10-Year Incidence of Diabetic Ketoacidosis at Type 1 Diabetes Diagnosis in Children Aged Less Than 16 Years From a Large Regional Center (Hangzhou, China)

Abstract

Background: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of type 1 diabetes (T1D), and a leading cause of death in children aged <15 years with new-onset T1D.

Aims: i) to assess the incidence of DKA in children and adolescents newly diagnosed with T1D over a 10-year period at a large regional center in China; and ii) to examine the clinical symptoms and demographic factors associated with DKA and its severity at diagnosis.

Methods: We carried out a retrospective audit of a regional center, encompassing all youth aged <16 years diagnosed with T1D in 2009-2018 at the Children's Hospital, Zhejiang University School of Medicine (Hangzhou, China). DKA and its severity were classified according to ISPAD 2018 guidelines.

Results: 681 children were diagnosed with T1D, 50.1% having DKA at presentation (36.0% mild, 30.0% moderate, and 33.9% severe DKA). The number of patients diagnosed with T1D progressively rose from approximately 39 cases/year in 2009-2010 to 95 cases/year in 2017-2018 (≈2.5-fold increase), rising primarily among children aged 5-9 years. DKA incidence was unchanged but variable (44.8% to 56.8%). At T1D diagnosis, 89% of patients reported polyuria and 91% polydipsia. Children presenting with DKA were more likely to report vomiting, abdominal pain, and particularly fatigue. DKA was most common among the youngest children, affecting 4 in 5 children aged <2 years (81.4%), in comparison to 53.3%, 42.7%, and 49.3% of patients aged 2-4, 5-9, and ≥10 years, respectively. Children with severe DKA were more likely to report vomiting, fatigue, and abdominal pain, but less likely to report polyuria, polydipsia, and polyphagia than those with mild/moderate DKA. Rates of severe DKA were highest in children aged <2 years (51.1%).

Conclusions: The number of children diagnosed with T1D at our regional center increased over the study period, but DKA rates were unchanged. With 9 of 10 children reporting polyuria and polydipsia prior to T1D diagnosis, increasing awareness of this condition in the community and among primary care physicians could lead to earlier diagnosis, and thus potentially reduce rates of DKA at presentation.

Keywords: DKA; adolescents; children; complications; symptoms.

Figure 1

Number of patients aged <16 years newly diagnosed with type 1 diabetes (T1D) at the Children’s Hospital of Zhejiang University School of Medicine (Hangzhou, China) in 2009-2018, and rates of diabetic ketoacidosis (DKA) at diagnosis. (A) Number of patients newly diagnosed with T1D (black line, scale on left y axis) and the respective rate of DKA (solid grey line, scale on right y axis) and no-DKA (dashed grey line, scale on right y axis) at diagnosis. (B) Proportion of patients with mild (dashed grey line), moderate (solid grey line), and severe (black line) DKA at T1D diagnosis.

Figure 2

Number of patients aged <16 years newly diagnosed with type 1 diabetes (T1D) at the Children’s Hospital of Zhejiang University School of Medicine (Hangzhou, China) in 2009-2018 according to age group, and rates of diabetic ketoacidosis (DKA) at diagnosis. Data are the number of patients newly diagnosed with T1D (black line, left y axis), and the respective rates of DKA (solid grey line, right y axis) and no-DKA (dashed grey line, right y axis) at T1D diagnosis.

Figure 3

Rates and severity of diabetic ketoacidosis (DKA) among patients aged <16 years newly diagnosed with type 1 diabetes (T1D) at the Children’s Hospital of Zhejiang University School of Medicine (Hangzhou, China), according to age group. (A) Percentage of patients with DKA according to age at diagnosis. (B) Proportion of cases according to DKA severity within age group, whose corresponding bars are color coded as per panel (A); the number of patients who had DKA at T1D diagnosis and data on its severity in each age group was: <2 years, n=45; 2–4 years, n=64; 5–9 years, n=118; and ≥10 years, n=106.