Ketoacidosis occurring in newly diagnosed and established diabetic children

Implementation of an Intravenous Fluid Titration Algorithm to Treat Pediatric Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a common cause of admission to the pediatric intensive care unit and many centers utilize the "two-bag system" to treat DKA. We developed an intravenous fluid (IVF) titration algorithm to standardize adjustments of the two bags. A retrospective cohort study was performed comparing 155 patients treated before and 175 patients treated after implementation of the IVF titration algorithm. Postimplementation patients reached the blood glucose target zone faster and had a higher probability of remaining at goal while on insulin infusion. There was no significant difference in incidence of cerebral edema or hypoglycemia between study groups. Overall IVF titration algorithm compliance was 95%. Implementation of an IVF titration algorithm is safe and effective when treating DKA in children.

"Keeping it on your radar"-assessing the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood: A qualitative study from the early detection of type 1 diabetes in youth study

AIMS

The aim of this study was to explore from the perspectives of key stakeholders involved in the pathway to diagnosis, the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood.

METHODS

Qualitative interviews and free-text analyses were undertaken in 21 parents with a child diagnosed with type 1 diabetes, 60 parents without a child diagnosed with type 1 diabetes, 9 primary healthcare professionals, 9 teachers and 3 community diabetes liaison nurses. Data were analysed thematically and 30% double coded.

RESULTS

Two key themes were identified, namely the importance of widespread awareness and knowledge and seeking healthcare professional help. Parents with a child diagnosed with type 1 diabetes described seeking opinions from a number of individuals prior to seeking health professional help. Healthcare professionals recognized the rarity of the condition and the need for it to be kept on their "radar", to ensure they considered it when examining an unwell child. The process of obtaining a primary healthcare appointment was identified as potentially playing a crucial role in the diagnostic process. However, most parents with a child diagnosed with type 1 diabetes described receiving an appointment on the day they sought it.

CONCLUSIONS

Knowledge and awareness of type 1 diabetes in childhood remain limited in the general population and misconceptions persist relating to how children present with this serious condition. An effective community-based intervention to raise awareness amongst key stakeholders is required to ensure children receive a timely diagnosis once symptomatic.

Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis

OBJECTIVE

To identify patterns of outpatient care associated with diabetic ketoacidosis (DKA) among pediatric patients with type 1 diabetes (T1D).

METHODS

Retrospective cohort study using Medicaid claims data from 2009 to 2012 for children with T1D enrolled ≥365 consecutive days in California Children's Services, a Title V program for low-income children with chronic disease. Outcome was DKA hospitalization >30 days after enrollment. Outpatient visits to primary care, endocrinology, pharmacies, and emergency departments (EDs) were assessed during the 6 months before an index date: either date of first DKA hospitalization or end of enrollment for those without DKA. Univariate and multivariate analysis was used to evaluate independent associations between DKA and outpatient care at clinically meaningful intervals preceding the index date.

RESULTS

Among 5263 children with T1D, 16.7% experienced DKA during the study period. Patients with DKA were more likely to have had an ED visit (adjusted odds ratio [aOR] 3.99, 95% confidence interval [CI]: 2.60-6.13) or a nonpreventive primary care visit (aOR 1.35, 95% CI: 1.01-1.79) within 14 days before the index date, and less likely to have visited an endocrinologist (aOR 0.76, 95% CI: 0.65-0.89) within the preceding 120 days. Preventive visits and pharmacy claims were not associated with DKA.

CONCLUSIONS

For children with T1D, recent ED visits and long intervals without subspecialty care are important signals of impending DKA. Combined with other known risk factors, these health-use indicators could be used to inform clinical and case management interventions that aim to prevent DKA hospitalizations.

Quality of care in rural youth with type 1 diabetes: a cross-sectional pilot assessment

BACKGROUND

Type 1 diabetes mellitus (T1DM) presents a significant health burden for patients and families. The quality of care (QOC) among those living in rural communities is thought to be subpar compared with those in urban communities; however, little data exist to reflect this, especially in pediatric diabetes.

OBJECTIVE

The purpose of this pilot study was to investigate diabetes QOC among families living in rural versus urban areas. 6 QOC markers were used to compare youth with T1DM: appointment adherence, patient-provider communication, diabetes education during clinic visit, congruency with diabetes standards of care, diabetes self-management behaviors, and diabetes-related hospitalizations.

RESEARCH DESIGN AND METHODS

Participants were rural or urban adult caregivers of youth ages 2-18 with ≥10-month history of T1DM receiving treatment at Seattle Children's Hospital, USA. Participants were from rural areas of central Washington, or urban areas of western Washington. Caregivers completed a 26-item survey pertaining to the 6 QOC markers. The 6 QOC markers were compared across 61 participants (34 rural, 27 urban), to determine how diabetes care quality and experiences differed. Data were collected over 12 months. Groups were compared using t-tests and χ² tests, as appropriate.

RESULTS

Compared with urban families, rural families reported significantly lower income and a 4-fold greater usage of public insurance. Among the QOC measures, rural participants were significantly worse off in the appointment adherence, patient-provider communication, and hospitalizations categories. Congruence with diabetes standards of care (foot care only) was also significantly poorer in rural participants.

CONCLUSIONS

The burden of travel in conjunction with the lack of resources in this rural population of families with T1DM youth is cause for concern and warrants further research.

Biomarkers and genetics of brain injury risk in diabetic ketoacidosis: A pilot study

Diabetic ketoacidosis (DKA) is the primary cause of death for children with diabetes, especially when complicated by cerebral edema. Central nervous system (CNS) involvement is common, however the mechanism of, and predictors of CNS dysfunction/injury are largely unknown. In this observational pilot study, blood was collected from pediatric DKA patients at three time points (consent, 12 hr and 24 hr after beginning treatment), to test genetic markers, ribonucleic acid expression and plasma biomarkers reflecting inflammation (tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and cerebral dysfunction and/or possible injury (S100β, glial fibrillary acidic protein [GFAP]). Thirty patients were enrolled in the study. The average age was 11.3 yr, 73% were new onset diabetes and 53% were female. Forty percent exhibited abnormal mentation (Glasgow Coma Scale <15), consistent with CNS dysfunction. IL-6 and TNF-α were elevated in plasma, suggesting systemic inflammation. GFAP was measurable in 45% of patients and correlated positively with GCS. Only two patients had detectable levels of S100β. In conclusion, children with DKA often present with evidence of acute neurologic dysfunction or injury. We have demonstrated the feasibility of exploring genetic and biochemical markers of potential importance in the pathophysiology of CNS dysfunction and/or possible injury in DKA. We have identified IL-6, TNF-α and GFAP as potentially important markers for further exploration. A larger, follow-up study will help to better understand the extent and type of CNS injury in DKA as well as the mechanism underlying this dysfunction/injury.

Delayed diagnosis and issues with pump usage are the leading causes of diabetic ketoacidosis in children with diabetes living in Newfoundland and Labrador, Canada

Background

Newfoundland and Labrador (NL) has a very high incidence of type 1 diabetes (T1DM) and admission rate for diabetic ketoacidosis (DKA). The purpose of this study was to identify characteristics and precipitating factors associated with pediatric DKA in this population.

Methods

This was a retrospective study on children diagnosed with DKA from 2007–2011 admitted to the province’s only tertiary care pediatric hospital. Demographics, biochemical characteristics, and reasons for DKA diagnosis were analyzed. Chi-square and Fisher Exact tests were performed for categorical variables; t- and non-parametric Kruskal-Wallis tests were performed for continuous variables.

Results

A total of 90 children were admitted with DKA (39.5% newly diagnosed; 60.5% were previously diagnosed). The rate of DKA on presentation for incident cases was 22.1%. More severe cases of DKA occurred in younger, newly diagnosed patients. Almost half of preexisting diabetes cases were recurrent DKA (49.1%). The most common presenting characteristics of newly diagnosed patients were weight loss, bedwetting, polyuria, polydipsia, and neurologic symptoms. Pre-existing diabetes patients most often presented with abdominal pain and vomiting. Diagnosis of diabetes in new patients and issues related to interrupted insulin delivery in pre-existing patients using insulin pump therapy were the most common factors associated with DKA. Of the newly diagnosed patients presenting in DKA, 64% had seen a physician in the weeks leading up to diagnosis.

Conclusions

Pediatric patients have predictable patterns associated with a diagnosis of DKA. Most cases of DKA could be prevented with earlier diagnosis and improved education and problem-solving by families and health care providers. DKA preventative strategies are recommended and should be aimed at patients, their families, and health care professionals especially those outside of pediatric centers.

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

AIMS/HYPOTHESIS

Type 1 diabetes is the most frequent endocrine disease in children, with 65,000 children diagnosed worldwide every year. Up to 80% of these children present with diabetic ketoacidosis (DKA), which is associated with both short-term risks and long-term consequences. This study aimed to characterise the worldwide variation in presentation of type 1 diabetes to inform future interventions to reduce this excess morbidity and mortality.

METHODS

This was a systematic review of studies indexed on PubMed, EMBASE, Web of Science, Scopus or CINAHL before March 2011 that included unselected groups of children presenting with new-onset type 1 diabetes, reported the proportion presenting with DKA and used a definition of DKA based on measurement of pH or bicarbonate.

RESULTS

Sixty-five studies of cohorts comprising over 29,000 children in 31 countries were included. The frequency of DKA at diagnosis ranged from 12.8% to 80%, with highest frequencies in the United Arab Emirates, Saudi Arabia and Romania, and the lowest in Sweden, the Slovak Republic and Canada. Multivariable modelling showed the frequency of DKA was inversely associated with gross domestic product, latitude and background incidence of type 1 diabetes.

CONCLUSIONS/INTERPRETATION

This is the first description of the variation in frequency of DKA at presentation of type 1 diabetes in children across countries. It demonstrates large variations that may, at least in part, be explained by different levels of disease awareness and healthcare provision and suggests ways to decrease the excess morbidity and mortality associated with DKA at diagnosis.

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

OBJECTIVE

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

DESIGN

Systematic review.

DATA SOURCES

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

STUDY SELECTION

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

RESULTS

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

CONCLUSIONS

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

Telehealth behavior therapy for the management of type 1 diabetes in adolescents

BACKGROUND

Poor management of type 1 diabetes mellitus (T1DM) may result in serious medical complications. Psychological intervention may improve adherence to medical regimens; however, access to trained professionals is limited, particularly in rural communities. Telehealth interventions may address this by allowing families to access services at home; however, little is known about the efficacy of such services.

METHOD

This study presents results from a pilot trial of a randomized waitlist controlled trial of Telehealth Behavioral Therapy (TBT) for youths with T1DM. Primary outcome measures were adherence to the diabetes regimen, glycemic control, and level of family discord. Thirty-two youths (23 female) with T1DM (aged 9 to 17 years) and one parent or caregiver participated. Telehealth Behavioral Therapy sessions were conducted thrice weekly for 12 weeks by phone and lasted an average of 15 min each.

RESULTS

Results indicated that youths in treatment decreased their hemoglobin A1c by 0.74 compared to 0.09 in the waitlist, though this was not statistically significant. Youths in treatment reported increased unsupportive and decreased caring parental behaviors.

CONCLUSION

Telehealth Behavioral Therapy improves access to knowledgeable providers and results in a clinically significant improvement in glycemic control. Despite some youths experiencing an increase in unsupportive parental behaviors, TBT is a promising method of service delivery that warrants further investigation.

Multisystemic therapy for adolescents with poorly controlled type 1 diabetes: reduced diabetic ketoacidosis admissions and related costs over 24 months

OBJECTIVE

The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated.

RESEARCH DESIGN AND METHODS

A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care.

RESULTS

Youth who received MST had significantly fewer hospital admissions than control subjects (chi(2) = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions.

CONCLUSIONS

The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

Hospital admission patterns subsequent to diagnosis of type 1 diabetes in children : a systematic review

Background

Patients with type 1 diabetes are known to have a higher hospital admission rate than the underlying population and may also be admitted for procedures that would normally be carried out on a day surgery basis for non-diabetics. Emergency admission rates have sometimes been used as indicators of quality of diabetes care.

In preparation for a study of hospital admissions, a systematic review was carried out on hospital admissions for children diagnosed with type 1 diabetes, whilst under the age of 15. The main thrust of this review was to ascertain where there were gaps in the literature for studies investigating post-diagnosis hospitalisations, rather than to try to draw conclusions from the disparate data sets.

Methods

A systematic search of the electronic databases PubMed, Cochrane LibrarMEDLINE and EMBASE was conducted for the period 1986 to 2006, to identify publications relating to hospital admissions subsequent to the diagnosis of type 1 diabetes under the age of 15.

Results

Thirty-two publications met all inclusion criteria, 16 in Northern America, 11 in Europe and 5 in Australasia. Most of the studies selected were focussed on diabetic ketoacidosis (DKA) or diabetes-related hospital admissions and only four studies included data on all admissions. Admission rates with DKA as primary diagnosis varied widely between 0.01 to 0.18 per patient-year as did those for other diabetes-related co-morbidity ranging from 0.05 to 0.38 per patient year, making it difficult to interpret data from different study designs. However, people with Type 1 diabetes are three times more likely to be hospitalised than the non-diabetic populations and stay in hospital twice as long.

Conclusion

Few studies report on all admissions to hospital in patients diagnosed with type 1 diabetes whilst under the age of 15 years. Health care costs for type 1 patients are higher than those for the general population and information on associated patterns of hospitalisation might help to target interventions to reduce the cost of hospital admissions.

Insulin glargine supplementation during early management phase of diabetic ketoacidosis in children

OBJECTIVE

To study the effect of subcutaneous administration of insulin glargine on the rate of resolution of acidosis and intravenous insulin infusion requirement in children with moderate and severe diabetic ketoacidosis (DKA).

STUDY DESIGN

Retrospective cohort study.

SETTING

Pediatric intensive care unit of a university-based children's hospital.

PATIENTS

Children with moderate to severe DKA admitted between March 2001 and February 2003.

RESULTS

The outcomes of children who received 0.3 units/kg of subcutaneous insulin glargine in the first 6 h of management in addition to the standard treatment (n=12) were compared with those of children who received standard treatment alone (n=59). Measured outcomes included dose of intravenous insulin required, duration of insulin infusion and acidosis correction time. The two groups were similar in demographics and severity of illness. The mean time for acidosis correction (venous pH>or=7.3) in the insulin glargine group was shorter than the standard therapy group (12.4+/-2.9 h and 17.1+/-6.2 h respectively, p<0.001). The insulin infusion time was shorter in the insulin glargine group (14.8+/-6.0 h vs 24.4+/-9.0 h, p<0.001). There was a trend towards shorter total hospital stay in the glargine group (3.2+/-1.0 days vs 3.72+/-1.06 days).

CONCLUSIONS

In our small series of children with moderate and severe DKA, supplementing with subcutaneous insulin glargine led to a faster resolution of acidosis without any adverse effects. This could potentially lead to a shorter need for insulin infusion and a shorter ICU length of stay.

Hypoglycemia and ketoacidosis with insulin pump therapy in children and adolescents

This review deals with the two most serious side effects encountered with insulin pump therapy, severe hypoglycemia and diabetic ketoacidosis (DKA). Although clinical follow-up studies reported decreased rates of severe hypoglycemia, randomized studies have not confirmed this, showing no difference between the pump and injection groups. Less-severe hypoglycemia (mild/moderate/symptomatic hypoglycemia) was found to be more common with pump use. Some patients have inadvertently dosed or overdosed while awake or during sleep, causing fatal outcome in rare cases. Population-based or retrospective clinical studies reported a low rate of DKA in pump users that was still a higher rate than those using injection therapy, at least in some countries. In research settings and for patients with good compliance and adequate family support, the risk of DKA seems lower; many short-term studies report no DKA at all, possibly due to the increased attention given to participants. The use of continuous subcutaneous insulin infusion (CSII) seems to decrease the risk in patients who had recurrent DKA before pump start. Most episodes of DKA occur early after pump start, suggesting a learning curve occurs in all new forms of treatment. Increased teaching and awareness programs are vital to prevent severe hypoglycemia and DKA in children and adolescents using insulin pumps.

Twenty years of a multidisciplinary paediatric diabetes home care unit

As only a minority of patients with type 1 diabetes are unwell at diagnosis, these patients could be managed at home if appropriate facilities were available. A multidisciplinary diabetes home care service was established over 20 years ago at Birmingham Children's Hospital, to support children with diabetes mellitus within the home environment from diagnosis, reducing emotional upset and separation. Despite increase in the size and distribution of the unit over this time (from 230 to 400 patients (now spread over two hospitals)), the proportion of newly diagnosed children managed wholly at home (median 43%; range 31-67%), and the reduction in number and duration of admissions has been sustained (readmission rate with diabetic ketoacidosis 4.1 bed-days per 100 patients/year; range 2.9-7.1), with no deterioration in overall blood glucose control. In this way the savings achieved by reductions in expensive hospital bed occupancy have more than offset the costs of maintaining the unit.

ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents

Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.