COVID-19:  More Evidence of Delayed Diabetes Diagnosis in Kids

Miriam E. Tucker

July 30, 2020

A significant increase in diabetic ketoacidosis (DKA) in youth at type 1 diabetes diagnosis occurred in Germany during the COVID-19 shutdown, further worsening a trend that was already happening in several countries — including Germany and the United States — prior to the pandemic. 

The new data are from the German Diabetes Prospective Follow-up Registry of 532 children and adolescents with new-onset type 1 diabetes between March 13, 2020, when most kindergartens and schools in Germany were closed because of the pandemic, and May 13, 2020.

The findings were published online July 20 in JAMA by Clemens Kamrath, MD, a pediatric endocrinologist at the Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany, and colleagues.

The proportion of youth presenting in DKA at diabetes diagnosis in Germany in 2020, at 44.7%, nearly doubled from the same period in the 2 years prior, at 24.5% in 2019 and 24.1% in 2018 (both P < .001).

Rates of severe DKA also increased, with the greatest rises seen in children younger than 6 years of age.

"At the beginning of the pandemic, many clinics distributed information via social media that called for patients not to come to the clinic unnecessarily or with symptoms of COVID-19 infection...However, this information was also misunderstood and some parents were unsure whether they should or should not go to the clinics or doctors' offices. Of course, many parents also worried about infection when they went to the doctor," Kamrath told Medscape Medical News.

Although the investigators haven't evaluated further data since mid-May, "we get feedback from many diabetes centers that a high rate of ketoacidosis is still noticed...Communication needs to be improved," he emphasized.

DKA, Severe DKA Rose During Pandemic, Especially in Younger Kids

In addition to the overall increased rate of DKA (defined as a pH < 7.3 and/or bicarbonate < 15 mmol/L) at type 1 diabetes onset during the pandemic, Kamrath and colleagues also found a significant increase in the frequency of severe DKA (pH < 7.1 and/or bicarbonate level < 5 mmol/L), which was 19.4% in 2020 compared with 13.9% in 2019 (P = .03) and 12.3% in 2018 (P = .004).

Children younger than 6 years had the highest rate of DKA in 2020, at 51.9% versus 18.4% in 2019 (P < .001) and 24.2% in 2018 (P < .001), as well as severe DKA, at 24.4% in 2020 versus 12.2% in 2019 (P = .02) and 11.7% in 2018 (P = .01).

DKA Rates at Type 1 Diabetes Onset Were Already Rising Pre-Pandemic

DKA rates at type 1 diabetes onset had been creeping upward even prior to the pandemic in Germany, and elsewhere, according to data published in May (Diabetologia. 2020;63:1530-41). The authors were an international team and include a coauthor of the current study, Reinhard W. Holl, MD, PhD, of the University of Ulm and the German Center for Diabetes Research, Munich-Neuherberg.

The Diabetologia study looked at temporal trends in DKA at diagnosis of pediatric type 1 diabetes between 2006 and 2016 in 13 countries on three continents.

There was a significant overall increase in DKA of 1.8%over the study period (P = .001), specifically in Australia (P = .026), Germany (P = .002), and the United States (P < .001). Italy was the only country with a significant decrease (P < .001).

In the United States, the proportion of youth presenting in DKA at the time of type 1 diabetes diagnosis in 2016, at 40.6%, was almost as high as the proportion in Germany during the pandemic, and had risen about 2% per year since 2010 (P = .01).

Those US data, from the five-site SEARCH for Diabetes in Youth Study, were presented in September 2019 at the European Association for the Study of Diabetes (EASD) 2019 Annual Meeting by Elizabeth T. Jensen, PhD, associate professor of epidemiology at the Wake Forest School of Medicine, Winston-Salem, South Carolina.

Asked to comment on the new pandemic-era data from Germany, Jensen told Medscape Medical News the latest report "further supports this assertion that delays in care could be an important contributing factor in what we have observed in the United States pre-COVID-19."

However, she cautioned, "there is significant heterogeneity across countries in what has been reported, attributable in part to the underlying population, but also to socioeconomic factors and, as the authors note, likely access to care."

"In our own study, we hypothesized that the relatively high proportion of DKA at diagnosis could be driven by delays in seeking care, possibly attributable to our health insurance landscape, although this specific hypothesis was not testable with the data we had."

What Needs to Be Done Going Forward?

Asked what can be done to facilitate earlier diagnosis of type 1 diabetes prior to development of DKA, Kamrath advised: "Any obstacles that can delay the presentation, or increase the effort for a presentation to the family doctor or in the clinic, must be removed.

"Free access to acute presentations must be guaranteed. Even without a pandemic, the proportion of ketoacidosis is too high. Prevention through education or antibody screening could reduce the rate, also after COVID-19."

Jensen said: "Certainly, this is of significant concern, and to the extent possible, we should try to allay concerns for patients seeking out primary care while simultaneously taking precautions to mitigate risk to patients who do seek care."

"Offering and making patients aware of the ability to access care through telehealth visits may help circumvent some of the added risk during this period of time," she added. 

She also observed: "It will be interesting to see what happens with increased access to telehealth visits and whether this will increase accessibility to care among some patients that otherwise, even before COVID-19, had difficulty accessing care."

But "it remains to be seen as to whether this will mitigate risk of delayed care in new-onset type 1 diabetes," she concluded.

Kamrath and Jensen have reported no relevant financial relationships.

JAMA. Published online July 20, 2020. Full text

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