Diabetic ketoacidosis at onset of type 1 diabetes remains frequent in children

New data indicate that diabetic ketoacidosis continues to occur at onset of type 1 diabetes in children and has not significantly changed in frequency or magnitude during the last 13 years.

Researchers in Germany assessed the frequency, clinical characteristics and trends associated with the occurrence of diabetic ketoacidosis at onset of type 1 diabetes in 14,664 German and Austrian patients (mean age, 9 years).

Diabetic ketoacidosis was observed in 21.1% of the children. About 21% of children had pH values <7.3 at onset of type 1 diabetes; about 10% had mild diabetic ketoacidosis, 5.4% had moderate diabetic ketoacidosis, and about 6% had severe diabetic ketoacidosis.

The highest frequency of diabetic ketoacidosis occurred in children aged 5 years or younger (P<.001). The second highest frequency was reported in children aged 10 to 15 years (22%).

The frequency and percentage of cases with severe diabetic ketoacidosis remained consistent during the 13-year study period (P>.486).

“Reinforced efforts aimed at educating both the general public and practicing physicians are imperative if the situation is to improve,” the researchers concluded. – by Jennifer Southall

Neu A. Diabetes Care. 2009;32:1647-1648.

This article by Neu et al chronicles the discouraging fact that the incidence of patients with new-onset diabetes presenting in diabetic ketoacidosis has been stable over the past 13 years, despite major advances in diabetes care over that time period. Diabetic ketoacidosis was observed in 21.1% of patients, with the highest frequency among children aged 5 years and younger (26.5%). The fact that so many of patients present in diabetic ketoacidosis indicates that there is poor recognition of the early symptoms of diabetes resulting in delay in diagnosis until insulin deficiency is virtually complete. This problem is exacerbated in young children in whom the symptoms of diabetes may mimic the symptoms of nonspecific viral illness and, in the very young, polyuria and polydypsia may not be recognized in children wearing diapers.

This lack of recognition of early symptoms of diabetes represents a failure of the medical community’s ability to adequately educate the public about the signs and symptoms of diabetes. We could learn much from the educational program conducted in Parma, Italy, from 1991 to 1998. The signs and symptoms of diabetes, including excessive urination, enuresis and excessive thirst, were depicted in eye-catching pamphlets and posters that were placed in schools, child care centers and pediatricians’ offices. This campaign resulted in a decrease in the rate of patients presenting with diabetic ketoacidosis at diabetes onset from 78% to 12.5%. The program is still in place and the low rate of diabetic ketoacidosis in newly diagnosed diabetes, slightly more than half of the rate described in this paper, has remained stable. The International Diabetes Federation is striving to raise public awareness about the symptoms of early diabetes and has made available a tool box that contains posters and pamphlets designed to raise public awareness. These materials can be downloaded at www.idf.org.

– Janet Silverstein, MD

Chief, Department of Pediatrics, University of Florida, Gainesville