The impact of COVID-19 on type 1 diabetes and ketoacidosis incidence in pediatric age
Chiara MameliGiulio FrontinoA. ScaramuzzaMaddalena MacedoniCiretta PellicciaBarbara FelappiL GuerraggioDaniele SpiriPatrizia MacellaroFrancesca RedaelliRoberta CardaniMaria ZampolliValeria CalcaterraSilvia SordelliElena CalziAnna CogliardiGian Vincenzo ZuccottiAndrea RigamontiRiccardo Bonfanti
0
Citation
0
Reference
20
Related Paper
Abstract:
Introduction: The COVID-19 pandemic has had a significant impact the region of Lombardy, causing more than 16,000 deaths. Fortunately, children, including those with type 1 diabetes (T1DM), were only slightly affected. It is debated as to whether COVID-19 infection may increase the incidence of T1DM in children and whether the conditions during and following lockdown may have led to an increased number of diabetic ketoacidosis (DKA) at onset. Objectives: To assess the impact of COVID-19 on T1DM and DKA incidence. Methods: A network of 11 regional pediatric T1DM clinics collected data in children of ages 0-18 years during the time period between March 1-May 31 in the years 2017-2020. Given that all T1DM children are hospitalized at onset and rarely escape this network of regional clinics, it was possible to define a minimal incidence of T1DM without a secondary source, Results: Number of onsets was stable (2017: 206 cases/year, 2018: 199 cases/year, 2019: 233 cases/year, 2020: 105 cases/5 months). DKA at onset varied between 36 and 40% of new onsets. By comparing the cases in the period March 1-May 302,017-2020, an increase in DKA incidence at onset from 11 to 24/1.7 million (p < 003) was found. The minimum regional incidence of T1DM showed a slight increase from 11.7 to 13.7 cases/100000 (0-18 years of age), comparable to previously collected regional data from 2008. Conclusion: These data suggest that COVID-19 infection in Lombardy was not correlated with an in increased T1DM incidence. Furthermore, the minimum regional incidence of TIDM in ages 0-18 years seems stable in the last 10 years. However, a significant increase in the number of DKA at onset was found, many of which were reported to be severe and probably consequent to delayed hospital presentation due to lockdown restrictions and fear of infection, emphasizing the indirect deleterious impact of pandemics on potentially lifethreatening conditions such as DKA.Keywords:
Diabetic ketoacidosis
Pandemic
2019-20 coronavirus outbreak
Cite
Diabetic ketoacidosis (DKA) has significant morbidity and mortality, and is common at diagnosis in children.Describe the frequency and severity of DKA at diagnosis of type 1 diabetes mellitus (T1DM) in children in Kuwait.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.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.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.
Ketonuria
Diabetic ketoacidosis
Ketoacidosis
Cite
Citations (54)
We evaluated the clinical characteristics and severity of diabetic ketoacidosis (DKA) in children before and after the coronavirus disease 2019 (COVID-19) outbreak to identify its indirect effects on DKA incidence.This retrospective study included 19 children with DKA admitted to the emergency room (ER) in two centers in Jeonbuk province, Korea during the first 6 months of the year from 2017 to 2020. Data were collected on age, height, body weight, clinical symptoms, diabetic mellitus (DM) type, and laboratory findings. DKA severity was based on the presence of acute kidney injury, cerebrovascular accident, and altered mental status. The ratio of patients with DKA in all pediatric patients who visited the study ERs and in the Jeonbuk population was also determined.There were no differences in anthropometric characteristics and complication rates between the pre-COVID-19 and COVID-19 periods; however, the rate of polydipsia was significantly higher in the COVID-19 period. All seven patients admitted during the COVID-19 pandemic (100%) had polydipsia and polyuria and were newly diagnosed with DM. The rate of pediatric patients with DKA admitted to the ER in 2020 (0.459%) was more than twice the mean rate of 0.206% for the four-year period. The incidence of DKA in the Jeonbuk population (0.00141%) also exceeded the mean rate (0.0009%).The incidence of pediatric DKA might be higher due to the indirect effect of COVID-19 pandemic. Physicians should be aware of nonspecific symptoms related to DKA in children admitted to the ER.
Diabetic ketoacidosis
Polyuria
Polydipsia
Cite
Citations (14)
Background
In the UK, around 25% of children and young people with type 1 diabetes mellitus (T1D) present in life-threatening diabetic ketoacidosis (DKA), a state of acute metabolic decompensation requiring hospitalisation. This carries significant morbidity and is associated with higher HbA1c (glycosylated haemoglobin), a maker of blood glucose exposure, both at diagnosis and in the long-term, which is a predictor of long-term complications. The SARS-CoV-2 (Covid-19) pandemic has changed how people access healthcare. In order to determine the impact that the pandemic has had on children presenting with T1D, we compared the presentation of new cases before and during the pandemic.Objectives
To compare presentations of new-onset T1D to the Oxford Children's diabetes service during two time points: pre-Covid-19 (Cohort 1; February 2019 to July 2019) Vs. the first Covid-19 peak (Cohort 2; February 2020 to July 2020).Methods
Medical records of patients aged under 18 years with new-onset T1D were reviewed retrospectively. Data were collected using a standardised proforma, which included symptom duration, route of referral, presence of DKA, presenting HbA1c and C-peptide.Results
We identified 13 patients in cohort 1 and 17 in cohort 2; median age was 11.92 years (range 1.5 - 17.4 years) vs 9.1 years (range 3.76 to 14.9 years). DKA rates were higher during the first phase of the pandemic; Cohort 1: 23% (n=3/13) vs Cohort 2: 71% (n=12/17); p=0.01. There was a trend towards a longer symptom duration during the pandemic, (Cohort 1: 2.3 weeks vs Cohort 2: 5.7 weeks) though this was not statistically significant (p=0.06). Presenting symptoms were comparable in the two cohorts with polydipsia being most frequently reported. There was no difference in mean HbA1c (HbA1c 109.6 mmol/mol vs 109.9 mmol/mol; p=0.98) or C-peptide levels (173.6 vs 189.8, p=0.98). The increased rates of DKA were seen in all severities (mild, moderate and severe).Conclusions
DKA rates are higher during the first wave of the pandemic and there was a trend towards a longer duration of symptoms preceding diagnosis. The reasons behind these findings are multifactorial involving changes to health-seeking behaviours, and reduced access to same day appointments in primary care. The increased DKA rate may be attributed to longer symptom duration prior to presentation, however a pro-inflammatory state associated with SARS-CoV-2 infection in paediatric populations is being increasingly recognised.Diabetic ketoacidosis
Pandemic
Cite
Citations (0)
Diabetic ketoacidosis (DKA) is a common complication among children with diabetes, accounting for 14% to 31% of all diabetes-related hospital admissions.1,2 Extrapolation of data from the National Commission on Diabetes3 suggests that there are approximately 160 000 admissions to private hospitals each year in the United States for DKA. The cost of hospitalizations for DKA is over one billion dollars annually. Sixty-five percent of all patients admitted are less than 19 years of age. The incidence of DKA is believed to be declining. However, because the numbers of subjects with insulin-dependent diabetes mellitus is increasing, the absolute number of hospitalizations for DKA is still increasing. It is the single most common cause of death in diabetic patients under 24 years of age.2The treatment of DKA has changed in recent years, particularly with the use of low-dose continuous intravenous insulin infusion and with the availability of blood pH levels. Severe DKA has been defined as
Diabetic ketoacidosis
Ketoacidosis
Cite
Citations (38)
The aim of this study was to compare the clinical manifestations and outcomes of patients with diabetic ketoacidosis (DKA) today and 20 years ago.A retrospective review was conducted of patients with DKA treated at our hospital from January 2001 through June 2002. The medical records were analyzed to identify clinical presentations, contributory factors, laboratory data, and outcomes. Additionally, data were compared with the records of patients with DKA in 1981 and 1982 at the same hospital.Data on 132 patients with 148 DKA episodes were included in the present study. When compared with the data from 20 years ago, clinical presentations, precipitating factors and laboratory data were similar. However, the mortality rate markedly decreased from 7.96% to 0.67%. Among patients with documented bacterial infections, a significantly high prevalence (70%) of Klebsiella pneumoniae infection was discovered. In patients with recurrent DKA, young women with type 1 diabetes accounted for most of the cases (67%) due to the omission of insulin. Eleven of 49 patients (22%) with newly diagnosed diabetes presenting with DKA were not insulin dependent during the 1.5-year follow up.After 20 years, the clinical presentations and precipitating factors of DKA were similar. However, the mortality rate was significantly reduced. Klebsiella pneumoniae was the leading cause of bacterial infections precipitating DKA in our hospital. Young women with type 1 diabetes were at high risk of repeat DKA.
Diabetic ketoacidosis
Medical record
Ketoacidosis
Cite
Citations (64)
Diabetic ketoacidosis
Ketoacidosis
Cite
Citations (0)
SH and DKA are common serious acute complications of type 1 diabetes (T1D), but whether rates have changed with recent improvements in diabetes management is not clear. We, thus examined data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study of childhood onset T1D (mean age 28 and duration 19 years, n=658) to determine if the hospitalized rates of SH and DKA have changed over 25 years of follow-up. Participants reported hospitalizations at each biennial survey for the prior 5 years (1986-1988, 2012-2014) or prior 3 years (1996-1998, 2004-2006). Rates per 100 person years for SH and DKA were then calculated by dividing the total number of self-reported SH or DKA admissions by the total appropriate accumulated person years of reporting at each follow-up. Hospitalization rates for SH declined after 1996-1998 with a fall in HbA1c suggesting better overall management. The DKA hospitalization rate was consistent throughout the follow-up. The factors underlying these encouraging trends require further investigation and survival bias cannot be excluded. Disclosure G. Pambianco: None. T.J. Orchard: None.
Diabetic ketoacidosis
Ketoacidosis
Ketonuria
Cite
Citations (0)
To investigate rates and risk factors of hospital admission for diabetic ketoacidosis (DKA) or severe hypoglycemia in young patients with established type 1 diabetes.In total, 31,330 patients with type 1 diabetes (median age 12.7 years) from the Diabetes Patienten Verlaufsdokumentation (DPV) Prospective Diabetes Registry treated between 2011 and 2013 in Germany were included.Admission rates for DKA (pH < 7.3 or bicarbonate <15 mmol/l) and severe hypoglycemia (requiring assistance from another person) were calculated by negative binomial regression analysis. Associations of DKA or hypoglycemia with patient and treatment characteristics were assessed by multivariable regression analysis.The mean admission rate for DKA was 4.81/100 patient-years (95% CI, 4.51-5.14). The highest DKA rates were observed in patients with HbA1c ≥ 9.0% (15.83 (14.44-17.36)), age 15-20 years (6.21 (5.61-6.88)) and diabetes duration of 2-4.9 years (5.60 (5.00-6.27)). DKA rate was higher in girls than in boys (5.35 (4.88-5.86) vs 4.34 (3.95-4.77), P = 0.002), and more frequent in migrants than in non-migrants (5.65 (4.92-6.49) vs 4.57 (4.23-4.93), P = 0.008). The mean admission rate for severe hypoglycemia was 1.45/100 patient-years (1.30-1.61). Rates were higher in migrants compared to non-migrants (2.13 (1.72-2.65) vs 1.28 (1.12-1.47), P < 0.001), and highest in individuals with severe hypoglycemia within the preceding year (17.69 (15.63-20.03) vs patients without preceding hypoglycemia 0.42 (0.35-0.52), P < 0.001). Differences remained significant after multivariable adjustment.The identification of at-risk individuals for DKA (patients with high HbA1c, longer diabetes duration, adolescents, girls) and for severe hypoglycemia (patients with preceding severe hypoglycemia, migrants) may facilitate targeted diabetes counselling in order to prevent these complications.
Diabetic ketoacidosis
Ketoacidosis
Cite
Citations (112)
Abstract Aims The aim of this study was to investigate changes in the clinical characteristics of diabetic ketoacidosis (DKA) in Korea over the last two decades. Methods A retrospective medical record review of all episodes of DKA from 1982 to 2002 in four University‐affiliated urban hospitals in Korea was performed. A total of 255 episodes of DKA (217 patients) were identified and divided into three consecutive 7‐year periods to compare trends over time. Clinical characteristics including precipitating factors and hospital mortality were analyzed. Results A dramatic increase in DKA admissions has occurred over the last two decades, accompanied by a marked increase in admissions of diabetic patients. The clinical characteristics of DKA remained constant over the observation period. Non‐compliance to treatment was the most common precipitating factor of DKA. A total of 30 patients died in hospital (11.8% of all episodes). Older age and infection appeared to influence mortality. Conclusions Our results suggest that rapidly increasing episodes of DKA in Korea, in parallel with increases in the numbers of diabetic patients, continue to be associated with significant mortality.
Diabetic ketoacidosis
Medical record
Cite
Citations (60)
Aim: To assess the characteristics of admissions with diabetic ketoacidosis (DKA) in a specialized children hospital in order to inform appropriate prevention and intervention strategies. Methods: This is a retrospective chart review of DKA admissions of children with T1DM at King Abdullah Specialized Children’s hospital, Riyadh, Saudi Arabia (March 2015- December 2017). Results: A total of 116/562 patients with type 1 diabetes (mean age 8.97±3.08 years, Females n=81 (55.5%)) presented with DKA during the study period. The majority were between 10-14 years of age (p=<0.001). We scrutinized data from (146/311, 47%) DKA events of all inpatient admissions of children with T1D. The frequency of DKA admissions was 26% (n=146/562 of all patients with T1DM, 25% (n= 42/141) were in newly diagnosed and 24.7% (n=104/421) were in previously diagnosed patients). Missing insulin was the main precipitating cause (p=0.001) in previously diagnosed patients. Recurrent episodes (n=30, 20.5% of all episodes) occurred in 15/116 patients and was more common in children 10 years old (P=0.024). The overall mean length of stay (LOS) was 2.67±2.04 days. Increased LOS was significantly associated with DKA severity (P=0.008). Conclusion: Missing insulin remained to be the main cause of DKA in previously diagnosed patients with type 1 diabetes even in advanced settings. Besides awareness campaigns to prevent DKA as an initial presentation of T1DM, intervention and prevention strategies should also focus on vulnerable groups of previously diagnosed patients such as adolescents and those with recurrent episodes of DKA.
Diabetic ketoacidosis
Ketoacidosis
Presentation (obstetrics)
Cite
Citations (0)