WASHINGTON — Ketoacidosis at the time of diabetes onset in young children is often the result of failure to recognize the signs and symptoms of diabetes during prior medical encounters, Dr. Helen Bui reported at the annual scientific sessions of the American Diabetes Association.
Reported rates of diabetic ketoacidosis (DKA) at the time of onset of type 1 diabetes in children vary widely (15%–67%), depending on the child's age and geographic location. Now, a retrospective analysis from two large Canadian databases suggests that children who present in DKA at the time of onset are significantly more likely than those not presenting in DKA to have had one or more medical encounters during the week preceding the diagnosis. This was particularly true for children younger than age 3 years.
The fact that DKA patients had more medical encounters “actually shows that signs and symptoms of hyperglycemia are being missed. … Our findings have implications for public and medical education to improve the index of suspicion,” said Dr. Bui, of the division of endocrinology at the Hospital for Sick Children, Toronto.
Of 3,947 children diagnosed with type 1 diabetes during 1995–2000, 18.6% (735) presented with DKA. Their mean age was 8.3 years, compared with 10.3 years among those who presented without DKA. Children younger than 3 years of age were at significantly increased risk, with 40% presenting with DKA. The rate dropped to 17% among 3- to 6-year-olds, 19% in those aged 7–10 years, 17% in young adolescents aged 11–14, and just 12% among older teens aged 15–18 years.
Although the overall incidence of type 1 diabetes increased by about 4.3% per year over the study period, the proportion presenting with DKA remained relatively constant, Dr. Bui noted.
During the 7-day period prior to diagnosis, 48% of those presenting with DKA had at least one medical encounter, compared with 41% of those who did not, a significant difference. The youngest children were the most likely to have had at least one encounter in the prior week: 58% of those under age 3, compared with 39% of those aged 3–10, 40% of the 11- to 14-year-olds, and 45% of the older teens.
Upper respiratory infections and gastroenteritis were the most common specific diagnoses noted in the charts for those visits among children of all ages, whereas “urine disorder” and nausea/vomiting were often listed for the older children. However, there was no recorded diagnosis for significant proportions of all the age groups, Dr. Bui said.
It was important to note, she said, that laboratory tests specifically related to the diagnosis of diabetes—including urinalysis, blood glucose, and hemoglobin A1c measurement—had been ordered for just 20% of the 735 children who subsequently presented with DKA, compared with 49% of the 3,212 children who were diagnosed without DKA.
These findings support the hypothesis that DKA at diagnosis represents a failure to detect the signs and symptoms of diabetes before metabolic deterioration to DKA occurs. As well, cases of DKA may signify more fulminant disease and/or symptomatology that are difficult to recognize. This appears to be particularly true in children younger than 3 years, she said.
A wall poster listing the signs and symptoms of DKA is available from the Children's Diabetes Foundation at Denver. Call 1-800-695-2873 or send an e-mail to cdfregina@qwest.net
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