Delayed diagnosis of diabetic ketoacidosis in children—a cause for concern

  • Poovazhagi VaradarajanEmail author
  • Saradha Suresh
Short Article


Diabetic ketoacidosis (DKA) is the major cause for mortality in children with diabetes mellitus (DM). Delayed diagnosis or missed diagnosis is common among children with DKA. This study was undertaken to identify the impact of delayed diagnosis on clinical presentation, complications, and mortality of DKA in children from a tertiary care center at Chennai. Among the 118 episodes of DKA in 100 children less than 12 years of age, delayed diagnosis was more common in new onset diabetes mellitus (DM). Forty-four out of 68 children with new onset DM with DKA (64.7 %) had delayed diagnosis. Thirty-two children with established diabetes presented with 50 episodes of DKA. Among these, eight episodes (16 %) had a delay in diagnosis; 85.7 % of infants, 76.9 % of toddlers, and 58 % of the preschool and school children had delayed diagnosis. Urinary tract infections, respiratory illness, vomiting, febrile illness, acute abdomen, and encephalopathy were the common diagnosis in children where DKA was missed. The causes for delay in diagnosis and management of DKA were lack of parental and physician awareness, improper referral, and delayed transport. Presence of shock, altered sensorium, severe DKA, lower PaCO2 at admission, and complications like renal failure and cerebral edema were higher in children with delayed diagnosis of DKA. This was found to be statistically significant. Delayed diagnosis was a significant risk factor for mortality in children with DKA (p = 0.00) in this study population.


Delayed diagnosis Missed diagnosis DKA in children 


Conflicts of interest



  1. 1.
    Levitsky L, Ekwo E, Goselink CA, Solomon EL et al. Death from diabetes (DM) in hospitalized children (1970–1998). Pediatr Res. 1991;29: Abstract A195Google Scholar
  2. 2.
    Curtis JR, To T, Muirhead S, Cummings E, et al. Recent trends in hospitalization for diabetic ketoacidosis in Ontario children. Diabetes Care. 2002;25(9):1591–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Lawrence SE, Cummings EA, Gaboury I, Daneman D. Population-based study of incidence and risk factors for cerebral edema in pediatric diabetic ketoacidosis. J Pediatr. 2005;146(5):688–92.PubMedCrossRefGoogle Scholar
  4. 4.
    Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990–96. Arch Dis Child. 1999;81(4):318–23.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Jayashree M, Singhi S. Diabetic ketoacidosis: predictors of outcome in a pediatric intensive care unit of a developing country. Pediatr Crit Care Med. 2004;5(5):427–33.PubMedCrossRefGoogle Scholar
  6. 6.
    Lokesh Kumar T, Jayashree M, Singhi S. Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: role of fluid refractory shock. Pediatr Crit Care Med. 2012;13(2):91–6.CrossRefGoogle Scholar
  7. 7.
    Prasad D, Arpita, Shally A. A retrospective case study of clinical profile of hospitalized children with type 1 diabetes mellitus at a tertiary health care center in northern India. Clin Epidemiol Glob Health. 2013. doi: 10.1016/j.cegh.2013.02.002.Google Scholar
  8. 8.
    Zabeen B, Nahar J, Mohsin F, Azad K, et al. DKA in children—an experience in a tertiary hospital. Ibrahim Med Coll J. 2008;2(1):17–20.Google Scholar
  9. 9.
    Kanwal SK, Bando A, Kumar V. Clinical profile of diabetic ketoacidosis in Indian children. Indian J Pediatr. 2012;79(7):901–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Poovazhagi V. Diabetic keto acidosis—among children with established diabetes from a pediatric tertiary care institute. Int J Diabetes Dev Ctries DOI 10.1007/s13410-013-0160-0Google Scholar
  11. 11.
    Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents—a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(5):1150–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Mallare JT, Cordice CC, Ryan BA, Carey DE, et al. Identifying risk factors for the development of diabetic ketoacidosis in new onset type 1 diabetes mellitus. Clin Pediatr. 2003;42(7):591–7.CrossRefGoogle Scholar
  13. 13.
    Bui H, To T, Stein R, Fung K, et al. Diabetic ketoacidosis at disease onset a result of missed diagnosis? J Pediatr. 2010;156(3):472–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Blanc N, Lucidarme N, Tubiana-Rufi N. Factors associated with childhood diabetes manifesting as ketoacidosis and its severity. Arch Pediatr. 2003;10(4):320–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Mortensen HB, Bendtson I. Diabetic ketoacidosis: diagnosis and initial emergency management. Diabetes in the Young. 1993;29:4–8.Google Scholar
  16. 16.
    Sperling MA. Diabetic ketoacidosis: persistence and paradox. Pediatr Diabetes. 2011;12(4.1):293–4.PubMedCrossRefGoogle Scholar
  17. 17.
    Klingensmith GJ, Tamborlane WV, Wood J, Haller M, et al. Diabetic ketoacidosis at diabetes onset: still an all too common threat in youth. J pediatr. 2013;162(2):330–4.PubMedCrossRefGoogle Scholar
  18. 18.
    Pawłowicz M, Birkholz D, Niedźwiecki M, Balcerska A. Difficulties or mistakes in diagnosing type 1 diabetes in children?—demographic factors influencing delayed diagnosis. Pediatr Diabetes. 2009;10(8):542–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Mc Grath N, Nicholson AJ, Murphy N. Diagnosis not to be missed in primary care—diabetic ketoacidosis in childhood. Ire Med J. 2013;106(1):29.Google Scholar
  20. 20.
    Levy-Marchal C, Patterson CC, Green A. Geographical variation of presentation at diagnosis of type I diabetes in children: the EURODIAB study. Diabetologia. 2001;44(3):B75–80.PubMedCrossRefGoogle Scholar
  21. 21.
    Abdul-Rasoul M, Al-Mahdi M, Al-Qattan H, Al-Tarkait N, et al. Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics. Pediatr Diabetes. 2010;11(5):351–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Vanelli M, Chiari G, Ghizzoni L, Costi G. Effectiveness of a prevention program for diabetic ketoacidosis in children. An 8-year study in schools and private practices. Diabetes Care. 1999;22(1):7–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Vanelli M, Chiari G, Lacava S, Iovane B. Campaign for diabetic ketoacidosis prevention still effective 8 years later. Diabetes Care. 2007;30(4):e12.PubMedCrossRefGoogle Scholar

Copyright information

© Research Society for Study of Diabetes in India 2014

Authors and Affiliations

  1. 1.Institute of Child Health and Hospital for ChildrenChennaiIndia

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