Primary studies included in this systematic review

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Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics.

Journal Pediatric diabetes
Year 2010
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BACKGROUND: Diabetic ketoacidosis (DKA) has significant morbidity and mortality, and is common at diagnosis in children. Objective: Describe the frequency and severity of DKA at diagnosis of type 1 diabetes mellitus (T1DM) in children in Kuwait. METHODS: Hospital records of 677 diabetic children less than 12 yr of age, diagnosed during the period of 2000-2006 were reviewed. DKA was defined as blood glucose > 11 mmol/L, pH < 7.3, and/or bicarbonate < 15 mmol/L with ketonuria. RESULTS: Of all patients diagnosed with T1DM, 255 (37.7%) presented with DKA. The frequency of DKA was constant between 2000 and 2002 (42.7-41.5%), but decreased in the following years to 30.7% in 2006 (p < 0.005). The majority had either mild or moderate DKA (74.1%). Fifty-one (36.7%) of all children in the 0-4 yr had severe DKA compared to ten (2.9%) in the 5- to 8-yr-old group, and three (1.5%) in 9- to 12-yr-old patients (p < 0.0001). Moreover, 83% of children with severe DKA were in the 0-4 yr age group. One child (0.15%) died and twenty-seven (4%) needed intensive care unit (ICU) care. CONCLUSION: Our study provides recent data on Middle Eastern population, for whom data are sparse. Although it has significantly decreased, the frequency of DKA at presentation of T1DM in children in Kuwait is still high, secondary to the high prevalence of diabetes in the community. Young children, especially those less than 2 yr old remain at high risk. Increasing the general awareness of the public as well as of pediatricians to the disease may lead to early diagnosis before the development of acidosis.

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Clinical features at the onset of childhood type 1 diabetes mellitus in Shenyang, China.

Authors Xin Y , Yang M , Chen XJ , Tong YJ , Zhang LH
Journal Journal of paediatrics and child health
Year 2010
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AIM: To describe the clinical picture and laboratory features of Chinese children with newly diagnosed type 1 diabetes mellitus. METHODS: The clinical and laboratory data of a total of 203 children who presented with newly diagnosed type 1 diabetes mellitus during a 5-year period (2004-2008) were retrospectively analysed based on hospital records. RESULTS: There were 88 boys (43.3%) and 115 girls (56.7%) with a median age of 8.3 years. The age distribution was categorised as 0-4 years: 52 (25.6%), 5-9 years: 57 (28.1%) and 10-14 years: 94 (46.3%). We found a peak incidence rate in the older age group. No significant seasonality was observed. The most common symptoms were polydipsia, polyuria and weight loss. Eighty-five (41.9%) of all patients presented with diabetic ketoacidosis (DKA). The average duration of presenting symptoms before the hospital encounter was 24.5 days. Young age group children had shorter duration (17.1 days, P = 0.03) and significantly lower levels of C-peptide (P = 0.003) and haemoglobin A1c (P = 0.049) than the other groups. Children with DKA had a higher incidence of preceding infections (P = 0.032), lower free triiodothyronine and free thyroxine levels (P= 0.035, 0.046), and higher white blood cell counts (P = 0.000) than the non-DKA group. CONCLUSION: The duration between the onset of the symptoms and diagnosis was long, and the proportion of DKA in children with newly diagnosed diabetes mellitus was high. These findings call for a collaborative effort for the early recognition of symptoms by patients and physicians in order to avoid more severe types of presentation.

Primary study

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

Journal Diabetes care
Year 2010
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECTIVE: We studied the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes in children in Finland. RESEARCH DESIGN AND METHODS: From 2002 to 2005, data on virtually all children <15 years of age diagnosed with type 1 diabetes (n = 1,656) in Finland were collected. RESULTS: DKA was present in 19.4% of the case subjects, and 4.3% had severe DKA. In children aged 0-4, 5-9, and 10-14 years, DKA was present in 16.5, 14.8, and 26.4%, respectively (P < 0.001). Severe DKA occurred in 3.7, 3.1, and 5.9%, respectively (P = 0.048). DKA was present in 30.1% and severe DKA in 7.8% of children aged <2 years. CONCLUSION: The overall frequency of DKA in children is low in Finland at diagnosis of type 1 diabetes. However, both children <2 years of age and adolescents aged 10-14 years are at increased risk of DKA.

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

Journal Diabetologia
Year 2010
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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AIM: The aim of the study was to analyse the prevalence of diabetic onset ketoacidosis (DKA) during a period of 20 years (1989-2008) on a population basis in the whole of Austria. METHODS: A prospective population-based incidence study (1989-2008) was performed. The registered data set comprised blood glucose, pH, ketonuria and clinical symptoms of DKA at manifestation. DKA was defined as pH < 7.3 and severe DKA as pH < 7.1. Time trends were estimated using linear regression models. RESULTS: During the study period, 3331 children <15 years of age (1,797 boys and 1,534 girls) were registered with newly diagnosed type 1 diabetes. Of these, 1,238 (37.2%) presented with DKA, 855 (25.7%) had a mild and 383 (11.5%) a severe form, and one patient died at onset. DKA frequency was negatively associated with age at onset (p < 0.0001). In children <2 years the prevalence was 60%, with a higher risk for girls (70% vs 54% for boys, p < 0.05). Despite a significant increase in diabetes incidence in Austria during the observation period from 8.4 to 18.4/100,000 (p < 0.0001), no significant change in the prevalence of DKA at manifestation was observed. CONCLUSIONS: The overall frequency of DKA in children with newly diagnosed type 1 diabetes in Austria is high and has not changed during the last 20 years despite a clear increase in the manifestation rate. In particular, children less than 2 years of age have a high risk of DKA at onset.

Primary study

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Is diabetic ketoacidosis at disease onset a result of missed diagnosis?

Authors Bui H , To T , Stein R , Fung K , Daneman D
Journal The Journal of pediatrics
Year 2010
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECTIVE: To determine the frequency of medical encounters before diagnosis of diabetes in children in Ontario, Canada; to determine risk factors for diabetic ketoacidosis (DKA). RESEARCH DESIGN: All medical encounters within 4 weeks before date of diagnosis for all new cases of diabetes in children <18 years were identified from April 1994 to March 2000 by use of administrative databases. The main outcome measure was the frequency of medical encounters before diagnosis in children presenting with and without DKA. RESULTS: A total of 3947 new cases of diabetes were identified, 735 (18.6%) with DKA. DKA rates were 39.7% for children < or =3 years and 16.3% for children >3 years (P < .001). During the week before diagnosis, 285 children with DKA (38.8%) and 1104 children with diabetes without DKA (34.4%; P = .026) had at least 1 medical visit. Children with diabetes overall had more medical encounters before diagnosis than control subjects. Children with DKA were less likely to have had relevant laboratory testing before diagnosis than children with diabetes without DKA. CONCLUSIONS: Children with diabetes presenting with DKA more frequently had a medical encounter before diagnosis compared with children with diabetes without DKA. These data have important implications for enhancing public and physician awareness of diabetes in children.

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Difficulties or mistakes in diagnosing type 1 diabetes in children?--demographic factors influencing delayed diagnosis.

Journal Pediatric diabetes
Year 2009
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: Diabetic ketoacidosis (DKA) development in children with new-onset type 1 diabetes (T1DM) is often the main consequence of delayed diagnosis. The aim of the study was to estimate the frequency of difficulties in T1DM diagnosis and to investigate if and how the demographic factors (gender, patient's age at presentation, family history of T1DM, level of maternal education, place of residence, and health service unit the patient called at) have any influence on diagnostic delays. SUBJECTS AND METHODS: Retrospective analysis of 474 children (243 boys-51.27% and 231 girls -48.73%) with new-onset T1DM aged below 17 yr and living in the Pomeranian region of Poland was carried out. The delay in diagnosis was recognized if the patient was not diagnosed on the first visit because of omission, wrong interpretation of main diabetic symptoms, exclusive treatment of additional signs, or concomitant diseases. RESULTS: Difficulties in diagnosing T1DM were found in 67 cases (14.13%) and they are the main cause of DKA development in these children (p = 0.00). Among the examined demographic factors, mainly the patient's age at presentation has a significant influence on diagnostic delays (p = 0.01), especially in children below 2 yr (p = 0.00). Most frequently family doctors were responsible for wrong preliminary diagnosis. CONCLUSIONS: Difficulties in diagnosing T1DM are a significant cause of DKA development in children with new-onset disease. Patient's age at presentation is the main risk factor of delayed diagnosis, especially in children below 2 yr. The increase in awareness among pediatricians concerning the possibility of T1DM development in children is needed.

Primary study

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Rapid weight gain in children soon after diagnosis of type 1 diabetes: is there room for concern?

Journal Pediatric diabetes
Year 2009
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECTIVE: To examine weight status in children at diagnosis (Dx) of type 1 diabetes and observe weight change post-Dx. Research design and methods: Data on 136 subjects (76 M/60 F) with type 1 diabetes diagnosed in 1998-2001 at Children's Hospital San Diego was obtained from Institutional Review Board (IRB)-approved database. All patients received two daily insulin injections (NPH/Regular) and were examined at least twice, up to 7 months post-Dx. RESULTS: Average age at Dx (SD) was 9.02 yr (4.46)yr; 63.9% were Caucasian, 25% Mexican American (MA), 2.9% African American, 0.7% Asian, and 7.3% mixed. Diabetic ketoacidosis rate was more common in MA (44.1%) vs. Caucasians (20.9%) at Dx (p < 0.02). Average body mass index Z-score (BMI-Z) at Dx was -0.28 (39th percentile); 13.5% had BMI > or = 85th percentile, and 7.2% were obese. By 2 wk, and 15-41 d post-Dx, mean weight gain was 9% (5.9) and 12.8% (8), respectively. Mean A1C at Dx, 42-70 and 71-139 d later, was 11.4, 7.6, and 6.9%, respectively. Coinciding with improved glycemic control, by 10 wk, mean BMI-Z reached a plateau of 0.86 (80th percentile). On average, MA were heavier than Caucasians at Dx (p = 0.006), and remained heavier. By 71-139 d, 31.7% had BMI > or = 85th percentile and 15.9% were obese; 47.8% of 2- to 5-yr olds had BMI > or = 85th percentile vs. 22.6% nationally (p < 0.005) CONCLUSIONS: Despite the initial weight loss at Dx of type 1 diabetes, by 10-20 wk post-Dx, almost one third were overweight and obese, more so in MA. In light of the obesity epidemic, closer attention to overall caloric intake in children with new onset diabetes is prudent.

Primary study

Unclassified

Delayed diagnosis in type 1 diabetes mellitus.

Authors Sundaram PC , Day E , Kirk JM
Journal Archives of disease in childhood
Year 2009
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Children with suspected type 1 diabetes mellitus (T1DM) should have same day referral to a paediatric diabetes team. 99 children (54 male; median age 10.5 years, range 0.9-15.9 years) were diagnosed with T1DM at our hospital between January 2004 and June 2007. 27 (27.2%) presented in diabetic ketoacidosis (DKA). 37 (37.3%) required hospital admission, while the rest had ambulatory management. In 21 (21.2%) children, diagnosis was delayed >24 h (median 3.0 days, range 1-14 days) due to missed diagnosis at the local hospital (four) or by the general practitioner (seven), arranging a fasting blood glucose test (nine) and outpatient appointment requested via fax (one). Children with delayed diagnosis presented more frequently in DKA (52.3% vs 20.5%, p<0.01), with a higher median presenting HbA1c (12.3% vs 10.9%, p<0.05). There were no differences in age and sex between the delayed diagnosis and immediate referral groups. Healthcare providers need to be aware of the importance of immediate referral of children newly diagnosed with T1DM.

Primary study

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Diabetes in African American youth: prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study.

Journal Diabetes care
Year 2009
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OBJECTIVE: To report the prevalence and incidence of type 1 and type 2 diabetes among African American youth and to describe demographic, clinical, and behavioral characteristics. RESEARCH DESIGN AND METHODS: Data from the SEARCH for Diabetes in Youth Study, a population-based, multicenter observational study of youth with clinically diagnosed diabetes aged 0-19 years, were used to estimate the prevalence for calendar year 2001 (692 cases) and incidence based on 748 African American case subjects diagnosed in 2002-2005. Characteristics of these youth were obtained during a research visit for 436 African American youth with type 1 diabetes and 212 African American youth with type 2 diabetes. RESULTS: Among African American youth aged 0-9 years, prevalence (per 1,000) of type 1 diabetes was 0.57 (95% CI 0.47-0.69) and for those aged 10-19 years 2.04 (1.85-2.26). Among African American youth aged 0-9 years, annual type 1 diabetes incidence (per 100,000) was 15.7 (13.7-17.9) and for those aged 10-19 years 15.7 (13.8-17.8). A1C was >or=9.5% among 50% of youth with type 1 diabetes aged >or=15 years. Across age-groups and sex, 44.7% of African American youth with type 1 diabetes were overweight or obese. Among African American youth aged 10-19 years, prevalence (per 1,000) of type 2 diabetes was 1.06 (0.93-1.22) and annual incidence (per 100,000) was 19.0 (16.9-21.3). About 60% of African American youth with type 2 diabetes had an annual household income of <$25,000. Among those aged >or=15 years, 27.5% had an A1C >or=9.5%, 22.5% had high blood pressure, and, across subgroups of age and sex, >90% were overweight or obese. CONCLUSIONS: Type 1 diabetes presents a serious burden among African American youth aged <10 years, and African American adolescents are impacted substantially by both type 1 and type 2 diabetes.

Primary study

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Childhood growth and age at diagnosis with Type 1 diabetes in Colorado young people.

Journal Diabetic medicine : a journal of the British Diabetic Association
Year 2009
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OBJECTIVE: Studies have suggested that the age at diagnosis of Type 1 diabetes (T1D) is decreasing over time. The overload hypothesis postulates that risk factors, such as accelerated growth, may be responsible for this decrease. We assessed changes in age, body mass index (BMI), weight and height at diagnosis with T1D in non-Hispanic white (NHW) and Hispanic (HISP) young people from Colorado, using data from the IDDM Registry and SEARCH Study. METHODS: In three time periods, 656 (1978-1983), 562 (1984-1988) and 712 (2002-2004) young people aged 2-17 years were newly diagnosed with T1D. Age, weight, height and presence of diabetic ketoacidosis (DKA) at diagnosis with T1D were obtained from medical records. Trends over the three time periods were assessed with regression analyses. RESULTS: Age at diagnosis decreased by 9.6 months over time (P = 0.0002). Mean BMI standard deviation score (SDS), weight SDS and height SDS increased over time (P < 0.0001), while prevalence of DKA decreased (P < 0.0001). Increasing height over time accounted for 15% (P = 0.04) of the decreasing age at diagnosis with T1D. CONCLUSIONS: Our study provides evidence that increased linear growth, but not increased BMI or weight over time, may account, at least in part, for the younger age at diagnosis of T1D in Colorado children. This finding supports the hypothesis that increasing environmental pressure resulting from changes in potentially preventable risk factors may accelerate the onset of T1D in children.