Elsevier

Diabetes & Metabolism

Volume 40, Issue 2, April 2014, Pages 137-142
Diabetes & Metabolism

Original article
Ketoacidosis at diagnosis of type 1 diabetes in French children and adolescents

https://doi.org/10.1016/j.diabet.2013.11.001Get rights and content

Abstract

Objectives

This study aimed to evaluate the frequency of diabetic ketoacidosis (DKA) and its associated factors at the diagnosis of type 1 diabetes (T1D) in French children and adolescents prior to launching a public-health campaign of information to prevent DKA.

Patients and methods

Over a 1-year period, 1299 youngsters (aged < 15 years) were diagnosed with T1D at 146 paediatric centres in all regions of France. Age, gender, duration of symptoms, patient's pathway to diagnosis, clinical and biological signs, and family history of T1D were collected for each newly diagnosed patient. DKA was defined as pH < 7.30 or bicarbonate < 15 mmol/L, and severe DKA as pH < 7.10 or bicarbonate < 5 mmol/L.

Results

At the time of diagnosis, 26% of the children were aged 0–5 years, 34% were 5–10 years and 40% were 10–15 years. The overall prevalence of DKA was 43.9% (0–5 years: 54.2%; 5–10 years: 43.4%; and 10–15 years: 37.1%) and 14.8% for severe DKA (0–5 years: 16.6%; 5–10 years: 14.4%; and 10–15 years: 13.9%; < 2 years: 25.3%). Severe DKA was more frequent when the child was hospitalized at the family's behest (26.6%) than when referred by a general practitioner (7.6%) or paediatrician (5.1%; 30.6%, 53.7% and 9.2%, respectively, by patients’ age group). The frequency of DKA decreased to 20.1% (severe DKA: 4.4%) in families with a history of T1D. Multivariate analysis showed that age, pathway to diagnosis, duration of polyuria/polydipsia (< 1 week) and family history of T1D were associated with the presence of DKA, while pathway to diagnosis and family history of T1D were associated with severe DKA.

Conclusion

DKA at the time of T1D diagnosis in children and adolescents is frequent and often severe. Patients’ age, pathway to hospitalization and family history of diabetes were the main factors associated with DKA. These data suggest that a public-health campaign to prevent DKA at diagnosis can help reduce the frequency of DKA and also provide baseline data for evaluating the efficacy of such a campaign.

Introduction

The incidence of type 1 diabetes (T1D) is steadily increasing in children and adolescents by 3–4% annually in those 0–15 years of age [1], [2], [3], and is growing approximately twice as fast in children aged < 5 years [4], [5]. The symptoms of diabetes often develop acutely in children and adolescents, especially in the youngest ones. The clinical condition can deteriorate rapidly, and diabetic ketoacidosis (DKA) is a common complication at the time of diagnosis [6], [7], [8]. The prevalence of DKA varies widely in different countries (15–67%) [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]; it has also been reported that DKA at diagnosis is less frequent when there is greater awareness, and when the disease is more common and better known [19]. In France, a study from about 20 years ago showed that the prevalence of DKA at diagnosis was > 40% [21].

DKA at diagnosis has a major impact in terms of morbidity and even mortality. In France [21], severe DKA represents a life-threatening risk and may require hospitalization in an intensive care unit (ICU), as described in around 10% of new cases, while five to six young people are expected to die of it every year [22], which is particularly intolerable as it can be avoided. Indeed, a campaign directed at health professionals and families launched in the Italian province of Parma lowered the prevalence of DKA from 78 to 12.5%, and has had long-lasting effects [23], [24]. For this reason, the association L’Aide aux jeunes diabétiques (AJD ; help for young diabetics) has decided to launch a national campaign for the prevention of DKA at the time of T1D diagnosis. The campaign's objective is to inform families and their doctors of the symptoms to look out for and that a quick diagnosis can shorten the time lag between the onset of symptoms and initiation of insulin treatment, thereby reducing the risk of DKA.

To evaluate the impact of the campaign, paediatric centres across France were invited to participate in a survey to prospectively determine the prevalence of DKA at diagnosis. The collection of data started a year before launching the campaign to establish current baseline rates on the frequency of DKA at diagnosis to allow for later evaluation of the impact of the campaign, and to identify any factors that might inform the best design for such a campaign. The present report is of the results on the frequency of DKA and its associated factors observed at centres participating in the French survey during the year prior to the campaign.

Section snippets

Patients and methods

Between June and November 2009, all metropolitan paediatric centres in France were invited to participate in the evaluation and follow-up study of the prevalence of DKA at diagnosis of T1D. Out of 230 paediatric centres in 22 metropolitan regions, 146 agreed to participate, representing 63% of all centres (33–83% depending on the region), 19% of which were university hospitals. Hospitals had the use of an ICU in 46% of cases. Healthcare providers at each participating centre volunteered to

Statistical analyses

Data for patients aged < 15 years were included in the analyses. Categorical data were expressed as numbers and percentages, with continuous quantitative data as means ± standard deviation (SD). Comparisons were performed across three groups (no DKA, moderate DKA and severe DKA) by univariate analysis, using analysis of variance (ANOVA) for quantitative variables and chi-square test for categorical variables. Variables significantly associated with the presence of DKA or severe DKA were then

Results

During the year of data collection, 146 paediatric centres provided information on 1322 patients aged < 15 years : 46.6% of the centres had five new patients or less, while 28.1% had six to 10, 13.7% had 11–20, 6.8% had 21–30, 2.7% had 31–50 and 2.1% had 51–70 new patients. However, 23 patients were not included in the analyses because of missing pH and bicarbonate data. Thus, the analyses included 1299 patients (48% girls and 52% boys). The number of new cases per month varied from 65 in June to

Discussion

The prevention of DKA at T1D diagnosis is a priority for ISPAD and the International Diabetes Federation (IDF). The present prospective study of patients newly diagnosed with T1D – performed thanks to the data collected by two-thirds of France's paediatric centres and representing about two-thirds of all new cases of T1D in people younger than 15 years [25] – had the main objectives of updating our data on the frequency of DKA at diagnosis to allow later evaluation of the efficacy of a national

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

AJD Study Group: list of co-authors

M. Abdelhadi, Provins; C. Ajzennman, Le Chesnay; R. Amira, Saint-Denis; E. Badet, Chambéry; E. Baechler-Sadoul, Nice; I. Barakat, Gonesse; S. Baron, Nantes; J. Beltrand, Paris; M. Bengrina, Remiremont; C. Bensignor, Dijon; P. Blanc, Poissy; C. Boniface, Saintes; L. Bornebusch, Grasse; M.N. Bortoluzzi, Nice; N. Bouhours-Nouet, Angers; S. Boulard, Libourne; H. Boussadia, Montmorency; K. Braun, Amiens; D. Briffaut, Lorient; I. Brintet, Agen; M Chambon, Villefranche-sur-Saône; A. Chergui, Vierzon;

Acknowledgements

We sincerely thank Alan Delamater for his careful and expert editorial work on the manuscript.

References (31)

  • J. Wolfsdorf et al.

    Diabetic ketoacidosis in infants, children, and adolescents. A consensus statement from the American Diabetes Association

    Diabetes Care

    (2006)
  • D.B. Dunger et al.

    European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents

    Pediatrics

    (2004)
  • A. Hekkala et al.

    Age-related differences in the frequency of ketoacidosis at diagnosis of type 1 diabetes in children and adolescents

    Diabetes care

    (2010)
  • E. Schober et al.

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

    Diabetologia

    (2010)
  • A. Neu et al.

    DPV initiative and the German BMBF competency network for diabetes mellitus. Ketoacidosis at diabetes onset is still frequent in children and adolescents. A multicentre analysis of 14 664 patients from 106 institutions

    Diabetes Care

    (2009)
  • Cited by (48)

    • Trends in childhood type 1 diabetes incidence in France, 2010–2015

      2019, Diabetes Research and Clinical Practice
      Citation Excerpt :

      At this age, the disease is characterized by a more severe mode of revelation, i.e. ketoacidosis, a high risk of complications, fast and large glycemic variability, a very high danger of hypoglycemia, interference of febrile concomitant diseases, child immaturity regarding treatment, and the time consuming care needed in adapted structures with multidisciplinary staff who are trained in diabetes care [35]. Furthermore, information campaigns on symptoms should be promoted to avoid late diagnosis and associated complications, such as ketoacidosis [5]. Finally, although many countries still use specific registries [27,36–38] as the reference (“gold standard”), some countries use medico-administrative databases [39,40] to estimate the incidence of type 1 diabetes.

    View all citing articles on Scopus
    View full text