Pediatric Diabetic Ketoacidosis Management in the Era of Standardization

Ildiko H Koves; Catherine Pihoker


Expert Rev Endocrinol Metab. 2012;7(4):433-443. 

In This Article


The biochemical definition of DKA proposed by the International Society of Paediatric and Adolescent Diabetes,[3,4] European Society of Pediatric Endocrinology and Lawson Wilkins Pediatric Endocrine Society is as follows:[5]

  • Hyperglycemia (blood glucose >200 mg/dl or >11 mmol/l)

  • Venous pH <7.3 or bicarbonate <15 mmol/l

  • Ketonemia (β-hydroxybutyrate [BOHB] >1 mmol/l) and/or ketonuria

Infrequently, DKA may occur at lesser hyperglycemia (euglycemic ketoacidosis),[6,7] particularly during pregnancy[8] or in partially treated young children. It may also present with hypoglycemia (hypoglycemic ketoacidosis) that may lead to challenges with initial diagnosis or in differentiating the condition from other rare conditions in the very young, such as glycogen storage disease. Acute decompensation with DKA has been recognized with Type 2 diabetes mellitus (T2DM) presentation.[9] The SEARCH for Diabetes in Youth, a large population-based study in the USA, reported a 7% incidence of presentation with DKA in T2DM.[9] This is more likely to occur in the African–American population.[10]

There is an arbitrary classification[3–5] of the severity of acidosis based on venous pH values with limited utility in management decisions based on this categorization:

  • Severe pH <7.1 or bicarbonate <5 mmol/l

  • Moderate pH <7.2 or bicarbonate <10 mmol/l

  • Mild pH<7.3 or bicarbonate <15 mmol/l


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