In the JournalsPerspective

Rising pediatric diabetic ketoacidosis numbers a result of underdiagnosed diabetes

The number of children with type 1 diabetes who present with diabetic ketoacidosis is increasing by 2% per year, and this may be due to underdiagnosing of diabetes, according to findings published in CMAJ Open.

“If [type 1 diabetes] is left undiagnosed and untreated, diabetic ketoacidosis (DKA) develops,” Meranda M. Nakhla, MD, MSc, a pediatric endocrinologist in the divisions of endocrinology and general pediatrics in the department of pediatrics at McGill University Health Centre in Montreal, and colleagues wrote. “The population burden of DKA may underscore gaps in health care access and/or in knowledge of the early symptoms of [type 1 diabetes] among the lay and medical community.”

Nakhla and colleagues identified 5,741 children aged 1 to 17 years who were diagnosed with diabetes between 2001 and 2014 (mean age at diagnosis, 10.1 years; 47.9% girls) according to information from health administrative databases from the Institut National de Santé Publique du Québec in Canada. Although the researchers were not able to differentiate between diagnoses for type 1 and type 2 diabetes, they noted that most children younger than 18 years with diabetes have type 1.

“Given that DKA can occur in both forms of diabetes, our finding of increasing trends of DKA at diagnosis is a concerning observation irrespective of the type of diabetes the child has, highlighting the importance of determining the underlying drivers,” they wrote.

Using the same databases, the researchers also identified children with diabetes who had DKA no more than 3 days after a diagnosis. Of the 5,741 children with diabetes, 25.6% developed DKA in this timeframe (n = 1,471). The prevalence of DKA was higher in 2014 (29.6%) than it was in 2001 (22%) and followed an upward trajectory between those years even as, according to the researchers, diabetes incidence “remained stable.” In fact, they noted that DKA incidence rose by 2% each year, and by 2014, there was a 38.6% higher risk for DKA among children with diabetes compared with children with diabetes in 2001 (RR = 1.39; 95% CI, 1.08-1.79).

Children aged 5 to 11 years experienced the highest rates of DKA increase each year at 2.7% (RR = 1.027; 95% CI, 1.009-1.045) compared with children aged 1 to 4 years (0.2%; RR = 1.002; 95% CI, 0.976-1.029) and children aged 12 to 17 years (2.3%; RR = 1.023; 95% CI, 1.004-1.042). In addition, there was a 30.1% reduction in DKA risk for children aged 12 to 17 years compared with those aged 1 to 4 years, the researchers wrote.

“Our results are concerning and underscore the need to increase physician and public awareness of the signs and symptoms of childhood diabetes before DKA develops and to impress upon physicians the importance of referring children immediately,” the researchers wrote. “As other countries have demonstrated stable or decreasing trends in DKA prevalence, future research, potentially through international collaborations, should investigate the reasons for our increasing DKA trends, to develop targeted and effective interventions.” – by Phil Neuffer

Disclosures: Nakhla reports she received funding from the Fonds de recherche du Québec — Santé (FRQS) and the Ministère de la Santé et des Services sociaux du Québec. Please see the study for all other authors’ relevant financial disclosures.

The number of children with type 1 diabetes who present with diabetic ketoacidosis is increasing by 2% per year, and this may be due to underdiagnosing of diabetes, according to findings published in CMAJ Open.

“If [type 1 diabetes] is left undiagnosed and untreated, diabetic ketoacidosis (DKA) develops,” Meranda M. Nakhla, MD, MSc, a pediatric endocrinologist in the divisions of endocrinology and general pediatrics in the department of pediatrics at McGill University Health Centre in Montreal, and colleagues wrote. “The population burden of DKA may underscore gaps in health care access and/or in knowledge of the early symptoms of [type 1 diabetes] among the lay and medical community.”

Nakhla and colleagues identified 5,741 children aged 1 to 17 years who were diagnosed with diabetes between 2001 and 2014 (mean age at diagnosis, 10.1 years; 47.9% girls) according to information from health administrative databases from the Institut National de Santé Publique du Québec in Canada. Although the researchers were not able to differentiate between diagnoses for type 1 and type 2 diabetes, they noted that most children younger than 18 years with diabetes have type 1.

“Given that DKA can occur in both forms of diabetes, our finding of increasing trends of DKA at diagnosis is a concerning observation irrespective of the type of diabetes the child has, highlighting the importance of determining the underlying drivers,” they wrote.

Using the same databases, the researchers also identified children with diabetes who had DKA no more than 3 days after a diagnosis. Of the 5,741 children with diabetes, 25.6% developed DKA in this timeframe (n = 1,471). The prevalence of DKA was higher in 2014 (29.6%) than it was in 2001 (22%) and followed an upward trajectory between those years even as, according to the researchers, diabetes incidence “remained stable.” In fact, they noted that DKA incidence rose by 2% each year, and by 2014, there was a 38.6% higher risk for DKA among children with diabetes compared with children with diabetes in 2001 (RR = 1.39; 95% CI, 1.08-1.79).

Children aged 5 to 11 years experienced the highest rates of DKA increase each year at 2.7% (RR = 1.027; 95% CI, 1.009-1.045) compared with children aged 1 to 4 years (0.2%; RR = 1.002; 95% CI, 0.976-1.029) and children aged 12 to 17 years (2.3%; RR = 1.023; 95% CI, 1.004-1.042). In addition, there was a 30.1% reduction in DKA risk for children aged 12 to 17 years compared with those aged 1 to 4 years, the researchers wrote.

PAGE BREAK

“Our results are concerning and underscore the need to increase physician and public awareness of the signs and symptoms of childhood diabetes before DKA develops and to impress upon physicians the importance of referring children immediately,” the researchers wrote. “As other countries have demonstrated stable or decreasing trends in DKA prevalence, future research, potentially through international collaborations, should investigate the reasons for our increasing DKA trends, to develop targeted and effective interventions.” – by Phil Neuffer

Disclosures: Nakhla reports she received funding from the Fonds de recherche du Québec — Santé (FRQS) and the Ministère de la Santé et des Services sociaux du Québec. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Terri H. Lipman

    Terri H. Lipman

    These data are of particular concern. Diabetic ketoacidosis is the most common cause of death in children with type 1 diabetes. Children under the age of 5 years are at highest risk for morbidity and mortality because of delayed diagnosis. There is a marked increase in the incidence of type 1 diabetes in young children — those at greatest risk for DKA. Data from the Philadelphia Pediatric Diabetes Registry, the longest ongoing such registry in the U.S., have demonstrated that the incidence of type 1 diabetes among children 0 to 4 years of age in Philadelphia increased by 70% over the 25 years of the study. A similar sharp rise in incidence in children 0 to 4 years of age was found in data from the Colorado, EURODIAB, Israel and Finland registries.

    Diabetes is often not part of primary care providers’ differential diagnosis when evaluating very young children who are ill. Parents may not be aware that young children develop type 1 diabetes. The best strategy to decrease the risk of diabetic ketoacidosis is to raise awareness among primary care providers and families to be alert for the signs and symptoms of type 1 diabetes, particularly in young children, and to consider diabetes when children present with an acute illness.  According to the researchers, “Our findings are concerning and demonstrate a need to continue to campaign to recognize type 1 diabetes before diabetic ketoacidosis supervenes.”

    • Terri H. Lipman, PhD, CRNP, FAAN
    • Assistant Dean for Community Engagement,
      Miriam Stirl Endowed Term Professor of Nutrition,
      Professor of Nursing of Children,
      Professor of Nursing in Pediatrics,
      Perelman School of Medicine,
      University of Pennsylvania School of Nursing

    Disclosures: Lipman reports no relevant financial disclosures.