Diabetic Ketoacidosis in Infants, Children, and Adolescents
A consensus statement from the American Diabetes Association
- Joseph Wolfsdorf, MB, BCH12,
- Nicole Glaser, MD3 and
- Mark A. Sperling, MD45
- 1Division of Endocrinology, Children’s Hospital Boston, Boston, Massachusetts
- 2Harvard Medical School, Boston, Massachusetts
- 3Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California
- 4Department of Pediatrics, Universiy of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 5Division of Endocrinology, Metabolism and Diabetes, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Address correspondence and reprint requests to Dr. Mark A. Sperling, Professor, Division of Endocrinology, Metabolism and Diabetes, Children’s Hospital of Pittsburgh, 3705 Fifth Ave., DeSoto 4A-400, Pittsburgh, PA 15213. E-mail: masp+{at}pitt.edu
- β-OHB, β-hydroxybutyrate
- CNS, central nervous system
- DKA, diabetic ketoacidosis
- ECF, extracellular fluid
The adage “A child is not a miniature adult” is most appropriate when considering diabetic ketoacidosis (DKA). The fundamental pathophysiology of this potentially life-threatening complication is the same as in adults. However, the child differs from the adult in a number of characteristics.
1) The younger the child, the more difficult it is to obtain the classical history of polyuria, polydipsia, and weight loss. Infants and toddlers in DKA may be misdiagnosed as having pneumonia, reactive airways disease (asthma), or bronchiolitis and therefore treated with glucocorticoids and/or sympathomimetic agents that only compound and exacerbate the metabolic derangements. Because the diagnosis of diabetes is not suspected as it evolves, the duration of symptoms may be longer, leading to more severe dehydration and acidosis and ultimately to obtundation and coma. Even in developed countries, some 15–70% of all newly diagnosed infants and children with diabetes present with DKA (1–8). Generally, the rates of DKA are inversely proportional to rates of diabetes in that community, but throughout the U.S., the overall rates of DKA at diagnosis have remained fairly constant at ∼25% (6). DKA, defined by blood bicarbonate <15 mmol/l and/or pH <7.25 (<7.3 if arterial or capillary), was present in 23.3% of a carefully analyzed cohort. However, the prevalence of DKA decreased significantly with age from 36% in children <5 years of age to 16% in those >14 years but did not differ significantly by sex or ethnicity (6).
2) The higher basal metabolic rate and large surface area relative to total body mass in children requires greater precision in delivering fluids and electrolytes. The degree of dehydration is expressed as a function of body weight, i.e., 10% dehydration implies 10% loss of total body weight as water. However, the calculation of basal requirements, although a constant per unit …
