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

Risk & Protective Factors

It is unclear why some children present in DKA and others do not. Bui et al. hypothesize that the development of DKA may be the consequence of missed diagnoses and treatment.[24] Neu et al. suggest variations in disease subtypes and more aggressive forms of diabetes.[25] Several risk factors were found to be associated with DKA presentations. A recent systematic review of 46 studies (involving ~24,000 children in 31 countries and 735 DKA episodes) published by Usher-Smith et al. found the following risk factors at new-onset T1DM diagnosis:[15]

  • Younger age (<5 years)

  • Diagnostic error

  • Ethnic minority

  • Lack of health insurance (a finding reported in the USA)

  • Lower BMI

  • Preceding infection

  • Delayed treatment

Another study by Flood et al. suggests that infections as a risk factor is uncommon and should be further investigated only if fever or other signs of illness are present.[26]

Protective factors include the following:[15]

  • First-degree relative with T1DM

  • Higher parental education

  • Higher background incidence of T1DM

  • Enrollment in T1DM research studies[14]

For established T1DM patients, the risk of DKA is 1–10% per patient-year.[3,27] The risk is increased for:[19]

  • Poor metabolic control

  • Previous DKA episode

  • Peripubertal and adolescent girls

  • Children with psychiatric disorders, including eating disorders

  • Children with difficult psychosocial backgrounds

  • Limited access to medical services

  • Insulin omission[28]

  • Insulin pump therapy[20]


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