Pediatric Diabetic Ketoacidosis Management in the Era of Standardization

Ildiko H Koves; Catherine Pihoker

Disclosures

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

In This Article

Epidemiology

There is a large variation in the frequency of DKA at initial presentation of diabetes, ranging from 11 to 67% globally.[13] Population-based studies in the USA and Europe report a frequency of approximately 15–26% in children at initial presentation.[14] Delay in diagnosis of diabetes is also associated with a higher frequency of DKA at presentation.[15] Participation in a research study has been shown to decrease the frequency of DKA at disease onset, probably due to heightened awareness, particularly in the youngest age group; in the TEDDY study the prevalence of DKA was 15%, compared with 40–54% in registry studies from the USA and Europe.[14] The frequency of DKA is high when children are seen by providers who are less familiar with pediatric diabetes. Symptoms of diabetes, such as polyuria, tachypnea and altered mental status, are quite nonspecific, and the diagnosis may be mistakenly made of a urinary tract infection, pneumonia or meningitis. Similarly, regions with a lower prevalence of diabetes are more likely to have higher frequencies of DKA.[16,17]

For patients with an established diagnosis of T1DM, there are few reports from the USA on the frequency of DKA, ranging from 1 to 15 per 100 patient-years.[18] Adolescent age, female sex, disadvantaged psychosocial milieu, barriers to receiving healthcare, eating disorders and mental health conditions are all risk factors for DKA. Poor glycemic control is a major risk factor for recurrent DKA, with a relative risk of 1.68 for each 1% increase in hemoglobin A1C.[19] Factors that have been associated with lower occurrences of DKA are more intensive regimens and continuous access to care.[20] The DCCT assessed acute complications, including DKA, in participants receiving conventional care or intensive care. The incidence of DKA was higher in those on conventional treatment: 4.7 per 100 patient-years versus 2.8 per 100 patient-years in the intensively treated group. Although advances have been made such that the intensive care used in the DCCT trial is now widely considered to be the standard of care, other elements of the study would probably not carry forth into a current management scenario, meaning the idealized situation with frequent phone contact between knowledgeable diabetes staff and interested participants. DKA is also observed more often in patients on an insulin pump. This is more common in the early stages, when patient or caregivers have less familiarity with the device.[20]

DKA can also occur in patients with T2DM, either at presentation or after diagnosis. The prevalence of DKA at diagnosis of T2DM ranges from 5 to 19%.[9] This is important to consider, as obesity and T2DM in children has increased over the past two to three decades. Non-Hispanic black, native American and Hispanic race/ethnicities were associated with a higher incidence of T2DM. Youth with T2DM may also present with hyperglycemic hyperosmolar state (HHS), also referred to as hyperosmotic hyperglycemic nonketotic coma which may be associated with acidosis if the patient is severely dehydrated. It is important to distinguish from HHS DKA, as the management differs, with more careful, individualized rehydration needed in HHS.[21] While HHS is observed more often in youth with T2DM who do not meet the criteria for DKA, it can also occur together with DKA, particularly in severely dehydrated children with T1DM.[22]

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