Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics

Development and validation of a nomogram to predict diabetes ketoacidosis resolution time in a tertiary care hospital in the United Arab Emirates

AIM

This study aimed to develop and validate a nomogram to predict prolonged diabetes ketoacidosis (DKA) resolution time (DRT).

METHODS

We retrospectively extracted sociodemographic, clinical, and laboratory data from the electronic medical records of 394 adult patients with DKA admitted to Tawam Hospital between January 2017 and October 2022. Logistic regression stepwise model was developed to predict DRT ≥ 24 h. Model discrimination was evaluated using C-index and calibration was determined using calibration plot and Brier score.

RESULTS

The patients' average age was 34 years; 54 % were female. Using the stepwise model, the final variables including sex, diabetes mellitus type, loss of consciousness at presentation, presence of infection at presentation, body mass index, heart rate, and venous blood gas pH at presentation were used to generate a nomogram to predict DRT ≥ 24 h. The C-index was 0.76 in the stepwise model, indicating good discrimination. Despite the calibration curve of the stepwise model showing a slight overestimation of risk at higher predicted risk levels, the Brier score for the model was 0.17, indicating both good calibration and predictive accuracy.

CONCLUSION

An effective nomogram was established for estimating the likelihood of DRT ≥ 24 h, facilitating better resource allocation and personalized treatment strategy.

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.

Using Clinical Vignettes to Understand the Complexity of Diagnosing Type 1 Diabetes in Sub-Saharan Africa

Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.

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.

The phenotype of type 1 diabetes in sub-Saharan Africa

The phenotype of type 1 diabetes in Africa, especially sub-Saharan Africa, is poorly understood. Most previously conducted studies have suggested that type 1 diabetes may have a different phenotype from the classical form of the disease described in western literature. Making an accurate diagnosis of type 1 diabetes in Africa is challenging, given the predominance of atypical diabetes forms and limited resources. The peak age of onset of type 1 diabetes in sub-Saharan Africa seems to occur after 18-20 years. Multiple studies have reported lower rates of islet autoantibodies ranging from 20 to 60% amongst people with type 1 diabetes in African populations, lower than that reported in other populations. Some studies have reported much higher levels of retained endogenous insulin secretion than in type 1 diabetes elsewhere, with lower rates of type 1 diabetes genetic susceptibility and HLA haplotypes. The HLA DR3 appears to be the most predominant HLA haplotype amongst people with type 1 diabetes in sub-Saharan Africa than the HLA DR4 haplotype. Some type 1 diabetes studies in sub-Saharan Africa have been limited by small sample sizes and diverse methods employed. Robust studies close to diabetes onset are sparse. Large prospective studies with well-standardized methodologies in people at or close to diabetes diagnosis in different population groups will be paramount to provide further insight into the phenotype of type 1 diabetes in sub-Saharan Africa.

Health system capacity to manage diabetic ketoacidosis in nine low-income and lower-middle income countries: A cross-sectional analysis of nationally representative survey data

BACKGROUND

There has been increasing awareness about the importance of type 1 diabetes (T1D) globally. Diabetic ketoacidosis (DKA) is a life-threatening complication of T1D in low-income settings. Little is known about health system capacity to manage DKA in low- and lower-middle income countries (LLMICs). As such, we describe health system capacity to diagnose and manage DKA across nine LLMICs using data from Service Provision Assessments.

METHODS

In this cross-sectional study, we used data from Service Provision Assessment (SPA) surveys, which are part of the Demographic and Health Survey (DHS) Program. We defined an item set to diagnose and manage DKA in higher-level (tertiary or secondary) facilities, and a set to assess and refer patients presenting to lower-level (primary) facilities. We quantified each item's availability by service level in Bangladesh (Survey 1: May 22 2014-Jul 20 2014; Survey 2: Jul 2017-Oct 2017), the Democratic Republic of the Congo (DRC) (Oct 16 2017-Nov 24 2017 in Kinshasha; Aug 08 2018-Apr 20 2018 in rest of country), Haiti (Survey 1: Mar 05 2013-Jul 2013; Survey 2: Dec 16 2017-May 09 2018), Ethiopia (Feb 06 2014-Mar 09 2014), Malawi (Phase 1: Jun 11 2013-Aug 20 2013; Phase 2: Nov 13 2013-Feb 7 2014), Nepal (Phase 1: Apr 20 2015-Apr 25 2015; Phase 2: Jun 04 2015-Nov 05 2015), Senegal (Survey 1: Jan 2014-Oct 2014; Survey 2: Feb 09 2015-Nov 10 2015; Survey 3: Feb 2016-Nov 2016; Survey 4: Mar 13 2017-Dec 15 2017; Survey 5: Apr 15 2018-Dec 31 2018; Survey 6: Apr 15 2019-Feb 28 2020), Tanzania (Oct 20 2014-Feb 21 2015), and Afghanistan (Nov 1 2018-Jan 20 2019). Variation in secondary facilities' capacity and trends over time were also explored.

FINDINGS

We examined data from 2028 higher-level and 7534 lower-level facilities. Of these, 1874 higher-level and 6636 lower-level facilities' data were eligible for analysis. Availability of all item sets were low at higher-level facilities, where less than 50% had the minimal set of supplies, less than 20% had the full minimal set, and less than 15% had the ideal set needed to diagnose and manage DKA. Across countries in lower-level facilities, less than 14% had the minimal set of supplies and less than 9% the full set of supplies for diagnosis and transfer of DKA patients. No country had more than 20% of facilities with the minimal set of items needed to assess or manage DKA. Where data were available for more than one survey (Bangladesh, Senegal, and Haiti), changes in availability of the minimal set and ideal set of items did not exceed 15%. Tertiary facilities performed best in Haiti, Ethiopia, Malawi, Nepal, Senegal, Tanzania, and Afghanistan. Secondary facilities that were rural, public, and had fewer staff had lower capacity.

INTERPRETATION

Health system capacity to manage DKA was low across these nine LLMICs. Although efforts are underway to strengthen health systems, a specific focus on DKA management is still needed.

FUNDING

Leona M. and Harry B. Helmsley Charitable Trust, and Juvenile Diabetes Research Foundation Ltd.

Factors Associated With Diabetic Ketoacidosis at Onset of Type 1 Diabetes Among Pediatric Patients: A Systematic Review

IMPORTANCE

Presenting with diabetic ketoacidosis (DKA) at onset of type 1 diabetes (T1D) remains a risk. Following a 2011 systematic review, considerable additional articles have been published, and the review required updating.

OBJECTIVE

To evaluate factors associated with DKA at the onset of T1D among pediatric patients.

EVIDENCE REVIEW

In this systematic review, PubMed, Embase, Scopus, CINAHL, Web of Science, and article reference lists were searched using the population, intervention, comparison, outcome search strategy for primary research studies on DKA and T1D onset among individuals younger than 18 years that were published from January 2011 to November 2021. These studies were combined with a 2011 systematic review on the same topic. Data were pooled using a random-effects model.

FINDINGS

A total of 2565 articles were identified; 149 were included, along with 46 from the previous review (total 195 articles). Thirty-eight factors were identified and examined for their association with DKA at T1D onset. Factors associated with increased risk of DKA were younger age at T1D onset (<2 years vs ≥2 years; odds ratio [OR], 3.51; 95% CI, 2.85-4.32; P < .001), belonging to an ethnic minority population (OR, 0.40; 95% CI, 0.21-0.74; P = .004), and family history of T1D (OR, 0.46; 95% CI, 0.37-0.57; P < .001), consistent with the 2011 systematic review. Some factors that were not associated with DKA in the 2011 systematic review were associated with DKA in the present review (eg, delayed diagnosis: OR, 2.27; 95% CI, 1.72-3.01; P < .001). Additional factors associated with risk of DKA among patients with new-onset T1D included participation in screening programs (OR, 0.35; 95% CI, 0.21-0.59; P < .001) and presentation during the COVID-19 pandemic (OR, 2.32; 95% CI, 1.76-3.06; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, age younger than 2 years at T1D onset, belonging to an ethnic minority population, delayed diagnosis or misdiagnosis, and presenting during the COVID-19 pandemic were associated with increased risk of DKA. Factors associated with decreased risk of DKA included greater knowledge of key signs or symptoms of DKA, such as a family history of T1D or participation in screening programs. Future work should focus on identifying and implementing strategies related to these factors to reduce risk of DKA among new patients with T1D.

Sociodemographic determinants of glycaemic control among children with type 1 diabetes in South Eastern Nigeria

INTRODUCTION

diabetic complications have been identified as the major causes of morbidity and mortality in persons with type 1 diabetes mellitus (T1DM). Lack of appropriate glycaemic control is a significant risk factor for the onset and progression of long term complications of diabetes. Identifying the determinants of good glycaemic control is therefore imperative.

METHODS

this was a cross-sectional, hospital-based study of children aged 3-18 years with T1DM. Subjects were consecutively enrolled after obtaining consent from their parents and assent from children aged ≥7 years. A questionnaire was completed recording their clinical history and sociodemographic variables. Their HbA1c was estimated and values ≤7.5% was defined as the cut-off for optimal glycaemic control.

RESULTS

seventy-one children with T1DM were enrolled for the study. Thirty-eight (53.5%) of them were males. Mean age (years) was 13.7±4. Mean age at onset of diabetes was 11.6 years (range: 3-16 years), mean duration of diabetes was 24.4 months (range: 4-84 months), mean HbA1c value was 10.5% (range: 6.4%-14%); a multivariate logistic regression analysis was performed to identify determinants of optimal glycaemic control. Only caregivers' involvement in diabetes management P<0.016, odd ratio 13.03 (95% CI: 1.60-105.95) was identified as determinant of good glycaemic control.

CONCLUSION

our data suggest that of all the sociodemographic factors studied, caregivers' involvement in diabetes management was the only strong determinant for optimal glycaemic control.

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.

Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP)

BACKGROUND AND AIM

Diabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations.

METHODS AND RESULTS

Electronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis.

CONCLUSION

Prompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.

The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis

OBJECTIVE

Despite the guidelines, significant variations can be encountered in initial therapy for pediatric diabetic ketoacidosis (DKA) in the prehospital setting. These variations occur mostly in fluid administration, insulin dosing, route of administration, and other aspects of the initial resuscitation and stabilization. The aim was to identify the effect of transport care on outcomes in children with DKA admitted to the emergency department (ED).

METHODS

Patients admitted to a tertiary-care pediatric ED between 2015-2019 with a diagnosis of DKA were retrospectively identified. Details of pre-pediatric ED care, including transport modality, patient demographics, clinical features, laboratory evaluation, fluid therapy, insulin dosing, and short-term outcome were recorded.

RESULTS

The study cohort included 147 episodes of DKA in 136 patients aged 9 months-21 years. Emergency Medical Service (EMS) transported only 37.4% of cases. EMS utilization rate was significantly higher (p=0.003) in severe cases, most of whom were >10 years (p=0.04). During transport 85% received intravenous fluid bolus. Use of fluids other than normal saline was significantly higher when transport time was >30 minutes (p=0.001). Acute kidney injury and cerebral edema developed in 21.7% and 7.4% of episodes, respectively. These complications were more common in the EMS transport group. Pediatric intensive care admission rate was also higher in the EMS compared to the non-EMS group (p=0.01).

CONCLUSION

Parents did not call the ambulance for most cases although a higher complication rate occurred in EMS patients. EMS providers and referral facilities should improve their knowledge of pediatric DKA.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

Association of diabetic ketoacidosis and HbA1c at onset with year-three HbA1c in children and adolescents with type 1 diabetes: Data from the International SWEET Registry

OBJECTIVE

To establish whether diabetic ketoacidosis (DKA) or HbA1c at onset is associated with year-three HbA1c in children with type 1 diabetes (T1D).

METHODS

Children with T1D from the SWEET registry, diagnosed <18 years, with documented clinical presentation, HbA1c at onset and follow-up were included. Participants were categorized according to T1D onset: (a) DKA (DKA with coma, DKA without coma, no DKA); (b) HbA1c at onset (low [<10%], medium [10 to <12%], high [≥12%]). To adjust for demographics, linear regression was applied with interaction terms for DKA and HbA1c at onset groups (adjusted means with 95% CI). Association between year-three HbA1c and both HbA1c and presentation at onset was analyzed (Vuong test).

RESULTS

Among 1420 children (54% males; median age at onset 9.1 years [Q1;Q3: 5.8;12.2]), 6% of children experienced DKA with coma, 37% DKA without coma, and 57% no DKA. Year-three HbA1c was lower in the low compared to high HbA1c at onset group, both in the DKA without coma (7.1% [6.8;7.4] vs 7.6% [7.5;7.8], P = .03) and in the no DKA group (7.4% [7.2;7.5] vs 7.8% [7.6;7.9], P = .01), without differences between low and medium HbA1c at onset groups. Year-three HbA1c did not differ among HbA1c at onset groups in the DKA with coma group. HbA1c at onset as an explanatory variable was more closely associated with year-three HbA1c compared to presentation at onset groups (P = .02).

CONCLUSIONS

Year-three HbA1c is more closely related to HbA1c than to DKA at onset; earlier hyperglycemia detection might be crucial to improving year-three HbA1c.

A Ten-Year Review of the Pattern and Outcome of Childhood Diabetes in Two State Teaching Hospitals in South-West Nigeria

BACKGROUND

Childhood diabetes mellitus is a poorly researched topic in Nigeria. Its contribution to morbidity and mortality is vague. This study intends to provide additional information to the background data in Nigeria and hopefully proffers strategies to improving the outcome of this disease.

METHODS

This is a retrospective descriptive study of all children managed for childhood diabetes mellitus at the Ekiti State University Teaching Hospital (EKSUTH) and LAUTECH Teaching Hospital (LTH), South West Nigeria, over a 10 year period. Relevant information was obtained from the case notes of all affected children. Data obtained were analysed with SPSS version 20 software.

RESULTS

A total of 20 children were treated for diabetes mellitus (DM); there were 7 (35.0%) boys and 13 (65.0%) girls giving a M:F ratio of 1.0:1.9. Age range at presentation was 5 to 16 years and the mean age at presentation was 12.7 ± 2.89 years. Diabetic ketoacidosis (DKA) was the most common form of presentation in 13 (65.0%). Most [18 (90.0%)] of the patients had type 1 DM. Type 2 DM and glucocorticoid-induced diabetes mellitus were recorded in a case each, Eighteen (90%)patients had not been previously diagnosed by any form of screening prior to their presentation and admission in the hospital. Seven (35.0%) of the patient's care were affected by parental financial constraints. Five mortalities were recorded and one left against medical advice while the majority [14 (70.4%)] were discharged well and alive. The association between the greater numbers of deaths recorded in children with financial constraints was statistically significant (p < 0.05).

CONCLUSION

Type 1 DM remains the most predominant form of diabetes in children and most of the patients presented in DKA. The proportion of deaths in this study is unacceptably high. There is a need to proffer strategies for earlier detection and management of children with diabetes mellitus prior to the onset or development of DKA and there is a need to assist with the funding of the care of children with diabetes mellitus.

Outcomes of Children and Adolescents Admitted with Diabetic Ketoacidosis at Kenyatta National Hospital (KNH), Kenya

BACKGROUND

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication that mainly occurs in patients with type 1 diabetes mellitus and is the foremost cause of death in these children. Overall mortality in children with DKA varies from 3.4% to 13.4% in developing countries. There is a need to understand outcomes among children with DKA in sub-Saharan African countries.

OBJECTIVE

To determine the death rate and clinical outcomes of children and adolescents aged 0-18 years managed for DKA at Kenyatta National Hospital (KNH). Study Methods. This was a retrospective study carried out among children aged 0-18 years admitted with DKA at KNH between February 2013 and February 2018. The study site was the central records department at KNH. The inclusion criteria were children aged 0-18 years admitted with a diagnosis of DKA based on the ISPAD guidelines biochemical criteria.

RESULTS

Out of the 159 files reviewed, the median age of children was 13 years (IQR 10-15). 41.1% of patients had severe DKA while 35.7% had moderate DKA. We reported a mortality of 6.9% while 93.1% of children recovered and were discharged home. The median duration of hospital stay was 8 days. High risk of mortality was reported among children who had high serum creatinine (OR 5.8 (95% CI 1.6-21.2)), decreased urine output (OR 9.0 (95% CI 2.2-37.3)), and altered level of consciousness (OR 5.2 (95% CI 1.1-25.1)).

CONCLUSION

DKA-associated mortality in our study was low at 6.9%. High serum creatinine, decreased urine output, and altered level of consciousness were associated with a significantly higher risk of mortality.

Type 1 diabetes mellitus in Gabon: A study of epidemiological aspects

BACKGROUND AND OBJECTIVE

Type 1 diabetes mellitus (T1DM) is the most frequent endocrinopathy in children. Its replacement therapy requires insulin, without which, death is inevitable. This treatment is expensive and a financial burden for diabetic children and their families, especially in Africa.In the absence of a national T1DM register, the purpose of this study was to describe epidemiological aspects of type 1 diabetes in children in Gabon, specify the difficulties met by the patients during the follow-up and identify factors explaining poor therapeutic observance and metabolic control.

MATERIAL AND METHODS

Prospective transversal monocentric study. Data were firstly extracted from the registers of the Endocrinology Department of the University Hospital of Libreville (CHUL), Gabon, between 2010 and 2017.Secondly, patients were interviewed by telephone about the availability and cost of insulin, their self-monitoring of blood glucose, and diet.

RESULTS

306 patients (154 girls and 152 boys) were diagnosed with T1D during the study period and followed-up in the Endocrinology Department at CHUL. Mean age at diagnosis was 17 ± 7 years (5% of patients were over 5 years of age, 30% were >20 years old). Mean follow-up period was 4.0 ± 2.0 years. 16% of the patients were hospitalized at least 2 times per month for ketoacidosis.Hospital mortality was about 7%. Number of factors linked with poor therapeutic observance (high cost of treatment, lack of patients' therapeutic education, etc.) were identified.

CONCLUSION

T1D prevalence is constantly increasing worldwide, but at slower pace in Africa in comparison to developed countries. Difficulties to access to high standard care and population poverty in Sub-Saharan Africa, represents a major independent factor of poor therapeutic observance.

Diabetic ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes in Tigray, Ethiopia: retrospective observational study

Background: Diabetic ketoacidosis (DKA) is the most severe acute complication of type 1 diabetes mellitus which results in increased risk of morbidity and mortality especially in developing countries. Objective: To assess prevalence and associated factors of diabetic ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes in hospitals of the Tigray region, Ethiopia. Methods: A facility based retrospective observational study design was conducted in newly diagnosed type 1 diabetic children and adolescents up to the age of 18 years who were registered in 13 general and two referral hospitals from January 1, 2013 to December 30, 2017. The diagnosis of diabetic ketoacidosis was made with the criteria below, Children presenting with polysymptoms, weight loss, vomiting, dehydration, and also the indirect signs or effects of acidosis on respiratory and central nervous systems like Kussmaul breathing, lethargy or coma and biochemically random blood sugar level >11 ml/L, glucosuria and urine ketone >+1 and diagnosed with type 1 diabetes for the first time. Descriptive, Mann-Whitney U and logistic regression analysis were carried out to describe and identify the associated factors with diabetic ketoacidosis. Results: More than three-quarters, 258/328 (78.7%) of the newly diagnosed type 1 diabetes patients, presented with diabetic ketoacidosis at initial diagnosis. Median age of diabetic ketoacidosis patients was 11 years. The patients with diabetic ketoacidosis were younger than nondiabetic ketoacidosis patients (11 vs 13 years, P=0.002). The mortality rate of diabetic ketoacidosis was 4.3%. Young age, presence of precipitating factors and symptoms of DKA/diabetes were found to be highly associated with diabetic ketoacidosis at initial diagnosis. Conclusions: The prevalence of diabetic ketoacidosis was alarmingly high. Young age group patients, precipitating factors and the presence of symptoms of diabetes/DKA like excessive drinking, vomiting and fatigue were highly associated with diabetic ketoacidosis.

Frequency, clinical characteristics, biochemical findings and outcomes of DKA at the onset of type-1 DM in young children and adolescents living in a developing country - an experience from a pediatric emergency department

Background As per the International Society for Pediatrics and Adolescent Diabetes (ISPAD) census, diabetic ketoacidosis (DKA) is the most frequent cause of diabetes-related death. In developing countries, DKA-related mortality rate ranges from 6% to 24% (Onyiriuka AN, Ifebi E. Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics. J Diabetes Metab Disord 2013;12:47) in contrast to 0.15%-0.31% in the Western world (Poovazhagi V. Risk factors for mortality in children with diabetic ketoacidosis from developing countries. World J Diabetes 2014;5:932-93.). In developing countries like Pakistan, the situation is more perplexing owing to uncertain or under-reported statistics about the spectrum of the disease and its prevalence, coupled with limited access to medical care and experts as well as less awareness. These limitations restrict our ability to develop interventions that are patient-centered. Our main objective was to determine the severity, clinical features, bio-chemical findings and outcomes of DKA in children aged 1 month to 16 years. Subjects and methods This retrospective study included the analysis of medical and laboratory records from patients' medical charts and the electronic database of all children aged 1 month to 16 years with newly diagnosed type-1 diabetes mellitus (T1DM) complicated with ketoacidosis, who presented to the emergency department (ED) at the Aga Khan University Hospital (AKUH), between January 2009 and December 2014. Results Diabetes mellitus complicated with DKA was the predominant diagnosis (n=113 [75.83%]) among endocrine diseases in children visiting the ED. Our study witnessed an increase in the incidence of DKA particularly after 5 years of age, with more severity in females. In our study, the mortality rate was 3.4%. Conclusions Considering the high incidence and mortality rate, it is emphasized that DKA should be considered in differential diagnosis. An awareness campaign for both general pediatricians and physicians as well as for the public is needed for better outcomes.

[Diabetic ketoacidosis in children: epidemiological and prognostic aspects]

INTRODUCTION

In Congo, data on diabetic ketoacidosis (DKA) in children are old and rare. This study aims to describe the sociodemographic features of DKA and to identify risk factors for mortality.

PATIENTS AND METHODS

We conducted an analytical study on DKA in childred at the University Hospital in Brazzaville over the period from January 2013 to June 2016. We examined the socio-demographic, clinical, paraclinical and evolutionary variables. Chi-Square Test, Fisher's exact test and odds ratio were used in the univariate analysis process and logistic regression model in the multivariate analysis.

RESULTS

Out of 172 children hospitalized with diabetes 55 (31%) were hospitalized with ketoacidosis. They were girls (33; 60%) with an average age of 11.1± 4.9 years (ranging from 1 months to 17 years), 61.8% of parents came from low socioeconomic status. Ketoacidosis was the revealing symptom in 67.2 % of cases. The diagnosis made before hospitalization was wrong (50%). The triggering factor was often an infection (52.7%). Mortality rate was 12.7%. The risk factors for mortality in the univariate analysis were: age < 5 years (p=0,000006), average consultation time higher than 7 days (p= 0.001), severe dehydration (p = 0.0006), hemodynamic disorders (p= 0.0006), severe undernutrition (p= 0.02), Glasgow Coma Scale < 9 (p= 0.007) and diarrhea (p= 0.001).

CONCLUSION

The importance and the seriousness of ketoacidosis impose preventive measures based on awareness, information and education campaigns as well as on the management of risk factors for mortality.

High incidence of diabetic ketoacidosis at diagnosis of type 1 diabetes among Polish children aged 10-12 and under 5 years of age: A multicenter study

AIM

Despite its characteristic symptoms, type 1 diabetes (T1D) is still diagnosed late causing the development of diabetic ketoacidosis (DKA). The aim of this study was to estimate the incidence of DKA and factors associated with the development of acidosis at T1D recognition in Polish children aged 0-17.

METHODS

The study population consisted of 2100 children with newly diagnosed T1D in the years 2010-2014 in 7 hospitals in eastern and central Poland. The population living in these areas accounts for 35% of the Polish population. DKA was defined as a capillary pH < 7.3, blood glucose > 11 mmol/L. The analyzed data included age, sex, diabetes recognition, pH, glycated hemoglobin (HbA1c), fasting C-peptide, and body mass index standard deviation score (BMI-SDS).

RESULTS

We observed DKA in 28.6% of children. There were 2 peaks in DKA occurrence: in children <5 years of age (33.9%) and aged 10-12 (34%). The highest incidence of DKA was noted in children aged 0-2 (48.4%). In the group with DKA, moderate and severe DKA occurred in 46.7% of children. Girls and children <2 years of age were more prone to severe DKA. The multiple logistic regression analysis showed the following factors associated with DKA: age (P = .002), fasting C-peptide (P = .0001), HbA1c (P = .0001), no family history of T1D (P = .0001), and BMI-SDS (P = .0001).

CONCLUSIONS

The incidence of DKA is high and remained unchanged over the last 5 years. Increasing the awareness of symptoms of DKA is recommended among children <5 years of age (especially <2 years of age) and aged 10-12. Children <2 years of age and girls were at the highest risk of severe DKA.

Clinical profile of diabetes at diagnosis among children and adolescents at an endocrine clinic in Ghana

AIM

To determine the clinical features of diabetes in children and adolescents in Ghana.

METHODS

Retrospective review of clinical features of all children and adolescents with new-onset diabetes seen at the paediatric endocrinology clinic of Komfo Anokye Teaching Hospital in Kumasi, from February 2012 to Auguest 2016.

RESULTS

One hundred and six subjects presented with diabetes. Ninety (84.9%) were diagnosed by clinical features and family history as type 1, and 16 (15.1%) type 2. For type 1 subjects, age range at diagnosis was 0.9-19.9 year (y), peak age of onset 12-13 year, and 3.3% were < 5 year, 21.1% 5- < 10 year, 45.6% 10- < 15 year and 30.0% 15- < 20 year. Seventy-one point one percent were female. Common clinical features were polyuria (100%), polydipsia (98.9%), and weight loss (82.2%). Mean BMI SD was -0.54, range -3.84 to 2.47. 60.0% presented in diabetic ketoacidosis (DKA). Nine had infections at onset (skin, abscess, leg ulcer). Mean ± SD HbA1c at diagnosis was 12.7% ± 1.9% (115 ± 21 mmol/mol). Four have since died: Hypoglycaemia (2), recurrent DKA (1), osteosarcoma (1). Two other type 1 cases died of DKA at presentation in emergency before being seen by the paediatric endocrinologist. Crude mortality rate including these 2 cases was 32.2/1000 patient years. Type 2 cases were 81% female, age of onset 9-19 year. Mean BMI SD was 1.49, range -0.87 to 2.61. Forty-three point eight percent presented in DKA. All type 2 cases had acanthosis nigricans. Overall, 9.8% did not have home refrigeration, most using clay pot evaporative cooling for insulin storage.

CONCLUSION

Type 1 occurs with a female preponderance and high DKA rates. Type 2 also occurs. Typology based on clinical features is difficult. Community and professional awareness is warranted.

Cortisol Levels in Children With Diabetic Ketoacidosis Associated With New-Onset Type 1 Diabetes Mellitus

There is little data documenting cortisol levels in children with diabetic ketoacidosis (DKA), despite the fact that untreated adrenal insufficiency (AI) could worsen the outcome of DKA. In this cross-sectional study, we assessed serum cortisol levels in 28 children with DKA and new onset type 1 diabetes mellitus evaluated at our center over a 5-year period. Average duration of diabetes-related symptoms was positively associated with age ( P = .002), and significantly lower hemoglobin A1c levels were observed in the youngest children. The mean cortisol level was 40.9 µg/dL, with a range of 7.8 to 119 µg/dL. Cortisol levels were found to be inversely associated with serum pH ( P = .007). There was no difference in the clinical outcome of the 4 patients who had cortisol levels less than 18 µg/dL. Overall, we did not find clinical or laboratory evidence of diminished cortisol reserve; however, the possibility of AI must be kept in mind when treating children with DKA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Childhood diabetes in Africa

PURPOSE OF REVIEW

This review summarizes the current state of diabetes in African children.

RECENT FINDINGS

Type 1 diabetes is the most common form of pediatric diabetes in Africa. Significant improvements have been achieved over the last 6 years, including the training of more than 60 pediatric endocrinologists who are now practicing in 14 African nations, greater training of other healthcare providers, increased availability of insulin through the efforts of philanthropic organizations and industry, modestly better availability of testing supplies, and the introduction of patient education materials in native languages. However, there is still a long way to go before the standard-of-care available to children in resource-rich nations is available to children with diabetes in Africa.

SUMMARY

Here, we review the known epidemiology, pathophysiology, complications, and treatment of diabetes in children in Africa.

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.

Glycemic Control in Kenyan Children and Adolescents with Type 1 Diabetes Mellitus

Background. Type 1 diabetes mellitus (T1DM) is the most common endocrine disorder in children and adolescents worldwide. While data about prevalence, treatment, and complications are recorded in many countries, few data exist for Sub-Saharan Africa. The aim of this study was to determine the degree of control in patients with T1DM aged 1-19 years over a 6-month period in 3 outpatient Kenyan clinics. It also sought to determine how control was influenced by parameters of patient and treatment. Methods. Eighty-two children and adolescents with T1DM were included in the study. Clinical history regarding duration of illness, type and dose of insulin, and recent symptoms of hypoglycemia/hyperglycemia were recorded. Glycaemia, HbA1c, and ketonuria were tested. HbA1c of 8.0% and below was defined as the cut-off for acceptable control. Results. The median HbA1c for the study population was 11.1% (range: 6.3-18.8). Overall, only 28% of patients had reasonable glycemic control as defined in this study. 72% therefore had poor control. It was also found that age above 12 years was significantly associated with poor control. Conclusions. African children and with T1DM are poorly controlled particularly in adolescents. Our data strongly support the necessity of Kenya children to receive more aggressive management and follow-up.

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.