Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review

Abstract

Study selection Cohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication.Results 46 studies involving more than 24 000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for <2 years old v older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35 (2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection (odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74 (1.10 to 2.77)). Protective factors were having a first degree relative with type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)), higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43 to 0.94) in two studies), and higher background incidence of type 1 diabetes (correlation coefficient -0.715). The mean duration of symptoms was similar between children presenting with or without diabetic ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0) respectively), and up to 38.8% (285/735) of children who presented with diabetic ketoacidosis had been seen at least once by a doctor before diagnosis.Conclusions Multiple factors affect the risk of developing diabetic ketoacidosis at the onset of type 1 diabetes in children and young adults, and there is potential time, scope, and opportunity to intervene between symptom onset and development of diabetic ketoacidosis for both parents and clinicians.

Trends in the Prevalence of Ketoacidosis at Diabetes Diagnosis: The SEARCH for Diabetes in Youth Study

“…19 Similar to our data, a systematic review of 46 studies involving .24 000 children in 31 countries worldwide identified younger age, ethnic minority, and lack of health insurance, among others, as major risk factors for DKA at onset with type 1 diabetes. 29 Younger age was consistently associated with increased risk of DKA at onset in numerous studies, and the reasons are likely multifactorial. 29 Toddlers are less likely to verbalize symptoms and early symptom recognition is more difficult in young children, leading to delayed diagnosis and treatment.…”

Clinical and Laboratory Characteristics of Pediatric Diabetic Ketoacidosis: A Single-Center Study

“…Approximately 10~70% of these patients experience DKA [14], which, in children, Factors that contribute to the incidence of DKA include poorly metabolic control [16] and a rapid decrease in pancreatic beta cell function [17]. In a recent study, age under 12 years, lower serum C-peptide level, preceding infection, and delayed diagnosis were strongly related to DKA; and severe DKA was increased in situations where there was limited parental education level and a prior episode of infection [18].…”

Trends in the Prevalence of Ketoacidosis at Diabetes Diagnosis: The SEARCH for Diabetes in Youth Study

“…29 Younger age was consistently associated with increased risk of DKA at onset in numerous studies, and the reasons are likely multifactorial. 29 Toddlers are less likely to verbalize symptoms and early symptom recognition is more difficult in young children, leading to delayed diagnosis and treatment. On the other hand, young children may experience more aggressive and faster metabolic deterioration.…”