What is Pediatric Diabetic Ketoacidosis?
Diabetic ketoacidosis (DKA) is a serious health issue often seen in people with type-1 diabetes, but it can also develop in people with type-2 diabetes when their bodies don’t have enough insulin. Insulin is a hormone that helps your cells use sugar for energy. DKA happens when there’s a shortage of insulin, which causes your body to burn fat for fuel instead, producing acid called ketones. High ketone levels can make your body’s blood chemistry very acidic.
The International Society for Pediatric and Adolescent Diabetes sets specific criteria for diagnosing DKA. They include:
- High blood sugar levels – over 200 mg/dL (which converts to 11 mmol/L in another measurement system).
- High acid levels in the blood – a lower than normal pH value (less than 7.3) or a low bicarbonate level (less than 15 mEq/L or 15 mmol/L), means the blood chemistry is off balance.
- High ketone levels – either ketones in the blood over 3 mmol/L or an above-normal amount of ketones in the urine.
Ketones are made by the liver when your body burns fat. They can be used as an alternative fuel source by your brain, heart, and muscles when there’s not enough glucose, the primary source of fuel in your body.
What Causes Pediatric Diabetic Ketoacidosis?
Ketone bodies are usually found in our blood, but their levels can become dangerously high when the body can’t use sugar properly. This can happen for various reasons, like not eating for a long time, physical exertion, or problems with insulin production – a hormone that helps our body use sugar. In type-2 Diabetes, for example, the body might produce enough insulin, but not at the necessary level to help funnel sugar into our cells.
Our body mainly stores fat as something called triglyceride. When our usual stores of sugar run out, the liver turns this triglyceride into three fatty acids and a glycerol molecule. These fatty acids can be broken down for energy, while glycerol gets converted back into sugar. If there’s enough insulin in the body, this sugar will be used for energy. However, without insulin, the body can’t use this sugar, and its levels can dangerously rise, sometimes even getting excreted in the urine.
When sugar levels in our blood are low, or the body can’t use it due to a lack of insulin, ketones become the main source of energy for our brain. Our brain doesn’t store any usable fuel and can only use sugar and ketones to operate.
On the other hand, our skeletal muscles – the muscles attached to our bones – can store and use something called glycogen. About 70% of the total glycogen, a type of sugar reserve, is stored in our muscles and can be converted back to sugar when necessary.
Risk Factors and Frequency for Pediatric Diabetic Ketoacidosis
DKA, or diabetic ketoacidosis, is often present when type 1 diabetes is first diagnosed, notably in about 3% of children in the United States and Canada. It’s the primary reason why kids with this type of diabetes are hospitalized. The fatality rate of DKA is between 0.15% and 0.31%. Kids with type 2 diabetes can also get DKA, but it happens less frequently.
When type 1 diabetes is first being diagnosed, DKA can be found in approximately 30% of children in the U.S and Canada. Certain factors make it more likely for kids to have DKA at the first diagnosis of type 1 diabetes:
- Being very young (especially under 2 years old)
- Belonging to an ethnic minority group
- Having a low socioeconomic status
- Living in countries where type 1 diabetes isn’t common
- Having a delayed diagnosis of diabetes
A study showed that a low socioeconomic status is important when diagnosing type 1 diabetes. The less common type 1 diabetes is in a population, the more likely DKA will occur at diagnosis because the disease is often missed.
If children already had a diagnosis of type 1 diabetes, DKA occurs yearly at a rate of 6 to 8%. There are various factors that can lead to DKA in these cases:
- Having poor metabolic control
- Being a girl going through puberty
- Having gastroenteritis with vomiting and dehydration
- Having a history of psychiatric disorders or family discord
- Having limited access to medical care
- Not taking prescribed insulin, including when an insulin pump fails
In a large study in the U.S., almost 60% of kids with type 1 diabetes who had DKA came from just 5% of the overall population. Similar results were found in the UK.
Kids with type 2 diabetes can also have DKA, but it happens less often. This is primarily seen in African American teenagers who are overweight. In a review of 69 patients aged 9 to 18 who had DKA, around 13% had type 2 diabetes.
Signs and Symptoms of Pediatric Diabetic Ketoacidosis
Type-1 Diabetes can complicate into a serious condition called Diabetic Ketoacidosis (DKA). This can often occur simultaneously with other health issues like infection or injury. Patients might experience symptoms like excessive thirst (polydipsia), frequent urination (polyuria), increased hunger (polyphagia), loss of appetite, weight loss, fatigue, or repetitive infections. Additional signs may consist of problems concentrating, poor school performance, changes in mental status, and confusion.
For children newly diagnosed with Type-1 Diabetes, they might look thin and dehydrated. Dehydration, unquenchable thirst, and frequent urination are common symptoms, mainly due to elevated sugar levels in the urine (glucosuria) and increased urination to eliminate excess sugar (osmotic diuresis). It’s important to note that stomach sensitivity and pain, nausea, and vomiting are also common. This can sometimes be mistaken for a simple stomach-related illness like gastroenteritis if these symptoms present initially in DKA.
Patients experiencing DKA will often have rapid, deep breaths (Kussmaul respirations) due to a condition called metabolic acidosis. This condition also gives their breath a fruity odor because of the elimination of a specific compound called acetone in the breath.
Depending on the severity of the acidosis, neurologic conditions can vary. Some patients might be alert, while others can become less responsive or even fall into a coma.
Testing for Pediatric Diabetic Ketoacidosis
Diabetic Ketoacidosis (DKA) is usually confirmed by conducting specific blood tests to detect high sugar levels and metabolic acidosis, or increased acidity in the blood. Testing for ketones, or chemicals your body produces when it burns fat for fuel, isn’t necessary but can be useful.
To diagnose DKA, your doctor can use several lab and point-of-care tests, which means tests performed at your bedside in a healthcare setting:
1. Anion gap: The anion gap is a calculation used to determine the concentration of certain ions (types of molecules) in your blood. If this gap is larger than usual, it might suggest that your blood is more acidic, a common symptom of DKA.
2. Blood glucose: A blood sugar level of above 200 mg/dL (11 mmol/l), but it could even be above 1000 mg/dL. For children, their blood sugar levels may not rise as much but they could still have DKA.
3. Serum BHB concentration: BHB, or Beta-Hydroxybutyric Acid, is a type of ketone your body produces for energy when there isn’t enough glucose. If you have a BHB level of above 31 mg/dL in your blood, you might have DKA.
Other tests doctors might use include measures for blood urea nitrogen (a waste product in your blood), creatinine (a waste product from muscle breakdown), the pH level in your blood, and a measure of carbon dioxide in your blood. A pH level below 7.2 can mean a worse outcome and often suggests you need to be in the intensive care unit.
A urine test for ketones might also be used, although it’s less accurate. The blood lactate concentration test can help rule out a condition called lactic acidosis, which can have similar symptoms as DKA. Hemoglobin A1c (HbA1c), a blood test that measures your average blood sugar levels over the past three months, can help evaluate how well you are managing your diabetes.
Diabetes-associated antibodies, such as Glutamic acid decarboxylase antibodies and insulin autoantibodies, can confirm you have type 1 diabetes. They are present in 80 to 85% of new diabetes patients. C-peptide levels, a product of insulin production, can differentiate between individuals who make enough insulin and those who don’t. A value of less than 0.2 nmol/l typically confirms a diagnosis of type 1 diabetes.
DKA can be divided into mild, moderate, and severe stages. Criteria for these categories consist of different levels of venous pH and bicarbonate, which affect the acidity and alkalinity levels in your blood. Milder forms of DKA may require different thresholds for these criteria, especially in less developed areas or for very young patients.
Treatment Options for Pediatric Diabetic Ketoacidosis
Treatment for a condition called Diabetic Ketoacidosis (DKA) follows a few specific steps. First up is making sure your airways, breathing, and circulation (the ‘ABCs’) are functioning well. You’ll also be given fluids to help your body recover. After these initial steps, doctors can start giving insulin treatment, which is usually done as a constant drip into a vein.
The medical team treating you will take several steps:
1. They’ll start by making sure you’re breathing okay, which can include giving you oxygen or inserting a breathing tube if needed. If you’re not able to wake up, they might put a tube in your nose or stomach and possibly into your bladder as well. They should also set up a good connection to a vein (preferably two) so they can give you insulin and other medications and take blood samples.
2. They will be on the lookout for any signs of an infection or other conditions and treat them as needed.
3. They’ll want to get an accurate weight so they can figure out how much insulin and other medications to give you.
For the insulin therapy, regular insulin is often used in a constant drip at a certain rate based on your weight. In some cases, insulin may be given under the skin, like in milder cases of DKA or if an infusion pump isn’t available.
Also, a type of sugar called dextrose will be added to your IV fluid, if your blood sugar levels drop drastically. It helps clear out the ketones (chemicals produced when your body burns fat for energy), allowing the insulin drip to continue till the ketoacidosis is completely resolved.
The next factor to consider is potassium, an essential nutrient that helps your nerves and muscles work well. When you begin insulin therapy, your body might suddenly require more potassium, risking a deficiency.
The insulin treatment will be stopped once you can take medications orally, your blood sugar decreases significantly, and your pH and ketone levels start to return to normal.
Rehydrating you is also crucial and will be taken care of with the IV fluids. They also help to decrease high blood sugar levels. At times, your sodium levels might be low due to high blood sugar. If this happens, the medical team will ensure to monitor your sodium levels carefully and increase the sodium in your IV fluids as required.
Potassium is another nutrient that your medical team will continuously monitor because diabetes and your body’s response to treatment can drastically affect potassium levels.
Also, the ketoacidosis is deemed resolved when your body’s pH returns to its regular level and the amount of certain chemicals in your blood (the anion gap and BHB) reach specific levels.
As your treatment progresses and your symptoms improve, you’ll be allowed to start eating again, and your insulin will then be switched from the IV drip to injections under the skin.
Finally, the medical team would work on preventing another episode of DKA by figuring out what caused it in the first place and educate you and your caregivers on what to do to prevent it from happening again.
What else can Pediatric Diabetic Ketoacidosis be?
These are some conditions that could possibly be present alongside or mistaken for others:
- Gastroenteritis
- Hyperosmolar hyperglycemic nonketotic syndrome
- Starvation ketosis
- Heart attack (Myocardial infarction)
- Pancreatitis
- Alcoholic ketoacidosis
- Lactic acidosis
- Sepsis
- Exposure to toxic substances (ethylene glycol, methanol, paraldehyde, salicylate)
- Overdose with diabetes medication
- Uremia (High levels of waste products in the blood)
- Respiratory acidosis (When your lungs cannot remove all of the carbon dioxide produced by your body)
- Respiratory distress syndrome
What to expect with Pediatric Diabetic Ketoacidosis
As medicine and intensive care continue to advance, the prognosis (or the likely course) of many diseases improves. When it comes to mortality rates, which are the percentage of patients who die from a disease, the range is between 0.15 to 0.31% in resource-developed countries like the United States, Canada, and the United Kingdom. This means a very small percentage of patients die from their condition in these countries.
The majority of these deaths are often due to cerebral injury, a severe brain damage. However, it’s important to note that mortality rates tend to be higher in resource-limited settings where access to medical care may not be as readily available.
Possible Complications When Diagnosed with Pediatric Diabetic Ketoacidosis
The most severe complication that can occur in children suffering from DKA (short for Diabetic Ketoacidosis) is a brain injury or swelling of the brain, also called cerebral edema. This complication:
- Happens in about 0.3% to 0.9% of pediatric DKA cases.
- Has a death rate ranging from 21% to 24%.
- Is linked to risk factors like severe acidic blood, severe dehydration, high blood pressure, and significantly high BUN (a type of blood test).
- Has no definitive cause. It was originally thought to be due to rapid fluid replacement through IV, but recent research has brought this into question, as they found no difference in patient outcomes.
The swelled brain can occur at any point – before, during, or after treatment but usually shows up within the first 12 hours of treatment. Symptoms include changes in mental status, new headache, recurrent vomiting, urinary incontinence, and Cushing Triad symptoms (slow heartbeat, irregular breathing, high blood pressure). Sometimes, brain swelling may not be visible in a CT brain scan. If this happens, treatment might start even if the CT scan appears normal. If there’s high suspicion of brain swelling, doctors may use treatments such as Mannitol, which withdraws water from the brain, or hypertonic saline. A consultation with a brain surgeon may also be necessary.
There are other complications that may also occur:
- Cognitive impairment (problems with thought processes)
- Venous thrombosis (blood clot in vein)
- High pancreatic enzymes
- Acute kidney injury
- Low potassium in blood
- Low blood sugar
- Rhabdomyolysis (muscle tissue breakdown)
- Fluid in lungs
- Multiple organ dysfunction syndrome
- Heart rhythm problems
Preventing Pediatric Diabetic Ketoacidosis
All patients should receive information about diabetes, a condition that affects the way your body uses sugars. This education should include the potential short-term and long-term problems that can be caused by this condition. It’s crucial that parents and children learn about checking their blood sugar levels, and get to know when it’s necessary to do this. They should also gain knowledge about certain medications that help control sugar levels in the blood, including oral hypoglycemic meds and insulin.
These medications need to be taken as instructed by the doctor to manage the disease effectively, so understanding their side effects and the importance of following the prescribed regimen is vital. Dieticians, nurses, and home health care team members play a critical role in providing this education and support. They can provide diet advice, medication guidance, and overall diabetes management tips to ensure the disease is kept under control.