Diabetic ketoacidosis in childhood and adolescence

Abstract Diabetic ketoacidosis (DKA) may occur at the time of diagnosis of diabetes, or at any time subsequently. It is the cause of very significant morbidity and remains the most common cause of death in childhood and adolescent diabetes (1–3). For a discussion of DKA in adults, see Chapter 13.4.10.1. Type 1 diabetes occurs in childhood (see Chapter 13.4.7) with an incidence that varies from more than 40 per year per 1 00 000 children under the age of 15 years old (in Finland), to less than 1 per 1 00 000 (in Asia). The mean age at diagnosis is usually 10–12 years old, although, in a number of countries, this seems to be declining. The younger the child is at diagnosis, the more aggressive the autoimmune-mediated destruction of the pancreatic β cell, and the more rapid the progression to complete insulin dependence (see Chapter 13.2.3). Children are thus more liable to DKA than adults. Furthermore, children experience more viral infections than do adults, and the metabolic stresses associated with these infections increase their risk of developing DKA. DKA has traditionally been considered to occur only in type 1 diabetes, but is now being reported in at least 25% of (usually obese) adolescents with newly diagnosed type 2 diabetes, especially when there are associated stress factors, such as infection (4, 5). Although the vast majority of diabetes in childhood and adolescence is type 1 diabetes, there has been a worldwide trend to the earlier development of type 2 diabetes in association with the overweight and obesity epidemic, especially in certain at-risk ethnic groups, e.g. Asians, African Americans, Hispanic Americans; see Chapter 13.4.3.1. The treatment of DKA in these patients is the same as for those with type 1 diabetes; however, the subsequent course of the treatment usually differs, and most patients are able to stop insulin and be treated with oral hypoglycaemic agents, weight reduction, exercise, and an appropriate food plan.