About a third of children are already in diabetic ketoacidosis by the time they are diagnosed with type 1 diabetes, which means that earlier signs of the disease were missed, according to researchers from the Pediatric Diabetes Consortium.
Among 805 children in the group’s database, 34% presented in diabetic ketoacidosis (DKA), half of whom had moderate or severe DKA (pH less than 7.2). The risk of DKA was 54% in children under 3 years old and 33% in older children (P = .006). The findings were consistent with previous studies.
Dr. William Tamborlane
"Unfortunately, there has been no apparent change in the rate of DKA at presentation of T1D [type 1 diabetes] in children over the past 25 years; the incidence of DKA in children at the onset of T1D remains high. Effective techniques for increasing awareness of the early symptoms of T1D in both the general public and primary care providers are needed to decrease the incidence of this life-threatening complication," the investigators wrote (J. Pediatr. 2013;162:330-4).
The problem is that those early T1D symptoms – often an abrupt increase in thirst and urination – are "not infrequently" overlooked by parents unfamiliar with the disease and sometimes even by clinicians, especially in very young children, said coinvestigator Dr. William Tamborlane, deputy director for clinical research at Yale University, New Haven, Conn., and chair of the diabetes consortium, a research collaboration between university pediatric diabetes centers.
The classic signs of diabetes in children have a variety of harmless possible explanations. Excess thirst might be chalked up to hot weather or a growth spurt. Polyuria might be mistaken for a urinary tract infection. Weight loss, particularly in an obese child, might be attributed to dieting. It’s also hard to tell the difference between normal and abnormal thirst and urination in children less than 1 or 2 years old, and they’re unlikely to be able to voice any complaints, he said in an interview.
Indeed, younger age (P = .002) proved to be an independent predictor of DKA at diagnosis, as did lack of private health insurance (P less than .001), African American race (P = .01), and no family history of T1D (P = .001).
Children in the study were under 19 years old and positive for at least one diabetes-associated autoantibody. Their average age was 9 years, half were girls, and 63% were non-Hispanic whites.
Almost all of the DKA kids (91%) were admitted to the hospital; 58% required ICU treatment and 3% had cerebral edema, but none died. Their mean hospital stay was 3 days. DKA was defined in the study as a venous pH below 7.3 and/or a serum bicarbonate below 15 mEq/L.
Commenting on the study, Dr. Alan Rogol, a Journal of Pediatrics editorial board member, wrote, "It is incumbent upon us as pediatricians and health care professionals to consider the diagnosis of T1D to prevent, or at least minimize, the severity of the acute metabolic disturbance and to enter into a long-term treatment plan."
Dr. Tamborlane noted that, like juvenile diabetes, DKA can be missed too, especially when its associated nausea and vomiting mimic a viral infection. "When a child presents with a flulike illness, it’s worth getting a simple urine dipstick to make sure there’s no sugar or ketones in the urine," he said.
The investigators said that they had no disclosures.