Review Identifies Factors Associated With Increased DKA Risk in Pediatric Patients


Considerable research on diabetic ketoacidosis (DKA) risk has been published since the publication of a 2011 systematic review, warranting an updated analysis.

Being younger than 2 years at type 1 diabetes (T1D) onset, belonging to an ethnic minority population, experiencing delayed diagnosis or misdiagnosis, and presenting during the COVID-19 pandemic were all associated with increased risk of diabetic ketoacidosis (DKA) at the onset of T1D among pediatric patients, according to a systematic review published in JAMA Pediatrics.

The study authors also identified factors associated with decreased risk of DKA, including greater understanding of key signs or symptoms of DKA, such as through a family history of T1D or participation in screening programs.

“Future work should focus on identifying and implementing strategies related to these factors to reduce risk of DKA among new patients with T1D,” the authors wrote.

To come to these findings, the study authors analyzed a total of 195 articles, including 46 from a review published in 2011 and 149 “considerable additional articles” that have been published since then, warranting an update to the previous review.

A total of 188,637 pediatric patients from 47 countries were included in the 149 new studies. Most of the studies included patients younger than 18 years and as young as newborns, with 8 studies including patients 20 years or older and 1 study including patients 24.8 years or older.

Proportionally, most (14.8%) of the studies were published in the United States. The authors also noted that 60.4% of the additional articles were high-quality retrospective cohort studies with low risk of bias.

Following an initial analysis of the 195 studies, 38 factors were identified, and the authors assessed their associations with DKA at T1D onset.

Consistent with findings published in the 2011 review, the new review found a significantly increased risk of presentation with DKA linked to younger age compared with older age, especially when patients were grouped by ages 2 and older vs younger than 2 years (odds ratio [OR], 3.51; 95% CI, 2.85-4.32; P < .001).

Also consistent with the 2011 review, patients belonging to an ethnic minority population (OR, 0.40; 95% CI, 0.21-0.74; P = .004) and patients with a family history of T1D (OR, 0.46; 95% CI, 0.37-0.57; P < .001) had a higher risk of presenting with DKA.

Some factors that were not associated with DKA in the 2011 systematic review were associated with DKA in the new review, including delayed diagnosis (OR, 2.27; 95% CI, 1.72-3.01; P < .001).

Other factors associated with DKA risk among patients with new-onset T1D included participation in screening programs (OR, 0.35; 95% CI, 0.21-0.59; P < .001) and presentation during the COVID-19 pandemic (OR, 2.32; 95% CI, 1.76-3.06; P < .001).

“A strategy to achieve reduced DKA may include screening of national populations to identify those at greatest risk,” the authors said. “However, with the potential for considerable psychological and economic burden, the beneficence of this strategy should be assessed carefully. In addition, although some educational campaigns were shown to be associated with reduced DKA incidence, they should be targeted appropriately to have greatest influence.”


Rugg-Gunn CEM, Dixon E, Jorgensen AL, et al. Factors associated with diabetic ketoacidosis at onset of type 1 diabetes among pediatric patients: a systematic review. JAMA Pediatr. Published online October 10, 2022. doi:10.1001/jamapediatrics.2022.3586

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