Risk factors for diabetic ketoacidosis through eight years of new-onset type 1 diabetes mellitus in a large Portuguese pediatric diabetes center: A shift towards younger age

ABSTRACT

Introduction: The rate of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) is multifactorial. There seems to be an inverse relationship between T1D's incidence and DKA's frequency. DKA has been reported to be more common among young children. Recently, the COVID-19 pandemic has posed additional challenges as to diagnosing T1D. Objectives: We aimed to assess the rate of DKA and associated risk factors in pediatric new-onset T1D in a large pediatric diabetes center in Portugal. Methods: Retrospective analysis of data of patients referred to a level III pediatric hospital between January 1st, 2013 and December 31th, 2020 (8 years). Results: We included 276 children and adolescents with a median age of 9,6 years, 20,1% under 5 years old. A mean incidence of 35 new cases/year was observed, with an upward trend. Newonset T1D cases under 5 years old raised progressively, having more than tripled throughout the study period (n=3 in 2013 vs. n=10 in 2020). In total, 38% children and adolescents presented with DKA, ranging from 23,3% in 2013 to 43,2% in 2020, while remaining stable (37,2%-40,9%) in the period in-between. Overall, DKA was considered severe in 24,8% of cases, ranging from 6% in 2017 to 47% in 2020. 20 (7,2%) patients were admitted to the intensive care unit. DKA at presentation was more frequent in the age group under 2 years old (p=0,016), in which 80% of patients presented with DKA. Non-DKA presentation was associated with family history of T1D (p=0,005). Conclusions: Our study shows an upward trend in T1D's incidence in children under 5 years old and a high DKA rate at disease onset, which was more frequent in patients under 2 years of age. In the first year of COVID-19 pandemic, 43% of DKA was considered severe. It is urgent to implement educational programs to promote earlier diagnosis. Broader studies are required to provide a representative national landscape of the epidemiology of T1D in pediatric population in Portugal.