Volume 197 - Issue 4
Consistently high incidence of diabetic ketoacidosis in children with newly diagnosed type 1 diabetes
Authors: Femke M A P Claessen, Kim Donaghue and Maria Craig
Med J Aust 2012; 197 (4): 216. || doi: 10.5694/mja12.10686
Published online: 20 August 2012
Published online: 20 August 2012
To the Editor: The incidence of type 1 diabetes (T1D) in children is rising globally, including in Australia.1 Diabetic ketoacidosis (DKA) is the leading cause of diabetes-related deaths in children.2 Clinical manifestations of DKA include dehydration; rapid, deep, sighing (Kussmaul respiration); nausea; vomiting; abdominal pain and a reduced level of consciousness.2 There is an inverse relationship between the frequency of presentation with DKA and background incidence ...
To the Editor: The incidence of type 1 diabetes (T1D) in children is rising globally, including in Australia.1 Diabetic ketoacidosis (DKA) is the leading cause of diabetes-related deaths in children.2 Clinical manifestations of DKA include dehydration; rapid, deep, sighing (Kussmaul respiration); nausea; vomiting; abdominal pain and a reduced level of consciousness.2 There is an inverse relationship between the frequency of presentation with DKA and background incidence of T1D in a given country,3 suggesting that the diagnosis is more likely to be considered earlier in countries with higher incidence of T1D, such as Australia.
We examined temporal trends in the incidence of DKA in children with newly diagnosed T1D from 1 January 1998 to 31 December 2010. We included 1073 children and adolescents aged up to 18 years presenting to The Children’s Hospital at Westmead, a tertiary hospital serving the population of Western Sydney. The diagnosis of T1D was based on clinical criteria and presence of islet autoantibodies. DKA was defined according to the following criteria: serum glucose level greater than 11 mmol/L, venous pH less than 7.30 or serum bicarbonate level less than 15 mmol/L, and ketonaemia or ketonuria.
The mean incidence rate of DKA was 37.7 per 100 person-years (95% CI, 34.1–41.5) and did not change significantly over time (P = 0.63). There was one death from DKA (giving a mortality rate of 0.3%).
It is of great concern that the incidence of DKA in young people at onset of T1D has remained consistently high for more than a decade. A public awareness campaign in Italy successfully decreased the incidence of DKA in children with new-onset T1D in the 1990s.4 Such interventions have not been tested in the Australian population; however, the importance of prompt referral is highlighted in the National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults.5
Our findings suggest that greater dissemination of these guidelines is needed to improve earlier recognition and diagnosis of diabetes. Young children and those from areas of lower socioeconomic status should be particularly targeted, since they are at greatest risk of DKA. A recent systematic review concluded that “there is potential time, scope, and opportunity to intervene between symptom onset and development of diabetic ketoacidosis for both parents and clinicians”.3 Nevertheless, further studies to explain the consistently high rate of DKA are essential.
Competing interests
No relevant disclosures.
References
- Catanzariti L, Faulks K, Moon L, et al. Australia’s national trends in the incidence of Type 1 diabetes in 0–14-year-olds, 2000–2006. Diabet Med 2009; 26: 596–601. 0_CBBFHCBB
- Wolfsdorf J, Craig ME, Daneman D, et al. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12: 118-133. 0_CBBBFCFI
- Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ 2011; 343: d4092. 0_CBBHEDCF
- Abdul-Rasoul M, Al-Mahdi M, Al-Qattan H, et al. Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics. Pediatr Diabetes 2010; 11: 351-356. 0_CBBDBJIE
- Craig ME, Twigg SM, Donaghue KC, et al. National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults. Canberra: Department of Health and Ageing, 2011. http://www.nhmrc.gov.au/guidelines/ publications/ext004 (accessed Jul 2012).