Diabetic Ketoacidosis at Diagnosis in Austrian Children: A Population-Based Analysis, 1989-2011

doi:10.1016/j.jpeds.2013.06.033

The Journal of Pediatrics

Volume 163, Issue 5, November 2013, Pages 1484-1488.e1

https://doi.org/10.1016/j.jpeds.2013.06.033 Get rights and content

Objective

To analyze the effect of a community-based, poster-focused prevention program on the frequency of diabetic ketoacidosis (DKA) at diabetes onset in Austria.

Study design

All newly diagnosed patients with diabetes ≤15 years of age were registered prospectively by the Austrian Diabetes Incidence Study Group. Registered data included initial blood glucose, pH, and ketonuria. DKA was defined as pH < 7.3 and severe DKA as pH < 7.1. Data between 1989 and 2011 were available. In autumn, 2009, a community-based prevention program similar to the Parma Campaign, in which posters were dispensed broadly, was initiated. The frequency of DKA at the onset of diabetes in the years 2005-2009 and 2010-2011 was compared.

Results

During the study period, 4038 children were registered. A total of 37.2% presented with DKA; 26% had a mild and 11.2% a severe form. The frequency of DKA was negatively associated with age at onset. In the years before the intervention program, 26% had mild DKA compared with 27% after the intervention (not significant). The prevalence of severe DKA in the years before the campaign was 12% compared with 9.5% thereafter (not significant). No significant change in the DKA rate at onset by the prevention program could be found when we compared age groups <5, 5 to <10, and 10 to <15 years, neither for mild nor for severe DKA.

Conclusion

The frequency of DKA in children with newly diagnosed type 1 diabetes in Austria is high and did not change despite the efforts of a community-based information program.

Section snippets

Methods

The study was approved by the ethic committee of the Medical University of Vienna. All newly diagnosed cases of DMT1 in children <15 years of age are registered prospectively by a nationwide network covering all pediatric hospitals, wards, and diabetologists since 1989 (Austrian Diabetes Incidence Study Group). The completeness of case ascertainment is >93%, with a uniform completeness of ascertainment over time. Since 1989 the Austrian incidence data are included in the Eurodiab ACE study, and

Results

During the observation period (1989-2011) 4038 children (boys: n = 2186, girls: n = 1852) younger than 15 years of age were registered in the Austrian Diabetes Incidence database. The incidence rate in Austria almost doubled, from 9/100 000 in the year 1989 to 17.5/100 000 in the year 2011. A total of 37.5% (95% CI 35.7-38.7) of the children presented with DKA, 26% (95% CI 24.6-27.3) had a mild form, and 11.2% (95% CI 10.3-12.2) a severe form. The frequency of onset of DKA was negatively

Discussion

The results of our study are disappointing. Despite a tremendous effort, no significant influence on the prevalence of DKA at diabetes onset in Austria could be observed. The results of a recent meta-analysis¹ and the Eurodiab study² found a significant inverse relationship between the onset of DKA and the regional diabetes incidence in the background population. Concerning the incidence of DMT1, Austria is a country with intermediate risk but with a clear increase of the incidence rate from 9

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Cited by (62)

Delayed Management of Insulin-Dependent Diabetes Mellitus in Children
2023, Journal of Pediatric Health Care
Diabetic ketoacidosis (DKA) is a common presentation for pediatric new-onset insulin-dependent diabetes mellitus (IDDM). Delayed diagnosis is the major risk factor for DKA at disease onset.
Two pediatric endocrinologists independently reviewed the admission records to assess the appropriateness of preadmission management in various health care settings.
Eighteen percent (n = 45) of patients with new-onset IDDM had a delayed diagnosis. Twenty-eight were misdiagnosed (respiratory [n = 9], nonspecific [n = 7], genitourinary [n = 4], gastrointestinal [n = 8] issues) and 17 were mismanaged. One child died within 4 hr of hospitalization, presumably because of a hyperosmolar coma. Forty-six percent (n = 21) of patients with delayed diagnosis presented with DKA, comprising 18% of all DKA cases.
A significant number of patients with new-onset IDDM were either misdiagnosed or mismanaged. All providers must be appropriately trained in diagnosing new-onset IDDM and follow the standard of clinical care practices.
A Multi-Intervention Campaign Lowers Pediatric and Young Adult Diabetic Ketoacidosis Hospitalizations in a Canadian Province
2021, Canadian Journal of Diabetes
The Newfoundland and Labrador diabetic ketoacidosis Project (NLdkaP) is a multi-intervention, province-wide project aimed at lowering rates of diabetic ketoacidosis (DKA) within the pediatric and young adult populations.
The NLdkaP interventions were first selected, developed and implemented. We then conducted a retrospective study of hospitalization data over three 2-year periods: pre-, during and post-NLdkaP. Data included demographic factors, DKA hospitalizations and length of hospital stay.
There were 412 DKA hospitalizations over the study period. Before the NLdkaP, the provincial hospitalization rate of DKA for patients <25 years of age was 55.61 per 100,000. During the NLdkaP, the rate dropped to 38.48 per 100,000 (p<0.001). After the NLdkaP, the rate rose to 54.53 per 100,000 (p<0.001). Hospitalization rates were highest for females (p<0.001) and for those in the 19- to 24-year age group (p<0.001).
The NLdkaP was associated with decreased rates of DKA hospitalizations, but the rates remained relatively stable in both the pre- and postintervention periods. Although the approach and resources developed in the NLdkaP appear effective, continuous preventive efforts are needed to sustain reductions in DKA hospitalizations.
Le projet sur l’acidocétose diabétique à Terre-Neuve-et-Labrador (NLdkaP pour Newfoundland and Labrador diabetic ketoacidosis Project) est un projet provincial multi-interventionnel qui visait la diminution des taux d’acidocétose diabétique (ACD) des enfants et des jeunes adultes.
Nous avons d’abord sélectionné, élaboré et mis en œuvre les interventions du NLdkaP. Nous avons ensuite mené une étude rétrospective sur les données d’hospitalisation de 3 périodes de 2 ans : avant, durant et après le NLdkaP. Les données regroupaient les facteurs démographiques, les hospitalisations liées à l’ACD et la durée des séjours à l’hôpital.
Il y a eu 412 hospitalisations liées à l’ACD au cours de la période étudiée. Avant le NLdkaP, le taux provincial des hospitalisations liées à l’ACD des patients de < 25 ans était de 55,61 sur 100 000. Durant le NLdkaP, le taux baissait à 38,48 sur 100 000 (p < 0,001). Après le NLdkaP, le taux augmentait à 54,53 sur 100 000 (p < 0,001). Les taux d’hospitalisations des femmes (p < 0,001) et du groupe des jeunes de 19 à 24 ans (p < 0,001) étaient plus élevés.
Le NLdkaP était associé à la diminution des taux d’hospitalisations liées à l’ACD, mais les taux demeuraient relativement stables pour les périodes préinterventionnelle et postinterventionnelle. Bien que l’approche et les ressources mises au point dans le NLdkaP semblent efficaces, des efforts continus en matière de prévention sont nécessaires au maintien de la réduction des hospitalisations liées à l’ACD.
Effectiveness of ketoacidosis prevention campaigns at diagnosis of type 1 diabetes in children: A systematic review and meta-analysis
2021, Diabetes Research and Clinical Practice
Citation Excerpt :
The campaigns were performed in different geographic areas of countries from four continents and ten countries, including Europe (Italy, United Kingdom, Austria, Turkey, France, Croatia), Australasia (Australia, New Zealand), North America (USA), and Asia (Saudi Arabia). Eleven studies [10,13,17–20,23,26–28] had at least three target populations, that consisted of the general population, schoolteachers and primary care physicians; six of these studies reporting a significant effect of the intervention campaign (Supplementary Table 1 [A]). Two studies [22,23] had two target populations, however the populations differed.
To determine if diabetes awareness campaigns are an effective intervention to reduce diabetes ketoacidosis at diagnosis of type 1 diabetes in children and youth.
Search strategies included PubMed, Scopus, CINAHL and WOS electronic databases, hand search of select journals and a grey literature search “Google” search to include all relevant information. Studies included community-based interventions focused on children younger than 18 years old. The difference in the frequency of DKA was measured in two separate comparisons; before and after perform awareness campaigns in the same area, and between areas with and without intervention campaigns.
Of 1136 records identified, 14 studies were eligible for the analysis. The first group of 12 studies measured DKA at diagnosis, before (n = 6548 individuals) and after (n = 4931 individuals) the awareness campaigns. The pooled difference was a reduction of 7.20% (95%CI: 0.99–13.41). The second group of four studies measured the difference in an area with no intervention (n = 338 individuals) and in an area with an awareness campaign (n = 187 individuals). The pooled difference in DKA was 35.71% (95%CI: 5.81–65.61).
This review demonstrated that DKA awareness campaigns are effective to reduce DKA among children and adolescents with type 1 diabetes and the core components that explain why these campaigns are effective.
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Diabetic ketoacidosis and neurodevelopment
2021, Diagnosis, Management and Modeling of Neurodevelopmental Disorders: The Neuroscience of Development
Diabetic ketoacidosis (DKA) is the most common cause of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). Cerebral injury due to DKA is the major cause of mortality and morbidity and cerebral edema accounts for 60%–90% of all deaths associated with DKA in children. Several studies on DKA and neurocognitive function have found deficits in memory, attention, and/or full-scale intelligence quotient (IQ) in children with T1DM who present with DKA. Studies on DKA and brain structure have found changes in total and specific white matter and gray matter volumes, initial decreases in a metabolic marker of neuronal density, and both increases and decreases in mean diffusivity after DKA, which can be associated with subtle cellular injury or acute/subacute brain injury respectively. More studies devoted specifically to DKA and its effect on brain structure and neurocognitive deficits are required to fully understand the effect of DKA and its natural history in neurodevelopment.
Type 1 diabetes in pediatrics: Public health and epidemiologic point of view
2020, Medecine des Maladies Metaboliques
Le diabète de type 1 (DT1) est l’une des maladies chroniques les plus fréquentes chez l’enfant. Ces dernières décennies ont été marquées par une augmentation importante de l’incidence de la maladie, en particulier chez des enfants de plus en plus jeunes, soulignant l’importance de renforcer les équipes spécialisées pour le suivi des enfants ayant un DT1. En revanche, malgré des campagnes de prévention en population générale ou auprès des professionnels de santé de premier recours, la fréquence de la révélation par acidocétose reste très préoccupante. La physiopathologie de cette maladie auto-immune, largement multifactorielle, est encore mal élucidée. Sur le plan génétique, si une large part a été faite au groupe HLA, d’autres loci ont été plus récemment impliqués dans la prédisposition au diabète de type 1. Sur le plan environnemental, différents facteurs sont considérés. Parmi ceux-ci, les rôles de l’alimentation ou des infections microbiennes ou virales pourraient être prépondérants, par l’intermédiaire d’une modification du microbiote ou bien d’une dysimmunité médiée par l’intestin. L’âge d’autant plus jeune de l’apparition de la maladie suggère leur rôle dès la période fœtale ou les premières années de vie. La disparité géographique et la saisonnalité observées permettent également de préciser les facteurs à élucider. Ces précisions devraient permettre le développement de stratégies préventives mieux ciblées.
Type 1 diabetes is one of the most common chronic condition in pediatrics. In the past few decades, a significant increase in the incidence of the disease has been described, particularly in toddlers, highlighting the importance of strengthening pediatric specialized teams. On the other hand, incidence of ketoacidosis at onset remains worrying despite prevention campaigns in general population or among primary care professionals. The pathophysiology of this multifactorial autoimmune disease is still unclear. HLA-group but also other genetic variants are implicated in the genetic susceptibility of type 1 diabetes. Different environmental factors could also be considered. Among these, the place of dietary factors and microbial of viral infections could be predominant through a modification of the microbiota or a gut-mediated dysimmunity. The younger age at onset of the disease suggests the role of these factors from early childhood to even fetal period. The geographical disparity and seasonality also help to specify the factors to be evaluated. The perspective is the development of better-targeted preventive strategies.
Is Age a Risk Factor for Cerebral Edema in Children With Diabetic Ketoacidosis? A Literature Review
2020, Canadian Journal of Diabetes
Citation Excerpt :
Two recent retrospective studies in the United States (18) and India (19) found no statistically significant difference in age between children with and without CE. Table 2 (20–46) describes the findings of the 27 studies published over the last 30 years which reported the incidence of DKA or severe DKA based on age categories. Published data covered patients managed for 50 years (1968–2017).
Cerebral edema (CE) is a rare but potentially fatal complication of diabetic ketoacidosis (DKA) in children with type 1 diabetes. CE is frequently mentioned as being more common in young children. The primary objective of this study was to review the evidence suggesting that younger age is a risk factor for the development of CE during DKA. The secondary objective was to assess if younger children are at a higher risk of DKA and severe DKA. A literature review was performed, and studies which reported the frequency of CE, DKA and severe DKA in children <3 and 3 to 5 years of age were included. Among the 6 studies reporting the frequency of CE that were identified, 5 good-quality studies found no significant association between younger age and higher risk of CE. Twenty-seven studies (DKA frequency: 11.3% to 54%) reported DKA frequency as a function of age. Most published studies found a higher frequency of DKA in children <5 years of age (20/25 studies), and in particular in those in the first 2 to 3 years of life (8/8 studies). There was inconclusive evidence to determine whether the severity of DKA was influenced by age. In conclusion, the commonly held view that CE is more common in younger children is not supported by the existing literature. Published data suggest that DKA (and possibly severe DKA) is more common in very young children. Regardless of age, all children with DKA should be monitored carefully for the development of CE.
L’œdème cérébral (OC) est une complication rare, mais potentiellement fatale de l'acidocétose diabétique (ACD) chez les enfants atteints du diabète de type 1. On mentionne souvent que l’OC est plus fréquent chez les jeunes enfants. L'objectif principal de la présente étude était d'examiner les données probantes qui montrent que les enfants de plus bas âge qui sont atteints d’ACD sont exposés au risque de développer un OC. L'objectif secondaire était d’évaluer si les enfants de plus bas âge sont exposés à un risque plus élevé d’ACD et d’ACD grave. Dans la revue de littérature réalisée, nous avons sélectionné les études qui rapportaient la fréquence de l’OC, l’ACD et l’ACD grave chez les enfants âgés de < 3 ans et de 3 à 5 ans. Parmi les 6 études qui rapportaient la fréquence de l’OC, 5 études de bonne qualité n'ont montré aucune association significative entre les enfants de plus bas âge et le risque plus élevé d’OC. Vingt-sept études (fréquence de l’ACD: de 11,3 % à 54 %) ont rapporté la fréquence de l’ACD en fonction de l’âge. La plupart des études publiées ont montré une fréquence plus élevée d’ACD chez les enfants <5 ans (20/25 études), et particulièrement dans les 2 à 3 premières années de vie des enfants (8/8 études). Les données probantes qui déterminaient si la gravité de l’ACD était influencée par l’âge n’étaient pas concluantes. En conclusion, selon la littérature existante, l’OC, contrairement à ce que l'on croit généralement, n'est pas plus fréquent chez les enfants de plus bas âge. Les données publiées montrent que l’ACD (et possiblement l’ACD grave) est plus fréquente chez les enfants très jeunes. Quel que soit leur âge, on devrait surveiller attentivement tous les enfants atteints d’ACD pour s'assurer qu'ils ne développent pas un OC.

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: Supported by Novo Nordisk Austria and Sanofi Aventis Austria. The poster campaign was supported by Abbott Austria, Bayer Healthcare Austria, Eli Lilly Austria, Medtronic Austria, Menarini Diagnostics Austria, Novo Nordisk Austria, Roche Austria, and Sanofi Aventis Austria. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors declare no conflicts of interest.

^∗: A list of members of the Austrian Diabetes Incidence Study Group is available at www.jpeds.com (Appendix).

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Original ArticleDiabetic Ketoacidosis at Diagnosis in Austrian Children: A Population-Based Analysis, 1989-2011

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

Diabetes Res Clin Pract

J Pediatr

Lancet

Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review

Diabetologia

Geographical variation of presentation at diagnosis of type I diabetes in children

Diabetologia

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

BMJ

Severity at onset of childhood type 1 diabetes in countries with high and low incidence of the condition

Diabetes Res Clin Pract

Diabetic ketoacidosis at diagnosis in Austrian children 1989-2008: a population-based analysis

Diabetologia

Ketoacidosis at diagnosis of type 1 diabetes in children in Northern Finland. Temporal changes over 20 years

Diabetes Care

The changing presentation of children with newly diagnosed type 1 diabetes mellitus

Pediatr Diabetes

Diabetic ketoacidosis at onset in children and adolescents with type 1 diabetes in Norway—a nationwide population-based cohort study (abstract)

Pediatr Diabetes

Effectiveness of a prevention program for diabetic ketoacidosis in children

Diabetes Care

Available tools for primary ketoacidosis prevention at diabetes diagnosis in children and adolescents. “The Parma campaign”

Acta Biomed

Campaign for diabetic ketoacidosis prevention still effective 8 years later

Diabetes Care

Original Article
Diabetic Ketoacidosis at Diagnosis in Austrian Children: A Population-Based Analysis, 1989-2011