Campaign for diabetic ketoacidosis prevention still effective 8 years later

Use of teplizumab in children and adolescents at risk of type 1 diabetes: perspectives of parents and caregivers from an Italian Pediatric Diabetes Center

AIMS

In view of the imminent introduction of a novel category of disease-modifying treatments for type 1 diabetes (T1D) in European countries, it becomes imperative to understand the existing awareness and viewpoints of parents and caregivers of children and adolescents predisposed to T1D. This study aims to evaluate the perspectives of a cohort of parents and caregivers regarding using teplizumab to delay the onset of T1D in predisposed children and adolescents.

METHODS

This single-center study used a survey-based approach. Parents or caregivers of children and adolescents with T1D having at least one additional child without T1D answered 15 questions assessing their awareness about teplizumab, their potential willingness to provide consent for its administration in case of eligibility, and their expectations regarding potential outcomes.

RESULTS

Approximately half of the participants (52.6%) expressed readiness to consent to teplizumab administration for their child if the prescription criteria were met in the future. Only 6.3% of parents claimed detailed knowledge about this innovative medication. Notably, parents with prior experience of diabetic ketoacidosis (DKA) demonstrated a higher inclination to consent to teplizumab treatment (p = 0.018).

CONCLUSIONS

Our findings underscore the necessity for comprehensive awareness campaigns spreading the current evidence concerning teplizumab in terms of both effectiveness and possible side effects. Additionally, our study reinforces the pivotal role of DKA prevention in successfully integrating disease-modifying treatments into clinical practice.

Identification of diagnostic biomarkers used in the diagnosis of cardiovascular diseases and diabetes mellitus: A systematic review of quantitative studies

AIMS

To perform a systematic review of studies that sought to identify diagnostic biomarkers for the diagnosis of cardiovascular diseases (CVDs) and diabetes mellitus (DM), which could be used in low- and middle-income countries (LMICs) where there is a lack of diagnostic equipment, treatments and training.

MATERIALS AND METHODS

Papers were sourced from six databases: the British Nursing Index, Google Scholar, PubMed, Sage, Science Direct and Scopus. Articles published between January 2002 and January 2023 were systematically reviewed by three reviewers and appropriate search terms and inclusion/exclusion criteria were applied.

RESULTS

A total of 18 studies were yielded, as well as 234 diagnostic biomarkers (74 for CVD and 160 for DM). Primary biomarkers for the diagnosis of CVDs included growth differentiation factor 15 and neurogenic locus notch homologue protein 1 (Notch1). For the diagnosis of DM, alpha-2-macroglobulin, C-peptides, isoleucine, glucose, tyrosine, linoleic acid and valine were frequently reported across the included studies. Advanced analytical techniques, such as liquid chromatography mass spectrometry, enzyme-linked immunosorbent assays and vibrational spectroscopy, were also repeatedly reported in the included studies and were utilized in combination with traditional and alternative matrices such as fingernails, hair and saliva.

CONCLUSIONS

While advanced analytical techniques are expensive, laboratories in LMICs should carry out a cost-benefit analysis of their use. Alternatively, laboratories may want to explore emerging techniques such as infrared, Fourier transform-infrared and near-infrared spectroscopy, which allow sensitive noninvasive analysis.

Diabetic ketosis vs ketoacidosis as initial presentation of pediatric type 1 diabetes mellitus. Associated features and rate of progression during the first two years after diagnosis

AIMS

In this study we described the clinical and laboratory features of children presented with diabetic ketosis or diabetic ketoacidosis at diagnosis of type 1 diabetes (T1DM) and evaluated its course up to 2 years after initial diagnosis to investigate the progression rate of T1DM in both groups.

METHODS

This was a prospective longitudinal cohort study that included 59 children and adolescents presented with either diabetic ketosis (DK) (n = 27) or diabetic ketoacidosis (DKA) (n = 32) at their first diagnosis with T1DM.

RESULTS

Apart from the metabolic state of presentation at diagnosis, differences in the other basic clinical and laboratory features of both DK and DKA were not statistically significant (age, BMI, pre- diagnosis symptomatic period, HbA1c, multiplicity of autoantibodies positivity, fasting insulin, and total IgG levels), except from the C-peptide and IgA levels which were lower in DKA (p < 0.05). Regarding family history, only the DK group had individuals with a parent diagnosed with T1DM (p = 0.001). During follow-up there was no difference in the levels of HbA1c, basal insulin dose, and insulin/carbohydrate ratio between the DK and DKA group at 3,6,12 and 24 months' time points.

CONCLUSIONS

The severity of presentation of T1DM (DK or DKA) is not associated to the rate of progression of the disease course after diagnosis.

Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic

The incidence of pediatric diabetic ketoacidosis (DKA) increased during the peak of the COVID-19 pandemic. The objective of this study was to investigate whether rates of hyperosmolar therapy administration for suspected clinically apparent brain injury (CABI) complicating DKA also increased during this period as compared to the three years immediately preceding the pandemic and to compare the characteristics of patients with suspected CABI before the pandemic, patients with suspected CABI during the peak of the pandemic, and those with DKA but without suspected CABI during the pandemic. Patients aged ≤18 years presenting with DKA before (March 11, 2017-March 10, 2020) and during the peak of the pandemic (March 11, 2020-March 10, 2021) were identified through a rigorous search of two databases. Predefined criteria were used to diagnose suspected CABI. Biochemical, clinical, and sociodemographic data were collected from a comprehensive review of the electronic medical record. The proportion of patients with DKA who received hyperosmolar therapy was significantly higher (P = 0.014) during the pandemic compared to the prepandemic period; however, this was only significant among patients with newly diagnosed diabetes. Both groups with suspected CABI had more severe acidosis, lower Glasgow Coma Scale scores, and longer hospital admissions (P< 0.001 for all) than cases without suspected CABI. During the pandemic, the blood urea nitrogen concentration was significantly higher in patients with suspected CABI than those without suspected CABI, suggesting they were more severely dehydrated. The clinical, biochemical, and sociodemographic characteristics of patients with suspected CABI were indistinguishable before and during the pandemic. In conclusion, administration of hyperosmolar therapy for suspected CABI was more common during the peak of the COVID-19 pandemic, possibly a result of delayed presentation, highlighting the need for increased awareness and early recognition of the signs and symptoms of diabetes and DKA, especially during future surges of highly transmissible infections.

Delayed Management of Insulin-Dependent Diabetes Mellitus in Children

INTRODUCTION

Diabetic ketoacidosis (DKA) is a common presentation for pediatric new-onset insulin-dependent diabetes mellitus (IDDM). Delayed diagnosis is the major risk factor for DKA at disease onset.

METHOD

Two pediatric endocrinologists independently reviewed the admission records to assess the appropriateness of preadmission management in various health care settings.

RESULTS

Eighteen percent (n = 45) of patients with new-onset IDDM had a delayed diagnosis. Twenty-eight were misdiagnosed (respiratory [n = 9], nonspecific [n = 7], genitourinary [n = 4], gastrointestinal [n = 8] issues) and 17 were mismanaged. One child died within 4 hr of hospitalization, presumably because of a hyperosmolar coma. Forty-six percent (n = 21) of patients with delayed diagnosis presented with DKA, comprising 18% of all DKA cases.

DISCUSSION

A significant number of patients with new-onset IDDM were either misdiagnosed or mismanaged. All providers must be appropriately trained in diagnosing new-onset IDDM and follow the standard of clinical care practices.

COVID-19 and diabetes in children

This review describes the impact of coronavirus disease 2019 (COVID-19) in children and adolescents, investigating changes in diabetes presentation during the COVID-19 pandemic, possible links between severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection and diabetes, and mechanisms of pancreatic β-cell destruction. Although glycemic control in individuals with already known diabetes mellitus did not worsen during the pandemic, there was a worrying increase in diabetic ketoacidosis in children with new-onset diabetes, probably due to containment measures and delayed access to emergency departments. Moreover, new evidence suggests that SARS-CoV-2 has the capacity to directly and indirectly induce pancreatic β-cell destruction, and the risk of newly diagnosed diabetes after COVID-19 increased in both children and adults. While long-term studies continue to follow children with SARS-CoV-2 infection, this review discusses available findings on the relationship between COVID-19 and diabetes. It is important to emphasize the need to maintain close links between families of children with chronic conditions and their pediatricians, as well as to promote early access to healthcare services, in order to reduce dangerous delays in diabetes diagnosis and prevent diabetic ketoacidosis.

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.

Peculiar characteristics of new-onset Type 1 Diabetes during COVID-19 pandemic

Background

The COVID-19 pandemic period is having a strong impact on the management of diabetes as well as other chronic diseases as shown by the most severe clinical presentation at onset. The aim of this study was to evaluate the severity of diabetic ketoacidosis (DKA) in youth with newly diagnosed type 1 diabetes in “Santissima Annunziata Hospital” (Chieti, Italy) during COVID-19 pandemic in comparison to the five previous years.

Methods

A retrospective population-based incidence study was performed. Data were obtained from hospital records of 172 patients with new onset type 1 diabetes divided into two groups according to the diagnosis: Group I, between January 2015 and February 2020; Group II, between March 2020 and April 2021. Data regarding anthropometric, socio-economic and laboratory test were analyzed. DKA (pH < 7.30) and different severity of the disease (severe pH < 7.10; moderate pH < 7.20, mild pH < 7.30) were evaluated. A Spearman correlation between pH values and the main variables of interest was performed.

Results

DKA frequency was increased by 19 percentage in Group II compared to Group I (55% vs 36%; P = 0.03) with a significant increased risk of severe DKA cases compared to the previous five years (severe DKA 22.5% vs. 8.4%, P = 0.01). pH values were significantly related with HbA1c, blood glucose and c-peptide values in all groups. In addition, in Group II but not in Group I, pH values correlated with Triglycerides and TG/HDL cholesterol ratio.

Conclusions

During COVID-19 pandemic the risk of more severe clinical presentation of type 1 diabetes at onset is increased. The correlation with lipid profile might suppose an additional effect of lifestyle changes beside the delay in the diagnosis. Modifications of health care system need to be implemented during this peculiar situation in order to avoid such a relevant complication at onset.

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.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Effectiveness of ketoacidosis prevention campaigns at diagnosis of type 1 diabetes in children: A systematic review and meta-analysis

AIM

To determine if diabetes awareness campaigns are an effective intervention to reduce diabetes ketoacidosis at diagnosis of type 1 diabetes in children and youth.

METHODS

Search strategies included PubMed, Scopus, CINAHL and WOS electronic databases, hand search of select journals and a grey literature search "Google" search to include all relevant information. Studies included community-based interventions focused on children younger than 18 years old. The difference in the frequency of DKA was measured in two separate comparisons; before and after perform awareness campaigns in the same area, and between areas with and without intervention campaigns.

RESULTS

Of 1136 records identified, 14 studies were eligible for the analysis. The first group of 12 studies measured DKA at diagnosis, before (n = 6548 individuals) and after (n = 4931 individuals) the awareness campaigns. The pooled difference was a reduction of 7.20% (95%CI: 0.99-13.41). The second group of four studies measured the difference in an area with no intervention (n = 338 individuals) and in an area with an awareness campaign (n = 187 individuals). The pooled difference in DKA was 35.71% (95%CI: 5.81-65.61).

CONCLUSIONS

This review demonstrated that DKA awareness campaigns are effective to reduce DKA among children and adolescents with type 1 diabetes and the core components that explain why these campaigns are effective. Back to top.

Prevalence and factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes: A report from a tertiary medical center in Central Pennsylvania

Objective

To explore the rate and factors associated with diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) in a single tertiary medical centre in Central Pennsylvania.

Methods

Retrospective chart review of all individuals ≤ 18 years of age who were diagnosed with T1D (N = 350) at the Penn State Hershey Pediatric Diabetes Clinic from January 2017 to December 2019. We report logistic regression models for DKA at diagnosis of T1D for age, gender, race/ethnicity, BMI percentile, health insurance, outcome of any healthcare encounter 30 days prior to T1D diagnosis, HbA1c level, altered mental status at diagnosis, and diagnosis of autism spectrum disorder and a multivariable logistic regression model including all aforementioned variables.

Results

Of the 350 newly diagnosed children with T1D from 2017 to 2019, 161/350 (46%) presented in DKA. Among patients with DKA, there were 45 (28%) in mild DKA and 116 (72%) in moderate/severe DKA, which represents 13% and 33% of all patients diagnosed with T1D, respectively. Variables associated with increased risk of DKA at presentation of T1D included age (<3 or 9-13), BMI percentile (<3% or > 97%), no referral during preceding healthcare encounter, HbA1c level and altered mental status. In a multivariable model, age (<3 or 9-13), no referral during preceding healthcare encounter, HbA1c level and altered mental status were associated with DKA at presentation, whereas gender, race/ethnicity, BMI percentile, health insurance and autism spectrum disorder diagnosis were not.

Discussion

Our study notes an overall higher rate of DKA at diagnosis (46%) compared to the SEARCH study (approximately 30%) but a lower rate compared to a recent study in Colorado children (58%).

Visits at the primary clinic do not reduce ketoacidosis rates at presentation in type 1 diabetes mellitus

AIM

The rate of diabetic ketoacidosis at time of diagnosis of type 1 diabetes remains high. We examined whether visits to a primary care clinic up to a month prior to diagnosis of new onset diabetes affected ketoacidosis rates.

METHODS

Retrospective chart review of children who were diagnosed with type 1 diabetes from January 1, 2010, to December 31, 2014. Data collection included demographics, age at diagnosis, number of visits to the primary care clinic during the month prior the diagnosis, relevance to diabetes and outcome of those visits and the presence of ketoacidosis at diagnosis. We examined the relationship between the rate of ketoacidosis at diagnosis and the number of visits in the clinic, and to the demographic characteristics.

RESULTS

Of 159 patients, 115 visited their clinic in the month prior to diagnosis of type 1 diabetes. The rate of ketoacidosis at diagnosis was similar between those who visited the clinic and those who did not (37.4% compared to 38.6%). There was no difference in ketoacidosis rates between the different ethnic and socio-economic groups.

CONCLUSION

Medical encounters in the month prior to diagnosis of type 1 diabetes did not reduce ketoacidosis rates in children.

Parent and Pediatrician Preferences for Type 1 Diabetes Screening in the U.S

OBJECTIVE

The purpose of this study was to use a discrete-choice experiment methodology to understand the relative importance of the attributes of screening tests for type 1 diabetes among parents and pediatricians in the U.S.

RESEARCH DESIGN AND METHODS

Online surveys presented hypothetical screening test profiles from which respondents chose their preferred test profile. Survey attributes were based on likely screening test options and included the mode of administration, where and when the test was conducted, the type of education and monitoring available to lower the risk of diabetic ketoacidosis (DKA), and whether a treatment was available that would delay onset of insulin dependence. Data were analyzed using random-parameters logit models.

RESULTS

Parents placed the highest relative importance on monitoring programs that could reduce the risk of DKA to 1%, followed by treatment to delay onset of insulin dependence by 1 or 2 years, and, finally, avoiding a $50 out-of-pocket cost. Pediatricians placed equal importance on monitoring programs that reduced a patient's risk of DKA to 1% and on avoiding a $50 out-of-pocket cost for the screening test, followed by the option of a treatment to delay the onset of insulin dependence. The mode of administration and location and timing of the screening were much less important to parents and pediatricians.

CONCLUSIONS

Parents and pediatricians preferred screening tests that were accompanied by education and monitoring plans to reduce the risk of DKA, had available treatment to delay type 1 diabetes, and had lower out-of-pocket costs.

Type 1 diabetes mellitus in children: experience in Indonesia

The prevalence of type 1 diabetes mellitus (T1DM) in children in Indonesia is increasing although the real number is unknown due to high rate of misdiagnosis. Public and healthcare awareness on T1DM in children is still low, reflected by the high number of children diagnosed with diabetic ketoacidosis (DKA). The Indonesian Pediatric Society (IPS) had published a guideline on T1DM management, which consists of insulin injection, daily monitoring of blood glucose, nutrition, physical activity, and education. Aside from low awareness, current challenges on T1DM management in Indonesia are funding by the national health insurance, fasting during Ramadan, and inequities on DM care. The involvement of society, healthcare workers, stakeholders, and the government is of importance to ensure optimal management for children with diabetes.

Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0-18 years

OBJECTIVE

After a previous survey on the incidence of diabetic ketoacidosis (DKA) at onset of type 1 diabetes in children in 2013-2014 in Italy, we aimed to verify a possible decline in the incidence of DKA at onset during a national prevention campaign.

DESIGN

Prospective observational study.

SETTING

Multicentre study throughout Italy.

INTERVENTION

National awareness campaign started in November 2015 and held until December 2017.

PATIENTS

During 2016 and 2017 we collected data on all patients aged 0-18 years with new-onset diabetes.

MAIN OUTCOME MEASURES

DKA (pH <7.30), severe DKA (pH <7.1), DKA in children below 6 years and DKA treatment according to the Italian Society for Pediatric Endocrinology and Diabetology (ISPED) protocol were evaluated.

RESULTS

Records (n=2361) of children with newly diagnosed type 1 diabetes were collected from 58 out of 68 (85.3%) centres of the original survey participants and 100% of the previously surveyed tertiary centres. Overall, DKA was observed in 1124 patients, with an increased rate when compared with the previous survey (47.6% vs 38.5%, p=0.002), and severe DKA in 15.3%. In children below 6 years, DKA was observed in 323 out of 617 (52.5%) and severe DKA in 16.7%; in this age group, occurrence of DKA reduced by 21.3% (p=0.009). DKA treatment according to the ISPED guidelines was adopted in 95% of the centres, with a 27% improvement (p=0.025).

CONCLUSIONS

During a 2-year awareness campaign, DKA at onset of diabetes in children and adolescents 0-18 years is still common and increased when compared with the 2013-2014 survey.

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

Incidence, prevalence and clinical manifestations at onset of juvenile diabetes in Tanzania

Better knowledge on incidence, prevalence and clinical manifestations is needed for planning diabetes care in Sub Saharan Africa.

AIMS

To find a crude incidence/prevalence of diabetes in children and young adults in a low resource setting, classify the diabetes and audit the health record keeping.

METHODS

A retrospective observational study based on medical recordings 2010-2016. Target population was children and adolescent registered in Changing Diabetes in Children (CDiC) or Life for a Child (LFAC) programs for children with T1DM and diagnosed at 5 diabetes clinics in three geographical regions of Tanzania. 604 patients' files were available from five hospitals.

RESULTS

336/604 files covered patients <15 years of age at diagnosis. The prevalence of diabetes <15 years of age ranged from 10.1 to 11.9 per 100,000 children and the annual incidence 1.8-1.9/100,000 children, with peak incidence at 10-14 years. A lot of data were missing. The great majority of the patients presented with typical signs and symptoms of T1D, 83.7% with plausible ketoacidosis (DKA).

CONCLUSIONS

Diabetes incidence and prevalence is still low. T1D seems to dominate with very high frequency of DKA at diagnosis. Increased awareness of diabetes both in health care and community is needed.

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

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

Misdiagnosis and Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes: Patient and Caregiver Perspectives

IN BRIEF Diabetic ketoacidosis (DKA) is a life-threatening complication that frequently occurs at diagnosis of type 1 diabetes, occurs more commonly when a patient is misdiagnosed, is the leading cause of death in children with type 1 diabetes, and is associated with worse long-term outcomes. Our retrospective online survey found that 25% of all participants were misdiagnosed and that misdiagnosis was associated with an 18% increased risk for DKA compared to those correctly diagnosed. Adult providers should consider type 1 diabetes when diagnosing type 2 diabetes, and pediatric providers should rule out type 1 diabetes when a patient reports nonspecific viral symptoms.

Peer review of rural and tertiary Queensland paediatric diabetes services: A pilot project from the National Health Service

AIM

Peer review is one component of the improvement of diabetes care delivered by the National Health Service (NHS) in England and Wales. Queensland has a decentralised model of service provision with an established state diabetes network.

METHODS

The NHS scheme was adapted for use in Australia, and seven trained reviewers were recruited to visit 14 'hub' centres, which in turn covered 29 'spoke' units delivering care to over 95% of all public patients <16 years old in the state. Details of control as measured by glycosylated haemoglobin (HbA1c), the rate of presentation of diabetic ketoacidosis (DKA), the use of state guidance and staffing levels were recorded. Thirteen minimum standards of care were used as a basis for assessment. A report for the use of each inspected unit was produced at the end of the process.

RESULTS

Most units had not previously collected outcome data; 45% of new cases presented with DKA. The centre mean HbA1c was 9.1%, and only 21% of patients achieved the Australian recommended level of <7.5%. Only three centres met some of the internationally recommended staffing levels. Only two centres provided transitional care to adult services. Of 13 NHS minimum standards of care, a mean of 5 were achieved (range 1-8), a mean of 4.6 partially achieved (range 3-6) and a mean of 3.9 not achieved (range 0-9). The care for 68 patients with type 2 diabetes was particularly poor.

CONCLUSIONS

Paediatric diabetes care in Queensland is suboptimal. Recommended remedial actions are suggested that may be applicable to other states.

Relationship between islet autoantibody status and the clinical characteristics of children and adults with incident type 1 diabetes in a UK cohort

OBJECTIVES

To describe the characteristics of children and adults with incident type 1 diabetes in contemporary, multiethnic UK, focusing on differences between the islet autoantibody negative and positive.

DESIGN

Observational cohort study.

SETTING

146 mainly secondary care centres across England and Wales.

PARTICIPANTS

3312 people aged ≥5 years were recruited within 6 months of a clinical diagnosis of type 1 diabetes via the National Institute for Health Research Clinical Research Network. 3021 were of white European ethnicity and 291 (9%) were non-white. There was a small male predominance (57%). Young people <17 years comprised 59%.

MAIN OUTCOME MEASURES

Autoantibody status and characteristics at presentation.

RESULTS

The majority presented with classical osmotic symptoms, weight loss and fatigue. Ketoacidosis was common (42%), especially in adults, and irrespective of ethnicity. 35% were overweight or obese. Of the 1778 participants who donated a blood sample, 85% were positive for one or more autoantibodies against glutamate decarboxylase, islet antigen-2 and zinc transporter 8. Presenting symptoms were similar in the autoantibody-positive and autoantibody-negative participants, as was the frequency of ketoacidosis (43%vs40%, P=0.3). Autoantibody positivity was less common with increasing age (P=0.0001), in males compared with females (82%vs90%, P<0.0001) and in people of non-white compared with white ethnicity (73%vs86%, P<0.0001). Body mass index was higher in autoantibody-negative adults than autoantibody-positive adults (median, IQR 25.5, 23.1-29.2vs23.9, 21.4-26.7 kg/m²; P=0.0001). Autoantibody-negative participants were more likely to have a parent with diabetes (28%vs16%, P<0.0001) and less likely to have another autoimmune disease (4%vs8%, P=0.01).

CONCLUSIONS

Most people assigned a diagnosis of type 1 diabetes presented with classical clinical features and islet autoantibodies. Although indistinguishable at an individual level, autoantibody-negative participants as a group demonstrated features more typically associated with other diabetes subtypes.

TRIAL REGISTRATION NUMBER

ISRCTN66496918; Pre-results.

Effectiveness of a tailored medical support to overcome the barriers to education, treatment and good metabolic control in children with type-1 diabetes from ethnic minorities

Aim:

To analyze the effectiveness of a tailored medical support to help children from ethnic minorities to achieve the same good metabolic control of autochthonous peers with type-1 diabetes (T1D).

Methods:

Children <10 years of age belonging to ethnic minority (EM) families (Group 1) were compared with autochthonous peers (Group 2) who received the diagnosis of T1D in 2014-2016. The Protocol for minorities included other than the standard protocol: booklets translated in ethnic minority languages; weekly visits at home or at school; family-guides; clinic visits supported by professional interpreters. After twelve months of this approach, parents of ethnic minority children answered a short questionnaire concerning satisfaction about educational tools for diabetes management.

Results:

From 1^st January 2014 to December 31^st 2016, 72 children received the diagnosis of T1D at the University Children Hospital of Parma, Italy. Nineteen children belonged to an EM family (26.38%), and were included in the Group 1. Twenty-one autochthonous peers were randomly recruited for the Group 2. T1D was diagnosed at the same mean age in Group 1 (5.2±2.2) and in Group 2 patients (5.7±2.4). Metabolic derangements at diagnosis were more severe in Group 1 than in Group 2 patients. However, patients of both Groups showed a similar decrease in HbA1c levels during the first 3 and 6 months post diagnosis. Patients did not differ in mean insulin doses at discharge and at follow up. The calls to the emergency toll-free telephone number were more numerous from the parents from Group 1 than from the parents of Group 2. Total cost to implement the tailored protocol in Group 1 was higher of 87% compared with the standard protocol used for Group 2 patients. Great majority of parents reported to be satisfied with the provided diabetes education program.

Conclusions:

1The results of this study suggested that children from EM families can achieve the same good metabolic control of autochthonous peers with T1D, providing a cost-effective tailored support to their family members. (www.actabiomedica.it)

Diabetic ketoacidosis at the onset of Type 1 diabetes in young children Is it time to launch a tailored campaign for DKA prevention in children <5 years?

AIM

To analyze clinical characteristics associated with the occurrence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes (T1D) in children aged <5 years in order to identify early signs or symptoms useful to prevent DKA appearance.

METHODS

Data of patients  with newly diagnosed TID aged <5 years (Group 1) and 6-10 years old  (Group 2) coming from the province of Parma were collected in the period 2012-2016.

RESULTS

Mild/moderate ketoacidosis at diabetes diagnosis occurred more frequently in Group 1 than in Group 2 patients (p<0.0015). Severe DKA incidence was higher in children below 5 (21.8%) than in those over 5 years of age (3.75%; p=0.021). Latent period before overt T1D diagnosis was longer in Group 1 than in Group 2 patients (p=0.0081). During this latent period similar indicators were recorded among parents of children <3 years old: frequent use of disposable baby diapers (87%), wet baby diapers because of a large amount of urine (86%), body weight loss (79%).  In children aged 3-4 years reported symptoms consisted of polyuria (89%), polydipsia (79%), fatigue (72%). In Group 2 patients predominant signs concern unusual episodes of  enuresis.

CONCLUSIONS

We believe that it is time to launch a DKA prevention campaign tailored for children under 5 years old and focused just on the above-mentioned three warning signs. Information program must involves pediatricians, pediatric nurses, new moms and nursery school teachers.

A survey of youth with new onset type 1 diabetes: Opportunities to reduce diabetic ketoacidosis

OBJECTIVE

Pediatric patients in Colorado with new onset type 1 diabetes (T1D) presenting with diabetic ketoacidosis (DKA) increased from 29.9% to 46.2% from 1998 to 2012. The purpose of this study was to compare differences between patients with newly diagnosed T1D who presented in DKA with those who did not across three domains: sociodemographic factors, access to medical care, and medical provider factors, aiming to identify potential targets for intervention.

METHODS

Sixty-one patients <17 years of age with T1D duration <6 months completed the questionnaire. Groups were compared using Fisher's exact test or the Kruskal-Wallis test.

RESULTS

Parents of 28% of patients researched their child's symptoms on the Internet prior to diagnosis. At the first healthcare visit for symptoms of T1D, 23% were not diagnosed. There were no significant differences between groups (DKA vs non-DKA) in demographics, first healthcare setting for T1D symptoms, provider type at first visit or at diagnosis, insurance status, or specific barriers to care. DKA patients had a longer interval between previous well visit to diagnosis (median 172 vs 263 days, P = 0.01). Non-DKA patients were more likely to have blood glucose measured at P = 0.02, and had fewer symptoms prior to (P = 0.01) the first visit for diabetes symptoms. Parents of non-DKA patients were more likely to be familiar with symptoms of diabetes (P < 0.001) and to suspect diabetes (P = 0.01).

CONCLUSION

Targets for campaigns to prevent DKA include increasing provider glucose and ketone testing, increasing public knowledge about diabetes, and understanding how socio-demographic factors may delay T1D diagnosis.

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

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

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

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

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

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

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

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

[Ketoacidosis at time of diagnosis of type 1 diabetes in children and adolescents: effect of a national prevention campaign]

The aim of the study was to evaluate, after the first year of a national information campaign, the effect on the frequency and severity of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) in children and adolescents in France. The following data were collected during a 2-year period in people younger than 15 years of age at diagnosis of T1D, in 146 pediatric centers: age, sex, duration of symptoms, patient's previous care, clinical and biological signs, and family history of T1D. DKA was defined as pH<7.30 or bicarbonate<15mmol/L, severe DKA as pH<7.10 or bicarbonate <5mmol/L. During the 2nd year, an information campaign targeting health professionals and families was launched with the objective of reducing the time to diagnosis. Data were compared between the year before the campaign (year 0) and the first year of the campaign (year 1). The number of new cases of T1D was 1299 for year 0 and 1247 for year 1. Between year 0 and year 1, the rate of DKA decreased from 43.9% to 40.5% (P=0.08), exclusively due to the decrease of severe DKA from 14.8 to 11.4% (P=0.01). In the 0- to 5-year-old and 5- to 10-year-old age groups, the relative decrease in the rate of DKA was 13% and 15%, and 23% and 41% for severe DKA, respectively. In patients referred to the hospital by a pediatrician or who came at the family's initiative, the decrease was 34% and 7%, and 39% and 32% for severe DKA, respectively. No change was observed in the 10- to 15-year-old group or in those children who were referred by a general practitioner. In multivariate analyses, a higher DKA rate was associated with the young age of the child (<5 years), being hospitalized at the parents' initiative rather than being referred by a doctor, and the absence of a family history of T1D. A higher rate of severe DKA was associated with these last two factors but not with the child's age. The frequency of DKA at diagnosis of type 1 diabetes remains high in children and adolescents, but the first year of an information campaign decreased it. The results have also helped better define the strategy and targets of the continuing prevention campaign, to more efficiently reduce the morbidity and mortality of T1D at diagnosis in children and adolescents in France.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Prevalence of ketoacidosis at diagnosis of childhood onset Type 1 diabetes in Wales from 1991 to 2009 and effect of a publicity campaign

AIMS

To determine the proportion of cases of childhood Type 1 diabetes that present with ketoacidosis and any temporal trend. To assess the impact of a publicity campaign promoting earlier diagnosis.

METHODS

We used an all-Wales register of incident cases with data on 2046 children from 1991 to 2009. The proportion with ketoacidosis at diagnosis was compared with the Yorkshire Childhood Diabetes Register. On World Diabetes Day posters were sent to every pharmacy, school and general practitioner surgery across Wales and radio interviews given. A questionnaire survey was conducted in Gwent to assess penetrance of the campaign.

RESULTS

Annually, in 1991-2009 the proportion presenting with ketoacidosis varied between 20% and 33% (mean 25%) with no change over time. Similar proportions occurred in Yorkshire. Ketoacidosis was more common before age 5 years (37% of cases) than at age 5-9 years (20%) or 10-14 years (23%) (P < 0.001). From November 2006-2007 30% of cases presented with ketoacidosis and from November 2007-2008 25% cases presented with ketoacidosis. After the campaign (November 2008-2009) 26% presented with ketoacidosis (P = 0.72). The information had reached a low proportion of families. General practitioners referred immediately cases that presented to them.

CONCLUSIONS

Over 20 years in Wales there has been no change in the proportion of children with Type 1 diabetes initially presenting with ketoacidosis. This presentation occurs in a higher proportion of new cases aged under 5 years. Publicity to increase awareness did not reduce the proportion with ketoacidosis at diagnosis in Wales. We need to get the educational message through to parents to reduce ketoacidosis at presentation.

A diabetes awareness campaign prevents diabetic ketoacidosis in children at their initial presentation with type 1 diabetes

OBJECTIVE

To evaluate the effect of a diabetes awareness campaign on the incidence of diabetic ketoacidosis (DKA) at the first presentation of type 1 diabetes in children (0-18 yr).

METHODS

This study was a controlled population intervention study with a 2-yr baseline period and a 2-yr intervention period. Data were collected on all children presenting with their initial diagnosis of type 1 diabetes [pH, bicarbonate, base excess, blood glucose level (BGL), urea, and creatinine] at Gosford, Newcastle, and Sydney (Sydney Children's Hospital and Royal North Shore Hospital). During the intervention period, diabetes education occurred in the intervention region (Gosford). Child care centers, schools, and doctor's offices were offered education and posters about the symptoms of type 1 diabetes. Doctor's offices were given glucose and ketone testing equipment. The control regions (Newcastle and Sydney) did not receive any educational intervention or test equipment. DKA was defined as pH < 7.3 or bicarbonate < 15 mmol/L.

RESULTS

In Gosford, the proportion of children presenting in DKA decreased from 37.5% (15/40) during the 2-yr baseline period to 13.8% (4/29) during the 2-yr intervention (p < 0.03). There was no significant change in the control regions during the same time periods, 37.4% (46/123) and 38.6% (49/127), respectively. In Gosford, the average BGL at presentation was 27.5 mmol/L during the baseline and 21.2 mmol/L during the intervention (p < 0.01).

CONCLUSION

During the diabetes awareness campaign, the rate of DKA at initial diagnosis of type 1 diabetes in children decreased by 64%.

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.

Current concepts and controversies in prevention and treatment of diabetic ketoacidosis in children

Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.

The risk factors of ketoacidosis in children with newly diagnosed type 1 diabetes mellitus

BACKGROUND AND AIMS

Diabetic ketoacidosis (DKA) is still a severe complication associated with significant morbidity and mortality. The aim of this study was to determine the predictors of DKA in children with newly diagnosed type 1 diabetes mellitus (T1DM).

MATERIAL AND METHODS

The study group consisted of new-onset type 1 diabetic patients admitted to our hospital between January 2006 and March 2008. One hundred and eighty-seven children were identified (95 females and 92 males) and their mean age was 8.9 ± 4.6 yr (0.8-17.8). Hemoglobin A1c, blood gases, and fasting c-peptide level were evaluated in all children. DKA was defined as a capillary pH < 7.3 and blood glucose >11 mmol/L.

RESULTS

At the time of T1DM diagnosis, 26% of children had DKA. Misdiagnosis was significantly associated with the incidence of DKA. In the group with DKA, c-peptide level was significantly lower than in the group without DKA (p = 0.003.) The most prone to DKA were children under 2 yr of age (n = 14). In this age group, DKA was present in 71% of individuals and the lowest c-peptide level was observed compared to older children (p < 0.0001). There was significant correlation between the c-peptide level and age of children (r = 0.41, p < 0.0001).

CONCLUSIONS

The incidence of DKA among newly diagnosed patients with T1DM remains unacceptably high and indicates greater necessity of medical alertness for this diagnosis, especially in the youngest children. Children under 2 yr of age remain the most prone to DKA, which may be related to delay in diagnosis and more aggressive β-cell destruction.

Is diabetic ketoacidosis at disease onset a result of missed diagnosis?

OBJECTIVE

To determine the frequency of medical encounters before diagnosis of diabetes in children in Ontario, Canada; to determine risk factors for diabetic ketoacidosis (DKA).

RESEARCH DESIGN

All medical encounters within 4 weeks before date of diagnosis for all new cases of diabetes in children <18 years were identified from April 1994 to March 2000 by use of administrative databases. The main outcome measure was the frequency of medical encounters before diagnosis in children presenting with and without DKA.

RESULTS

A total of 3947 new cases of diabetes were identified, 735 (18.6%) with DKA. DKA rates were 39.7% for children < or =3 years and 16.3% for children >3 years (P < .001). During the week before diagnosis, 285 children with DKA (38.8%) and 1104 children with diabetes without DKA (34.4%; P = .026) had at least 1 medical visit. Children with diabetes overall had more medical encounters before diagnosis than control subjects. Children with DKA were less likely to have had relevant laboratory testing before diagnosis than children with diabetes without DKA.

CONCLUSIONS

Children with diabetes presenting with DKA more frequently had a medical encounter before diagnosis compared with children with diabetes without DKA. These data have important implications for enhancing public and physician awareness of diabetes in children.

Difficulties or mistakes in diagnosing type 1 diabetes in children?--demographic factors influencing delayed diagnosis

BACKGROUND

Diabetic ketoacidosis (DKA) development in children with new-onset type 1 diabetes (T1DM) is often the main consequence of delayed diagnosis. The aim of the study was to estimate the frequency of difficulties in T1DM diagnosis and to investigate if and how the demographic factors (gender, patient's age at presentation, family history of T1DM, level of maternal education, place of residence, and health service unit the patient called at) have any influence on diagnostic delays.

SUBJECTS AND METHODS

Retrospective analysis of 474 children (243 boys-51.27% and 231 girls -48.73%) with new-onset T1DM aged below 17 yr and living in the Pomeranian region of Poland was carried out. The delay in diagnosis was recognized if the patient was not diagnosed on the first visit because of omission, wrong interpretation of main diabetic symptoms, exclusive treatment of additional signs, or concomitant diseases.

RESULTS

Difficulties in diagnosing T1DM were found in 67 cases (14.13%) and they are the main cause of DKA development in these children (p = 0.00). Among the examined demographic factors, mainly the patient's age at presentation has a significant influence on diagnostic delays (p = 0.01), especially in children below 2 yr (p = 0.00). Most frequently family doctors were responsible for wrong preliminary diagnosis.

CONCLUSIONS

Difficulties in diagnosing T1DM are a significant cause of DKA development in children with new-onset disease. Patient's age at presentation is the main risk factor of delayed diagnosis, especially in children below 2 yr. The increase in awareness among pediatricians concerning the possibility of T1DM development in children is needed.