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. 2011 Jul 7:343:d4092.
doi: 10.1136/bmj.d4092.

Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review

Juliet A Usher-Smith  1 , Matthew J Thompson, Stephen J Sharp, Fiona M Walter
Affiliations

Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review

Juliet A Usher-Smith et al. BMJ. .

Abstract

Objective: To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.

Design: Systematic review.

Data sources: PubMed, EMBASE, Web of Science, Scopus, and Cinahl and article reference lists.

Study selection: Cohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication.

Results: 46 studies involving more than 24,000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for <2 years old v older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35 (2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection (odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74 (1.10 to 2.77)). Protective factors were having a first degree relative with type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)), higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43 to 0.94) in two studies), and higher background incidence of type 1 diabetes (correlation coefficient -0.715). The mean duration of symptoms was similar between children presenting with or without diabetic ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0) respectively), and up to 38.8% (285/735) of children who presented with diabetic ketoacidosis had been seen at least once by a doctor before diagnosis.

Conclusions: Multiple factors affect the risk of developing diabetic ketoacidosis at the onset of type 1 diabetes in children and young adults, and there is potential time, scope, and opportunity to intervene between symptom onset and development of diabetic ketoacidosis for both parents and clinicians.

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Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Selection of studies used in review
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Fig 2 Influence of individual, family, physician, and disease factors on risk of diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults
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Fig 3 Forest plot showing the effect of different age cut-off points on the risk of presenting in diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults
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Fig 4 Forest plot showing the effect of sex on the risk of presenting in diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults
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Fig 5 Forest plot showing the effect of diagnostic error on the risk of presenting in diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults
See this image and copyright information in PMC

Comment in

References

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    1. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child 1999;81:318-23. - PMC - PubMed

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