Anecdotally, cases of diabetic ketoacidosis (DKA) in children are on the rise in Australia, sometimes with tragic consequences, says paediatric endocrinologist Associate Professor Gary Leong — and empirical evidence supports this observation.
One random-effects meta-analysis of pooled data from 15 studies, for example, found the incidence rate of DKA was higher during the pandemic compared to the pre-pandemic period.
Timely diagnosis is crucial to prevent adverse outcomes, so Associate Professor Leong is on a mission to dispel some of the common misconceptions that could impede it.
Diagnosing diabetes is particularly challenging in infants and children younger than five years of age, who are at high risk of DKA. Associate Professor Leong says it’s essential to consider that even a very young child could have diabetes.
“The youngest child I’ve seen with type 1 diabetes was about eight months of age,” Associate Professor Leong says. “We had an 11-month-old present to us just a few months ago.”
He tells the story of a two-year-old boy who had classic symptoms of diabetes. His mother took him to the same practice on three consecutive days, but he was not assessed for diabetes.
By the second day, his breathing was tachypnoeic and he was prescribed prednisone, which made his sugars worse. On day four, he started vomiting and went into a coma. “His mother thought he was going to die,” Associate Professor Leong says. “They took him straight to emergency where they diagnosed DKA. He was transferred by ambulance helicopter on Saturday afternoon to intensive care at the Sydney Children’s Hospital.”
“Any child that presents with diabetes symptoms from six months of age until young adulthood, you should automatically think: Do they have type 1 diabetes? Are they at risk of diabetic ketoacidosis and if so, what should I do?”
Associate Professor Leong says the above case is one of the worst he has seen, but it is not isolated. Nor is it the worst possible outcome.
While data about death rates due to DKA in Australia is yet to be gathered, he says about 3,000 children up to the age of 18 years are diagnosed with type 1 diabetes each year. Approximately 40% of them will develop DKA, and studies suggest 0.2 to 0.4% of children with DKA will die, he says.
“This works out to be about one to two children who will die every year of DKA in this country. It may not seem like a lot, but if you’re the mother of a 10-year-old who should have survived, that’s a tragedy. And it’s totally preventable.”
Another common misconception is that you need pathology tests to assess kids for diabetes, Associate Professor Leong says.
“GPs should trust their clinical judgement. You don’t need to send the child for a formal fasting blood sugar test, which often gets delayed because the parents don’t get the message that it’s urgent.”
Instead, he suggests performing a finger-prick blood glucose test. “The practice nurse could do it,” he says.
“If random blood sugar is 11.1 [mmol/L] or above, they have type 1 diabetes until proven otherwise. Or if it’s a fasting one above 7.1 [mmol/L], they have diabetes unless proven otherwise. Then they need to go straight to the nearest emergency to confirm the diagnosis, start insulin therapy, and meet with the local diabetes team.”
In addition to a finger-prick test, Associate Professor Leong recommends conducting a midstream urine analysis to check for ketones and glucose. “If they’re passing a lot of urine, you don’t have to wait long to do a urine sample,” he says. “Even in a baby you can put a urine bag on.”
Associate Professor Leong has developed educational materials, which have been translated into 14 languages, to assist with diagnosis. They frame the early symptoms of diabetes as the ‘4 Ts’:
1. Toilet (polyuria)
2. Thirst (polydipsia)
3. Tired (lethargy)
4. Thinner (weight loss)
There are other, more subtle signs and symptoms GPs should look out for, he adds. These include:
• vaginal thrush in girls
• nocturnal enuresis in a previously dry child.
Infants with type 1 diabetes may present with an increased number of wet nappies, increased appetite and dehydration.
DKA should be considered in all young children who present with any of the above symptoms.
Tachypnoea suggesting Kussmaul breathing, ketone smell on the breath, significant dehydration with vomiting and abdominal pain or altered consciousness are all signs of severe DKA that indicate the need for immediate medical care.
Associate Professor Leong is hopeful the Type 1 Diabetes National Screening Pilot will help identify children at the preclinical phase.
His website has information about DKA and T1DM. Clinical Excellence Queensland also has resources on diabetes and DKA.
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