Delayed diagnosis in children presenting in diabetic ketoacidosis

Children in whom a diagnosis of type 1 diabetes is missed during a first medical consultation have a 3-fold increased risk of presenting later in diabetic ketoacidosis, according to researchers from the United Kingdom.

The increased risk of presenting in diabetic ketoacidosis because of diagnostic error was independent of the presence or absence of infection preceding diagnosis, but diagnostic error was significantly more likely to occur in younger children.

Researchers examined factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes from 46 studies of more than 24,000 children in 31 countries.

The reasons for the association between younger age and increased risk of diabetic ketoacidosis are "probably multifactorial," the researchers said. "Clinicians may have a lower index of suspicion for diabetes among younger children." Beta cell destruction also may be more aggressive in young children.

Other individual and family factors that increased the risk of diabetic ketoacidosis were being an ethnic minority, a low body mass index, and a lack of private insurance.

Up to 38.8% of the children who presented with diabetic ketoacidosis had been seen at least once by a physician before diagnosis. In addition to diagnostic error, the other physician factor that increased the risk was a delay of more than 24 hours between diagnosis and treatment.

Having a first-degree relative with diabetes was protective: Such children had a 6-fold decreased risk of presenting with ketoacidosis at diagnosis. Higher parental education and living in an area with a higher background incidence of type 1 diabetes were other protective factors.

Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. 2011:343:d4092.