitalization lengths, and medical costs. 25.5% of the children were delayed in diagnosis. Logistic regression analysis showed that elevated HbA1c levels and hyperglycemia were independent risk factors for DKA. On the other hand, C-peptide and 25- hydroxyvitamin D were protective factors for DKA.

CONCLUSIONS

The incidence of DKA among children and adolescents in the Henan Province is very high. Moreover, DKA can be easily delayed in diagnosis. Newly diagnosed infants with T1DM are more likely to present with DKA, suffer more severe metabolic disorders, endure longer hospital stays, and accrue higher medical costs.

The global impact of COVID-19 pandemic on the incidence of pediatric new-onset type 1 diabetes and ketoacidosis: A systematic review and meta-analysis

Viral infections may increase the risk of developing type 1 diabetes (T1D), and recent reports suggest that Coronavirus Disease 2019 (COVID-19) might have increased the incidence of pediatric T1D and/or diabetic ketoacidosis (DKA). Therefore, this meta-analysis aims to estimate the risk of global pediatric new-onset T1D, DKA, and severe DKA before and after the COVID-19 pandemic. A systematic search of MEDLINE/PubMed, CINAHL, Scopus, and EMBASE was conducted for articles published up to March 2022. A random-effects meta-analysis was performed to compare the relative risk of T1D and DKA among pediatric patients with T1D between the COVID-19 pre-pandemic and pandemic periods. We also compared glucose and HbA1c values in children who were newly diagnosed with T1D before and after the COVID-19 pandemic. The global incidence rate of T1D in the 2019 period was 19.73 per 100 000 children and 32.39 per 100 000 in the 2020 period. Compared with pre-COVID-19 pandemic, the number of worldwide pediatric new-onset T1D, DKA, and severe DKA during the first year of the COVID-19 pandemic increased by 9.5%, 25%, and 19.5%, respectively. Compared with pre-COVID-19 pandemic levels, the median glucose, and HbA1c values in newly diagnosed T1D children after the COVID-19 pandemic increased by 6.43% and 6.42%, respectively. The COVID-19 pandemic has significantly increased the risk of global pediatric new-onset T1D, DKA, and severe DKA. Moreover, higher glucose and HbA1c values in newly diagnosed T1D children after the COVID-19 pandemic mandates targeted measures to raise public and physician awareness.

Supraventricular tachycardia associated with severe diabetic ketoacidosis in a child with new-onset type 1 diabetes mellitus

Diabetic ketoacidosis is one of the most serious and common complications of diabetes, with between 15 and 70% of new-onset type 1 diabetes mellitus worldwide presented with diabetic ketoacidosis. Supraventricular tachycardia, however, is an infrequent complication of diabetic ketoacidosis. We present the case of a child with a new-onset type 1 diabetes mellitus with supraventricular tachycardia as a complication of paediatric diabetic ketoacidosis. The patient received intravenous fluid resuscitation, insulin, and potassium supplementation and subsequently developed stable supraventricular tachycardia initially, confirmed on a 12-lead electrocardiogram despite a structurally normal heart and normal electrolytes. Vagal manoeuvers failed to achieve sinus rhythm. The patient went into respiratory distress and was intubated, for mechanical ventilation. She received one dose of adenosine with successful conversion to sinus rhythm and a heart rate decreased from 200 to 140 beats per minutes. We conclude that supraventricular tachycardia can occur as a complication of diabetic ketoacidosis, including in new-onset type 1 diabetes mellitus. Furthermore, a combination of acidosis, potassium derangement, falling magnesium, and phosphate levels may have precipitated the event. Here, we report a case of supraventricular tachycardia as a complication of paediatric diabetic ketoacidosis.

Adherence to the 2015 and 2020 British Society of Paediatric Endocrinology and Diabetes guidelines and outcomes in critically ill children with diabetic ketoacidosis: a retrospective cohort study

OBJECTIVES

To compare clinical management and key outcomes of critically ill children with diabetic ketoacidosis (DKA) in two cohorts (2015 cohort: managed according to the 2015 British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines; 2020 cohort: managed according to the 2020 BSPED guidelines).

DESIGN

Retrospective cohort study using prospectively collected data.

SETTING

A critical care advice and transport service based in London, and referring hospitals within the critical care network.

PATIENTS

All children 0-17 years referred for advice and/or critical care transport with a clinical diagnosis of DKA over a 30-month period (from September 2018 to March 2021).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Admission to intensive care unit (ICU), clinically diagnosed cerebral oedema and death.

RESULTS

There were significant differences in fluid and insulin administration practices between the 2015 and 2020 cohorts (fluid bolus >20 mL/kg: 3% vs 30%, p<0.001; median total fluid given in the first 24 hours: 84 mL/kg vs 117 mL/kg, p<0.01; starting insulin infusion rate 0.1 U/kg/hour: 54% vs 31%, p<0.01). However, these differences were consistent with guideline recommendations (initial fluid infusion rate within 5% of guideline-recommended rate: 80% in the 2015 group vs 84% in the 2020 group). There were no significant differences in outcomes (ICU admission: 26% vs 35%, p=0.2; cerebral oedema: 21% vs 23%, p=0.8).

CONCLUSIONS

Our study findings indicate that changes to fluid and insulin administration occurred after the 2020 BSPED guideline publication, with strong adherence to the guideline, but these changes were not associated with changes in key outcomes.

Investigating Polyphenol Nanoformulations for Therapeutic Targets against Diabetes Mellitus

Diabetes mellitus (DM) is a fatal metabolic disorder, and its prevalence has escalated in recent decades to a greater extent. Since the incidence and severity of the disease are constantly increasing, plenty of therapeutic approaches are being considered as a promising solution. Many dietary polyphenols have been reported to be effective against diabetes along with its accompanying vascular consequences by targeting multiple therapeutic targets. Additionally, the biocompatibility of these polyphenols raises questions about their use as pharmacological mediators. Nevertheless, the pharmacokinetic and biopharmaceutical properties of these polyphenols limit their clinical benefit as therapeutics. Pharmaceutical industries have attempted to improve compliance and therapeutic effects. However, nanotechnological approaches to overcome the pharmacokinetic and biopharmaceutical barriers associated with polyphenols as antidiabetic medications have been shown to be effective to improve clinical compliance and efficacy. Therefore, this review highlighted a comprehensive and up-to-date assessment of polyphenol nanoformulations in the treatment of diabetes and vascular consequences.

Fluid management in hospitalized pediatric patients

The proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.

Moderate and severe diabetic ketoacidosis at type 1 diabetes onset in children over two decades: A population-based study of prevalence and long-term glycemic outcomes

OBJECTIVE

To investigate in a population-based pediatric cohort: prevalence of moderate-severe diabetic ketoacidosis (DKA) at type 1 diabetes (T1D) diagnosis over two decades and its association with long-term glycemic control.

RESEARCH DESIGN AND METHODS

Children <16 years diagnosed with T1D in Western Australia 2000-2019 were included and followed up for ≤14 years. Moderate-severe DKA at diagnosis was defined as serum pH < 7.2 or bicarbonate<10 mmol/L with hyperglycemia and ketosis. HbA1c was measured ~3-monthly. Trend in prevalence of moderate-severe DKA at diagnosis was investigated using a logistic regression model adjusting for sex, age, socioeconomic status, and area of residence. Long-term glycemic control associated with DKA at diagnosis was investigated using linear mixed models adjusting for the same variables and also for visit frequency, CGM and pump use.

RESULTS

Moderate-severe DKA occurred in 534 of 2111 (25.3%) participants. Odds of presenting with moderate-severe DKA increased by 4.1% (95% CI: 2.3, 5.9; p < 0.001) per year. Patients with moderate-severe DKA at diagnosis had higher HbA1c levels than other patients initially; the groups were similar between 2 and 6 years duration; from 7 years HbA1c levels tracked higher in the group with moderate-severe DKA at diagnosis with significant differences at 8 and 12 years (p < 0.05).

CONCLUSION

The increasing prevalence of DKA at diagnosis of pediatric T1D is concerning and highlights the need for early detection programs. Unlike a similar US study, this study did not find a consistent, clinically significant relationship between DKA at diagnosis and long-term HbA1c, raising important questions about the influence of other factors on long-term glycemic outcomes.

Multimodal Neurologic Monitoring in Children With Acute Brain Injury

Children with acute neurologic illness are at high risk of mortality and long-term neurologic disability. Severe traumatic brain injury, cardiac arrest, stroke, and central nervous system infection are often complicated by cerebral hypoxia, hypoperfusion, and edema, leading to secondary neurologic injury and worse outcome. Owing to the paucity of targeted neuroprotective therapies for these conditions, management emphasizes close physiologic monitoring and supportive care. In this review, we will discuss advanced neurologic monitoring strategies in pediatric acute neurologic illness, emphasizing the physiologic concepts underlying each tool. We will also highlight recent innovations including novel monitoring modalities, and the application of neurologic monitoring in critically ill patients at risk of developing neurologic sequelae.

Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols

The best protocol for severe inaugural diabetic ketoacidosis (DKA) in children remains unclear. We compared two protocols by assessing effects during the first 24 h on osmolality, serum sodium, and glucose variations, which are associated with the risk of cerebral oedema, the most dreaded complication of DKA. We also recorded complications. We retrospectively included children aged 28 days to 18 years and admitted for severe DKA to either of two paediatric intensive care units (PICUs) in Paris (France). The two protocols differed regarding hydration volume, glucose intake, and sodium intake. From 17 June 2010 to 17 June 2015, 93 patients were included, 29 at one PICU, and 64 at the other. We compared severe glycaemic drops (> 5.5 mmol/L/h), mean glycaemia variations, serum sodium, serum osmolality, and the occurrence of cerebral oedema (CE) during the first 24 h after PICU admission. Severe glycaemic drops occurred in 70% of patients, with no between-group difference. Blood glucose, serum sodium, and serum osmolality variations were comparable. Seven (7.5%) patients were treated for suspected CE, (4 [10.3%)] and 3 [6.3%]) in each PICU; none had major residual impairments.

CONCLUSION

 The two paediatric DKA-management protocols differing in terms of fluid-volume, glucose, and sodium intakes had comparable effects on clinical and laboratory-test changes within 24 h. Major drops in glycaemia and osmolality were common with both protocols. No patients had residual neurological impairments.

WHAT IS KNOWN

• Cerebral oedema is the most severe complication of diabteic ketoacidosis in children.The risk of cerebral oedema is dependant on both patient related and treatment-related factors. • The optimal protocol for managing severe inaugural diabetic ketoacidosis in children remains unclear, and few studies have targeted this specific population.

WHAT IS NEW

• Two management protocols that complied with ISPAD guidelines but differed regarding the amounts of fluids, glucose, and sodium administered produced similar outcomes in children with severe inaugural diabetic ketoacidosis. • Cerebral oedema was rare with both protocols and caused no lasting impairments.

Diabetic Ketoacidosis at the Onset of Type 1 Diabetes Mellitus Among Children and Adolescents in Jeddah, Saudi Arabia: A Study From the Emergency Department

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM) and a leading cause of morbidity and mortality in children. We aim to assess the frequency, clinical characteristics, biochemical findings, and outcomes of DKA at the onset of T1DM in young children and adolescents.

DESIGN AND METHODS

This retrospective cohort study analyzed the medical records of patients ≤ 16 years old seen in the emergency department at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between April 2015 and June 2019. The severity of DKA was classified according to the International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria.

RESULTS

Out of 207 patients with T1DM, 53 presented with DKA as a new onset. The mean age was 8.51 ± 3.81 years, with the majority being 5-10 years old (52.8%). Polyuria (98.1%), polydipsia (86.8%), weight loss (62.3%), and abdominal pain and vomiting (45.3%) were the most frequent symptoms. Mean random blood glucose was 424.09 ± 108.67 mg/dL and mean venous pH was 7.15 ± 0.36 mmol/L. Of patients, 66% had no associated complications, 24.4% had hypokalemia, 20.8% developed hypoglycemia, and 18.9% developed hyperchloremic metabolic acidosis. One patient had cerebral edema and coma. Based on metabolic acidosis, 24.5% had mild DKA, an equal percentage had severe DKA, and 9.4% had moderate DKA. Of patients, 88.7% were admitted to the pediatric ward and 15.1% to the intensive care unit.

CONCLUSION

A total of 25% of patients diagnosed with T1DM below the age of 17 years presented with DKA. No permanent disabilities or deaths were reported. Forming a registry dedicated to T1DM is needed to follow up on these patients, especially among school-age children, as well as aid in the development of future research locally.

Has the COVID-19 Pandemic Affected the Prevalence of Diabetic Ketoacidosis in Polish Children with Newly Diagnosed Type 1 Diabetes? An Example of the Largest Polish Pediatric Diabetes Center (Upper Silesia—Katowice, Poland)

Purpose: The aim of this study was to analyze the prevalence of diabetic ketoacidosis (DKA) in children with newly disclosed type 1 diabetes (T1D) during the COVID-19 pandemic in 2020 compared to 2019. Methods: A retrospective analysis of the history database of all hospitalized children in our department. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines were used for the diagnosis of DKA. Results: The database of children with newly disclosed T1D included 196 patients (89 girls and 107 boys) from 2019, and 223 patients (113 girls and 110 boys) from 2020 (a total of 419 patients—202 girls and 217 boys) aged 0 to 18 years. A significantly higher percentage of DKA was observed in 2020 compared to the previous year (47.53% vs. 35.2% [p = 0.005]). The percentage of severe DKA increased in 2020 compared to 2019 (18.39% vs. 14.07% [p = 0.118]). Compared to 2019, the average HbA1c level was higher in 2020 (12.57 ± 2.75% vs. 11.95 ± 2.89% [p < 0.025]), and the average pH level (7.26 vs. 7.31 [p = 0.002], and average HCO3 level (16.40 vs. 18.66 [p = 0.001]) were lower, respectively. Conclusions: During the COVID-19 (2020) pandemic, the incidence of DKA increased in Polish children with newly diagnosed T1D. The conclusions from the analysis of the functioning of health systems during the pandemic should be used in the future to prevent, in similar periods, an increase in severe complications of delayed diagnosis of T1D.

Time trend in excess mortality in children with type 1 diabetes from 1987 to 2016 in mainland France

BACKGROUND

Mortality risk for children with type 1 diabetes (T1D) is unknown in France and their causes of death are not well documented.

AIM

To determine the standardized mortality ratios (SMRs) and causes of death in children aged 1-14 years with T1D from 1987 to 2016.

METHODS

The French Center for Epidemiology on Medical Causes of Death collected all death certificates in mainland France. SMRs, corrected SMRs (accounting for missing cases of deaths unrelated to diabetes), and 95% confidence intervals were calculated.

RESULTS

Of 146 deaths with the contribution of diabetes, 97 were due to T1D. Mean age at death of the subjects with T1D was 8.8 ± 4.1 years (54% males). The cause of death was diabetic ketoacidosis (DKA) in 58% of the cases (70% in subjects 1-4 years), hypoglycemia or dead-in-bed syndrome in 4%, related to diabetes but not described in 24%, and unrelated to diabetes in 14%. The SMRs showed a significant decrease across the years, except for the 1-4 age group. In the last decade (2007-2016), the crude and corrected SMRs were significantly different from 1 in the 1-4 age group (5.4 [2.3; 10.7] and 6.1 [2.8; 11.5]), no longer significant in the 5-9 age group (1.7 [0.6; 4.0] and 2.1 [0.8; 4.5]) and borderline significant in the 10-14 age group (1.7 [0.8; 3.2] and 2.3 [1.2; 4.0]).

CONCLUSIONS

Children with T1D aged 1-4 years still had a high mortality rate. Their needs for early recognition and safe management of diabetes are not being met.

Alarming Increase of Ketoacidosis Prevalence at Type 1 Diabetes-Onset in Austria-Results From a Nationwide Registry

OBJECTIVE

We analyzed the annual prevalence of onset-DKA (diabetic ketoacidosis) from 2012 to 2020 with a sub-analysis for lockdown-periods during the COVID-19 pandemic in 2020.

DESIGN

All newly diagnosed children with type 1 diabetes (T1D) aged <15 years are prospectively registered in the population-based Austrian Diabetes Incidence Study in Austria.

MAIN OUTCOME MEASURES

The annual DKA prevalence was analyzed using Joinpoint regression. Definition of DKA: pH <7.3, mild DKA: pH 7.3 to ≤ 7.1, severe DKA: pH <7.1. DKA prevalence during the lockdown periods in 2020 and the corresponding periods in 2015-2019 were examined using Fisher's exact test.

RESULTS

In the years 2012-2020 the mean prevalence for onset-DKA in Austria was 43.6% [95%CI (confidence interval): 41.6, 45.7] and thus above the mean prevalence of previous decades (1989-2011) of 37,1 % (95%CI: 35.6, 38.6). A particularly high prevalence was found among children <2 years of age (72.0% DKA, 32.8% severe DKA). No significant gender difference was found. Prevalence of severe DKA at T1D-onset increased significantly since 2015 (p = 0.023). During the lockdown in 2020, 59.3% of children were diagnosed with DKA at T1D-onset, compared to 42.1% during the previous 5 years (p = 0.022). Moreover, 20% of children had severe DKA at T1D diagnosis, compared to 14% during the comparison period.

CONCLUSIONS

The previously already high prevalence of DKA at T1D-onset has further increased over time. The COVID-19 pandemic has exacerbated the problem of a late or delayed diagnosis of diabetes in children resulting in onset-DKA. The alarmingly increased prevalence of DKA in Austrian children with T1D calls for urgent action.

Aversion to Hospital Admission Due to Fear of COVID Infection Leading to Fatality From Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a potentially life-threatening condition that occurs in patients with diabetes mellitus (DM) where the decrease in the insulin level leads to a state of metabolic acidosis and hyperglycemia. Based on the literature review, the risk of severity of DKA in children was significantly associated with coronavirus disease-2019 (COVID-19) cases during the first wave of the pandemic. This could be attributed to social distancing restrictions which delayed hospital presentation and timely treatment and interventions. We present the case of a 15-year-old female, with non-insulin-dependent diabetes (type 2), who presented during the COVID-19 pandemic with severe DKA from another hospital. She had elevated glucose level at home for three days that was worsening but her parents continue to manage the patient at home out of fear of the patient contracting COVID-19 if she was brought to the hospital. After she deteriorated, the parents took her to the nearest hospital which did not have a pediatric intensive care unit (PICU). She was immediately transferred to our facility. The patient was intubated immediately on arrival because of altered mental status possibly due to cerebral edema from severe metabolic acidosis and elevated glucose level. The patient rapidly progressed into shock, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction syndrome (MODS). She was managed aggressively with vasopressors, fluid resuscitation, and insulin drip. She had four cardiac arrests for which she was resuscitated. Despite all efforts, she subsequently expired less than 24 hours after admission. We intend on shedding light on an emerging phenomenon due to the ongoing COVID-19 pandemic, wherein due to the fear of contracting COVID-19, many parents opt to keep and manage sick children at home. This report highlights the important role that the aversion of presenting to medical establishments out of fear of contracting COVID-19 may have led to the untimely and preventable death of our patient. It also outlines the importance of future educational reforms toward changing the patient and family’s perception of hospitals and medical institutions, especially in children with pre-existing chronic medical conditions.

New-Onset Pediatric Diabetes Complicated By Diabetic Ketoacidosis and Invasive Rhinocerebral Mucormycosis With Internal Carotid Artery Occlusion

BACKGROUND

Diabetic ketoacidosis (DKA) has increased in prevalence in the emergency department (ED) in recent years. The complications of DKA are life threatening and necessitate rapid identification and management. Pediatric complications include cerebral edema, venous thrombosis, acute kidney injury, and severe infections including necrotizing fasciitis and mucormycosis. Rhinocerebral mucormycosis carries a high mortality rate and requires early treatment with antifungals and surgical debridement.

CASE REPORT

A 16-year-old boy with no significant past medical history presented to the ED with new-onset DKA complicated by hypothermia, hyperosmolar hyperglycemic state, cerebral edema, and multifactorial shock. During a complicated pediatric intensive care unit admission, he was found to have fatal invasive rhinocerebral mucormycosis, causing internal carotid artery occlusion with evidence of both direct and hematogenous spread into his brain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early identification of shock and appropriate management with intravenous fluids, vasopressors, and reversal of the underlying process is key in hypotensive children. In pediatric DKA, the emergency physician must consider cerebral edema, appropriate fluid resuscitation, and identify the likely precipitants leading to the onset of DKA. Thorough workup for potential precipitants should be initiated in the ED, searching for etiologies including infection, intoxication, insulin deficiency, inflammation, and ischemia. We must remember that pediatric patients, especially those with new DKA, are susceptible to life-threatening infection, including mucormycosis. Mucormycosis is a rare diagnosis, and management includes antifungal therapies and involvement of otorhinolaryngology.

Diabetic Ketoacidosis at Manifestation of Type 1 Diabetes in Childhood and Adolescence

BACKGROUND

Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic disorder that can occur with manifestation of type 1 diabetes mellitus (T1D). The aim of this study was to analyze the incidence of DKA at the time of the diagnosis of T1D in childhood and adolescence, the risk factors, and regional approaches to reduce the incidence of ketoacidosis.

METHODS

We investigated the proportion of patients under 18 years of age with DKA (defined as pH <7.3, severe DKA pH <7.1) at the manifestation of T1D in Germany in the period 2000-2019, based on data from the German-Austrian registry of diabetes (Diabetes-Patienten-Verlaufsdokumentation, DPV). The influence of the following factors was evaluated: year of manifestation, age, sex, family history of migration (MiH), and distance from the hospital. Moreover, data from the region with and the region without a pilot screening project from 2015 onwards were compared.

RESULTS

Of the 41 189 patients with manifestation of T1D, 19.8% presented with DKA (n = 8154, slight increase [p <0.001] over the study period) and 6.1% (n = 2513) had severe DKA. Children under 6 years of age had DKA more often than adolescents (12-17 years) (21.7% versus 18.6%, OR 1.22 {95% CI: [1.14; 1.30]}). Girls had a higher rate of DKA than boys (20.5% versus 19.2%, OR 1.10 [1.03; 1.14]), and patients with MiH were more likely to have DKA than those without MiH (21.4% versus 18.2%, OR 1.40 [1.32; 1.48]). In the region with a pilot screening project, the DKA rate stayed the same, at 20.6%, while in the control region the rate was 22.7% with a decreasing tendency.

CONCLUSION

The frequency of DKA at the time of diagnosis of T1D did not decrease between 2000 and 2019 and increased towards the end of the observation period. Children with MiH, children under 6, and girls were at a higher risk of DKA.

Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline

Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.

A review of risk factors associated with insulin omission for weight loss in type 1 diabetes

Research suggests that as many as 60% of people with type 1 diabetes (T1D) admit to misusing insulin. Insulin omission (IO) for the purpose of weight loss, often referred to as diabulimia, is a behaviour becoming increasingly recognised, not least since prolonged engagement can lead to serious vascular complications and mortality. Several risk factors appear to be relevant to the development of IO, most notably gender, anxiety and depression and increased weight concerns and body dissatisfaction. Evidence suggests that women, especially young girls, are more likely to omit insulin as a method of weight loss compared to men. Mental health conditions such as anxiety and depression are increasingly prevalent in people with T1D compared to their peers, and appear to contribute to the risk of IO. Increased weight concerns and body dissatisfaction are further prominent risk factors, especially given increases in weight which often occur following diagnosis and the monitoring of weight by diabetes teams. This review presents evidence examining these risk factors which increase the likelihood of a person with T1D engaging in IO and highlights the complications associated with prolongment of the behaviour. Further research looking at the comorbidities of these risk factors, alongside other factors, would provide greater insight into understanding IO in people with T1D.

Brain injury in children with diabetic ketoacidosis: Review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema

Cerebral edema (CE) is a potentially devastating complication of diabetic ketoacidosis (DKA) that almost exclusively occurs in children. Since its first description in 1936, numerous risk factors have been identified; however, there continues to be uncertainty concerning the mechanisms that lead to its development. Currently, the most widely accepted hypothesis posits that CE occurs as a result of ischemia-reperfusion injury, with inflammation and impaired cerebrovascular autoregulation contributing to its pathogenesis. The role of specific aspects of DKA treatment in the development of CE continues to be controversial. This review critically examines the literature on the pathophysiology of CE and attempts to categorize the findings by types of brain injury that contribute to its development: cytotoxic, vasogenic, and osmotic. Utilizing this scheme, we propose a multifactorial pathway for the development of CE in patients with DKA.

First report on the nationwide prevalence of paediatric type 1 diabetes in Serbia and temporal trends of diabetes ketoacidosis at diagnosis-a multicentre study

We aimed to collect data on all paediatric patients who were diagnosed with type 1 diabetes mellitus (T1DM) between the years 2000 and 2019 in Serbia and estimate for the first time its prevalence. Also, the trends of diabetes ketoacidosis (DKA) occurrence at the time of diagnosis are monitored. We collected and retrospectively analysed the data of patients <19 years with newly diagnosed T1DM. T1DM was diagnosed in 3134 patients (53.2% male). Total number of youth <19 years with T1DM was 1735 with prevalence of 135.25/100000 at the end of study period. T1DM was diagnosed most frequently between the ages of 5 and 11 years (42.1%). At the time of diagnosis, 35.7% presented in DKA. The incidence and severity of DKA were more significant at the youngest age (p<0.001). There were significant annual percentage increase (2.2%) in the number of new cases of DKA (p=0.007). Conclusion: This first report of nationwide prevalence of T1DM in youth shows that Serbia is among countries with high prevalence of T1DM in youth. System changes are needed in order to provide better quality of health care to these patients.

Diabetic ketoacidosis at diagnosis among youth with type 1 and type 2 diabetes: Results from SEARCH (United States) and YDR (India) registries

BACKGROUND

There is significant global variation in the prevalence of diabetic ketoacidosis (DKA) at diagnosis among youth with type 1 diabetes (T1D). However, data for youth with type 2 diabetes (T2D) are limited, even in developed countries. We compared the prevalence of DKA at diagnosis among individuals with T1D and T2D from the SEARCH for Diabetes in Youth (SEARCH) and the Registry of Youth Onset Diabetes in India (YDR) registries.

METHODS

We harmonized the SEARCH and YDR registries to the structure and terminology in the Observational Medical Outcome Partnership Common Data Model. Data used were from youth with T1D and T2D diagnosed before 20 years and newly diagnosed between 2006 and 2012 in YDR and 2009 and 2012 in SEARCH.

RESULTS

There were 5366 US youth (4078 with T1D, 1288 with T2D) and 2335 Indian youth (2108 with T1D, 227 with T2D). More than one third of T1D youth enrolled in SEARCH had DKA at diagnosis which was significantly higher than in YDR (35.3% vs 28.7%, P < .0001). The burden of DKA in youth with T1D was significantly higher among younger age groups; this relationship was similar across registries (P = .4). The prevalence of DKA among T2D in SEARCH and YDR were 5.5% and 6.6% respectively (P = .4).

CONCLUSIONS

There is significant burden of DKA at diagnosis with T1D among youth from United States and India, especially among the younger age groups. The reasons for this high prevalence are largely unknown but are critical to developing interventions to prevent DKA at diagnosis.

10-Year Incidence of Diabetic Ketoacidosis at Type 1 Diabetes Diagnosis in Children Aged Less Than 16 Years From a Large Regional Center (Hangzhou, China)

BACKGROUND

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of type 1 diabetes (T1D), and a leading cause of death in children aged <15 years with new-onset T1D.

AIMS

i) to assess the incidence of DKA in children and adolescents newly diagnosed with T1D over a 10-year period at a large regional center in China; and ii) to examine the clinical symptoms and demographic factors associated with DKA and its severity at diagnosis.

METHODS

We carried out a retrospective audit of a regional center, encompassing all youth aged <16 years diagnosed with T1D in 2009-2018 at the Children's Hospital, Zhejiang University School of Medicine (Hangzhou, China). DKA and its severity were classified according to ISPAD 2018 guidelines.

RESULTS

681 children were diagnosed with T1D, 50.1% having DKA at presentation (36.0% mild, 30.0% moderate, and 33.9% severe DKA). The number of patients diagnosed with T1D progressively rose from approximately 39 cases/year in 2009-2010 to 95 cases/year in 2017-2018 (≈2.5-fold increase), rising primarily among children aged 5-9 years. DKA incidence was unchanged but variable (44.8% to 56.8%). At T1D diagnosis, 89% of patients reported polyuria and 91% polydipsia. Children presenting with DKA were more likely to report vomiting, abdominal pain, and particularly fatigue. DKA was most common among the youngest children, affecting 4 in 5 children aged <2 years (81.4%), in comparison to 53.3%, 42.7%, and 49.3% of patients aged 2-4, 5-9, and ≥10 years, respectively. Children with severe DKA were more likely to report vomiting, fatigue, and abdominal pain, but less likely to report polyuria, polydipsia, and polyphagia than those with mild/moderate DKA. Rates of severe DKA were highest in children aged <2 years (51.1%).

CONCLUSIONS

The number of children diagnosed with T1D at our regional center increased over the study period, but DKA rates were unchanged. With 9 of 10 children reporting polyuria and polydipsia prior to T1D diagnosis, increasing awareness of this condition in the community and among primary care physicians could lead to earlier diagnosis, and thus potentially reduce rates of DKA at presentation.

Effects of ketogenic diet and ketone bodies on the cardiovascular system: Concentration matters

Ketone bodies have emerged as central mediators of metabolic health, and multiple beneficial effects of a ketogenic diet, impacting metabolism, neuronal pathologies and, to a certain extent, tumorigenesis, have been reported both in animal models and clinical research. Ketone bodies, endogenously produced by the liver, act pleiotropically as metabolic intermediates, signaling molecules, and epigenetic modifiers. The endothelium and the vascular system are central regulators of the organism’s metabolic state and become dysfunctional in cardiovascular disease, atherosclerosis, and diabetic micro- and macrovascular complications. As physiological circulating ketone bodies can attain millimolar concentrations, the endothelium is the first-line cell lineage exposed to them. While in diabetic ketoacidosis high ketone body concentrations are detrimental to the vasculature, recent research revealed that ketone bodies in the low millimolar range may exert beneficial effects on endothelial cell (EC) functioning by modulating the EC inflammatory status, senescence, and metabolism. Here, we review the long-held evidence of detrimental cardiovascular effects of ketoacidosis as well as the more recent evidence for a positive impact of ketone bodies—at lower concentrations—on the ECs metabolism and vascular physiology and the subjacent cellular and molecular mechanisms. We also explore arising controversies in the field and discuss the importance of ketone body concentrations in relation to their effects. At low concentration, endogenously produced ketone bodies upon uptake of a ketogenic diet or supplemented ketone bodies (or their precursors) may prove beneficial to ameliorate endothelial function and, consequently, pathologies in which endothelial damage occurs.

Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus

Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.

A combined risk score enhances prediction of type 1 diabetes among susceptible children

Type 1 diabetes (T1D)-an autoimmune disease that destroys the pancreatic islets, resulting in insulin deficiency-often begins early in life when islet autoantibody appearance signals high risk1. However, clinical diabetes can follow in weeks or only after decades, and is very difficult to predict. Ketoacidosis at onset remains common2,3 and is most severe in the very young4,5, in whom it can be life threatening and difficult to treat6-9. Autoantibody surveillance programs effectively prevent most ketoacidosis10-12 but require frequent evaluations whose expense limits public health adoption13. Prevention therapies applied before onset, when greater islet mass remains, have rarely been feasible14 because individuals at greatest risk of impending T1D are difficult to identify. To remedy this, we sought accurate, cost-effective estimation of future T1D risk by developing a combined risk score incorporating both fixed and variable factors (genetic, clinical and immunological) in 7,798 high-risk children followed closely from birth for 9.3 years. Compared with autoantibodies alone, the combined model dramatically improves T1D prediction at ≥2 years of age over horizons up to 8 years of age (area under the receiver operating characteristic curve ≥ 0.9), doubles the estimated efficiency of population-based newborn screening to prevent ketoacidosis, and enables individualized risk estimates for better prevention trial selection.

Diabetic Ketoacidosis Complicated by a Brain Death

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). Cerebral edema (CE) can complicate DKA management. We report a patient with no significant medical history who presented with DKA and a new-onset DM; she received the standard management with regular insulin and IV fluids, the management resulted in a rapid drop in serum osmolality, the patient`s mental status deteriorated and became nonresponsive, brain imaging confirmed CE, a few days later the patient was declared brain dead by neurology. This case highlights the importance of gradual correction of hyperosmolar conditions including hyperglycemia and urges all healthcare providers to closely trend glucose levels in the management of DKA.

Children with onset-ketoacidosis are admitted to the nearest hospital available, regardless of center size

Background To investigate longitudinal trends of admissions with diabetic ketoacidosis (DKA) in new-onset type 1 diabetes (T1D) and subsequent duration of hospitalization in association with structural health care properties, such as size of treatment facility, population density and linear distance between home and treatment centers. Methods Data from 24,321 German and Austrian pediatric patients with newly-diagnosed T1D between 2008 and 2017 within the DPV registry were analyzed. Results Onset-DKA rates fluctuated at around 19% and slightly increased over the observation period (p<0.001). Compared to children without onset-DKA, children with onset-DKA were more frequently treated at centers located closer to their homes, independent of center size or urbanity. Annual median duration of hospitalization decreased from 13.1 (12.6;13.6) to 12.7 (12.3;13.2) days (p<0.001). It was highest in patients younger than 5 years, with migration background, and in severe DKA. Conclusion Patients with onset-DKA are admitted to the nearest hospital, independent of center size. Facilities close to patients' homes therefore play an important role in the acute management of T1D onset. In Germany and Austria, diabetes education at diagnosis is mainly performed in inpatient settings. This is reflected by a long duration of hospitalization, which has decreased only slightly over the past decade.

Fatal Cerebral Edema in a Young Adult with Diabetic Ketoacidosis: Blame the Bicarbonate?

Cerebral edema is a devastating complication of DKA which is extremely rare in adults but is the leading cause of diabetes-related death in the pediatric population. Newly diagnosed diabetes, younger age, first episode of DKA, severity of DKA at presentation, and administration of bicarbonate are predictive of cerebral edema in DKA. We present a case of a young adult with DKA as the presenting symptom of diabetes, whose clinical course was complicated by renal failure, refractory shock, and cerebral edema. This case addresses the controversy surrounding bicarbonate therapy in DKA and its possible role in the development of a rare fatal complication of DKA.

Lifestyle changes and glycemic control in type 1 diabetes mellitus: a trial protocol with factorial design approach

BACKGROUND

Type 1 diabetes (T1D) has been increasing globally over the past three decades. Self-monitoring of blood glucose is a challenge in both developed as well as developing countries. Self-management guidelines include maintaining logbooks for blood glucose, physical activity, and dietary intake that affect glycated hemoglobin (HbA1c) and a multitude of life-threatening acute complications. Innovative, cost-effective interventions along with beneficial lifestyle modifications can improve home-based self-monitoring of blood glucose in T1D patients. The overall objective of this study is to evaluate the relationship between maintaining log books for blood glucose levels, reinforcement by e-messages, and/or daily step count and changes in HbA1c.

METHODS/DESIGN

A randomized controlled trial will enroll participants aged 15 years and above in four groups. Each group of 30 participants will be working with a newly designed standard log book for documenting their blood glucose. The first group will be entirely on routine clinical care, the second group will be on routine care and will receive an additional e-device for recording step count (fit bit), the third group will receive routine care and daily motivational e-messages to maintain the log book, and the fourth group along with routine care will receive an e-device for measuring step count (fit bit) and e-messages about maintaining the log book. Patients will be enrolled from pediatric and endocrine clinics of a tertiary care hospital in Karachi. All groups will be followed up for a period of 6 months to evaluate outcomes. Log book data will be obtained every 3 months electronically or during a patient's clinic visit. HbA1c as a main outcome will be measured at baseline and will be evaluated twice every 3 months. A baseline questionnaire will determine the socio-demographic, nutritional, and physical activity profile of patients. Clinical information for T1D and other co-morbidities for age of onset, duration, complications, hospitalizations, habits for managing T1D, and other lifestyle characteristics will be ascertained. Behavioral modifications for maintaining daily log books as a routine, following e-messages alone, fit bit alone, or e-messages plus using fit bit will be assessed for changes in HbA1c using a generalized estimated equation.

DISCUSSION

The proposed interventions will help identify whether maintaining log books for blood glucose, motivational e-messages, and/or daily step count will reduce HbA1c levels.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03864991. March 6, 2019.

A Quality Improvement Initiative to Reduce Hospitalizations for Low-risk Diabetic Ketoacidosis

BACKGROUND AND OBJECTIVES

Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness.

METHODS

We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes.

RESULTS

We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; P = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized.

CONCLUSIONS

Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.

Comparison of Intraoperative Glycemic Levels in Infants with the Use of Ringer Lactate with Supplemental 1% versus 2% Dextrose as Maintenance Fluid

Context

There is no consensus regarding the concentration of dextrose supplementation to be used in pediatric patients intraoperatively.

Aims

The primary objective was to assess the effect of using Ringer lactate (RL) with 1% versus 2% dextrose as maintenance fluid in infants on intraoperative blood glucose levels. The secondary objectives included assessment of incidence of hyperglycemia and hypoglycemia in both groups.

Settings and Design

This was a prospective randomized study conducted in a tertiary care teaching institute.

Subjects and Methods

Forty infants undergoing cheiloplasty or palatoplasty were included. All patients fasted 6 h for solids and formula feeds, 4 h for breast milk, and 2 h for clear fluids and received general anesthesia as per standardized protocol. Patients belonging to Group 1 received RL with 1% dextrose supplementation, whereas Group 2 received RL with 2% dextrose added to it as an intraoperative maintenance fluid. Random blood sugar (RBS) was checked preoperatively and then at 60 min and 120 min after induction. Hypoglycemia was defined as RBS <70 mg/dL and hyperglycemia as RBS >150 mg/dL.

Statistical Analysis Used

Independent sample ttest and Pearson's Chisquare test were used for statistical analysis.

Results

Preoperative RBS was comparable in both groups. RBS at 60 and 120 min was significantly higher in Group 2 compared to Group 1. There was no incidence of hypoglycemia in both groups, and the incidence of hyperglycemia was similar in both groups.

Conclusion

Use of RL with 2% dextrose as intraoperative maintenance fluid in infants resulted in significant increase in blood sugar levels as compared to addition of 1% dextrose although the incidence of hyperglycemia remained comparable in both groups.