الفهرس 
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Abstract
The study was conducted over two years (from July 2012 to June 2014) at Pediatrics Department, Sohag University Hospital. The study included 265 children with type 1 diabetes mellitus (T1DM). One hundred-thirty five children presented with DKA. They were classified into 2 groups:
Group (A): Patients with new-onset T1DM (74 patients).
Group (B): Patients with established T1DM (61 patients).
The remaining 130 children presented without DKA were also classified into 2 groups:
Group (C): Patients with new-onset T1DM (67 patients).
Group (D): Patients with established T1DM who had no DKA since diagnosis (63 patients).
All studied children were subjected to clinical and laboratory assessments. Risk factors for DKA at onset of T1DM were studied in patients with new-onset T1DM presented with DKA (group A) and without DKA (group C), while risk factors for DKA in patients with established T1DM were assessed in patients with DKA (group B) and without DKA (group D). The characteristics and outcomes of DKA were evaluated in 135 patients presented with DKA (group A and group B).
For assessment of DKA at onset of T1DM, the study found that DKA was significantly more common in children younger than 5 years of age and patients with lower BMI. Patients presented with DKA had significantly lower maternal and paternal educational levels. Positive family history of type 1 diabetes mellitus in a first degree relative was found in 12.8% of patients.
The commonest symptoms in children with new onset T1DM were polyuria (97.2%) and polydipsia (90.1%). Patients presented with DKA had significantly shorter duration of diabetes mellitus symptoms before diagnosis. Diagnosis was made at first clinical visit in 52.2% of patients presented without DKA. Wrong initial diagnosis was made in 15.6% of patients with new-onset T1DM. The most frequent wrong diagnoses made by the physicians were nocturnal enuresis (32%), urinary tract infection (27%).
Patients with new-onset T1DM presented with DKA had higher HbA1c and lower fasting serum C-peptide level. Islet cell antibodies (ICA) were positive in 73% of patients at time of diagnosis.
The multivariate analysis revealed that the most important risk factors for DKA development at onset of T1DM were illiterate or just read and write parents, lower BMI, short duration of diabetes mellitus symptoms, delay in medical diagnosis by physician and low fasting serum C-peptide level.
For assessment of risk factors of DKA in patients with established T1DM the study found that patients presented with DKA had significantly lower BMI. They also had significantly lower maternal educational level and significantly lower socioeconomic class.
The use of multiple daily insulin injections regimen and the use of sick day regimen were less common among patients presented with DKA. The daily insulin doses and HbA1c level were significantly higher in patients with DKA. Patients with DKA had less frequent blood glucose monitoring at home. There was no health insurance coverage for 13.1% of patients with DKA compared to only 3.2% of patients without DKA.
The multivariate analysis revealed that the most important risk factors for DKA development in patients with established T1DM were illiterate mothers, very low socioeconomic class, lower BMI, conventional insulin therapy, lack of health insurance coverage, higher daily insulin dose, lack of sick day regimen use and higher HbA1c.
The study found that Infection was the most frequent precipating cause for DKA (43.3%), followed by omission of insulin dose (26%). The most frequent infections were upper respiratory tract infections (38.5%) and urinary tract infection (23.1%).
The most frequent symptom of DKA was rapid breathing (88.7%) followed by abdominal pain (78%), vomiting (77.3%) and disturbed conscious level (34%). Severe acidosis at admission was found in 69 episodes (46%).
Only one patient died (0.7%). Complications occurred in 27.3% of DKA episodes. The most frequent complication was hypokalemia (24%), followed by hypoglycemia (18.7%). Other complications were infrequent. The average duration for stay in PICU was 37.2 ± 13.2 hours, while the average duration of hospitalization was 4.6 ± 1.1 days. Patients < 5 years of age and patients with severe acidosis had more frequent complications and longer duration of PICU and hospital stay.
Multivariate analysis revealed that the most important risk factors for development of DKA complications were rapid decline of blood glucose level (>100mg/dl/hour), age below 5 years and high calculated effective serum osmolarity at admission.
In conclusion, this study showed that both parental and physician’s unawareness of diabetes mellitus symptoms in children with new-onset T1DM were the main reason behind delayed presentation and diagnosis. Good outpatient management for children with established T1DM could produce better glycemic control and reduce the incidence of DKA. Infection and omission of insulin dose were the most frequent precipating causes for DKA. Severe DKA was common due to delayed presentation. The death rate of DKA was less than 1%. However, DKA complications were frequent. Gradual reduction of blood glucose during management of DKA is important to prevent complications of DKA.
Recommendations
- Enhancing public awareness about symptoms of diabetes mellitus in children through national public campaigns in schools and media.
- Enhancing physicians’ awareness about diabetes mellitus symptoms in children through special training courses for general practitioners and junior pediatricians.
- Establishment of specialized diabetes mellitus clinics for children in district hospitals to provide proper outpatient management for children with diabetes mellitus.
- The provision of sufficient supplies of insulin, injection pens and syringes, blood glucose measurement devices and strips through the health insurance system for children with type 1 diabetes mellitus.
- Training of junior doctors on standardized protocols for management of diabetic ketoacidosis in children and how to avoid development of DKA complications during management.
- For future researches in the field of DKA in children with T1DM, we recommend the following:
- Assessment of the effect of puberty and sex hormones on the glycemic control and development of DKA in adolescent patients- especially girls- with T1DM.
- Assessment of the effect of sodium bicarbonate therapy in a randomized controlled trial design to assess whether its use in DKA in hazardous or beneficial.
- Multicenter studies are needed to assess rare but serious complications of DKA as cerebral edema and hyperchloremic metabolic acidosis (HMA) as well as the risk factors for their development.