ABSTRACT- Introduction: Paediatric Diabetic Ketoacidosis (DKA) studies are limited in Asia and none have
investigated markers of disease severity or prolonged hospital Length Of Stay (LOS). We investigate predictors of disease
severity and prolonged hospital LOS by analysing the demographics and signs and symptoms of patients with DKA.
Methods: We conducted a retrospective study of the medical records of patients who presented to the emergency
department of a tertiary paediatric hospital in Singapore between 2012 and 2013 and were diagnosed with DKA, obtaining
demographics, signs, symptoms, serum pH levels, precipitating causes, and hospital LOS for the 67 eligible patients.
Results: 82.1% of patients were tachycardic, 44.8% tachypneic and 20.9% febrile; none were hypotensive. The most
common symptoms were nausea and vomiting (56.7%), polyuria and polydipsia (50.7%), lethargy (34.3%), and fever
(22.4%).Half had mild DKA (48.5%) while a quarter of patients each had moderate (24.2%) and severe DKA (27.3%). A
higher proportion of those with severe DKA presented with tachypnea (p=.007). Prolonged LOS patients were younger at
presentation (p = .010), and a higher proportion had no prior history of DM (p=.061), presented with polyuria or
polydipsia (p=.062) and had a lower pH on presentation (p=.056).
Conclusions: Paediatric patients with DKA present with non-specific symptoms. Patients with tachypnea were more
likely to have a worse disease severity. Younger patients, those without a history of DM, or had lower serum pH, and
polyuria and polydipsia were more likely to have a prolonged hospital LOS.
Key-words- Diabetic Ketoacidosis,Child;Emergency Medicine, Length of Stay, Severity of Illness Index
The prevalence of diabetes mellitus (DM) among the
paediatric population is steadily increasing worldwide.1-2
This increase is mirrored in Indonesia whereby the overall
incidence of Type 1 DM has increased from 000,383 per
100,000 in 2000to 002,819 per 100,000 in 2010.3As a
consequence, complications such as diabetic ketoacidosis
(DKA) are also expected to increase.
However, paediatric patients with DKA tend to present with
non-specific signs and symptoms and diagnosis can be
difficult and delayed, especially among those not
previously diagnosed with DM.4
Worldwide, there are papers that examine the demographics
and common signs and symptoms among paediatric
patients with DKA.5–7A systematic review, which included
65 studies on over 29,000 children from 31 countries, was
conducted to determine the frequency of DKA at first
presentation of Type 1 DM in children. This review only
included 2 studies from Asia and no studies from
South-East Asia were available.8To the best of our
knowledge, there are no Asian studies analysing predictors
of disease severity and hospital length of stay (LOS).
The aim of this retrospective study was twofold: (1) to
identify demographic and medical variables in paediatric
patients diagnosed with DKA; and (2) to identify predictors
of disease severity and prolonged hospital LOS so that
aggressive treatment and the proper monitoring of such
patients can be instituted early. Because of the lacuna in the
extant literature amongst the Asian population, we were
unable to generate any a priori hypotheses to guide the
analyses and this study remained exploratory.
MATERIALS AND METHODS
Procedures and Participants:
In this retrospective study, information from the medical
records of patients who presented to the Children's
Emergency department of a large tertiary paediatric
hospital in Singapore and were diagnosed with DKA
between 1st January 2012 and 31st December 2013 were
reviewed. In accordance with the American Diabetes
Association (ADA), we defined our inclusion criteria as
DKA with a venous pH =7.3 in the presence of
hyperglycaemia and ketonemia or ketonuria.
The following information were collected from patients’
medical records: basic demographics, history of DM, vital
signs, symptoms, venous pH, known precipitating cause of
DKA and hospital length of stay. A median split was used
to segregate patients into normal or longer than normal
LOS. Venous pH was used to determine DKA severity:
mild (pH 7.20–7.30), moderate (pH 7.10–7.19), and severe
Data was analysed using the Statistical Package for Social
Sciences Version 21 (Chicago, IL, USA), and all
significance levels were set at 0.05 unless stated. Univariate
analyses were conducted to ascertain the demographic and
clinical profile of the sample of patients diagnosed with
DKA during the specified time period. Bivariate analyses,
such as t, Chi-square, and Fisher’s Exact tests, were
employed to determine if there are group differences or
relationships on the demographic or clinical variables that
may be related to DM status, severity of DKA, or LOS.
Since continuous variables proved to be non-normal,
non-parametric analogues of the aforementioned tests were
RESULTS AND DISCUSSION
Of the 207 patients reviewed, 67 patients met the inclusion
criteria (inclusion rate 32.3%). Table I demonstrate the
demographics of the total sample and divided by known
DM status. A majority were female (60%, n = 40), of
Chinese ethnicity (57%, n = 38), and nearly half were
previously not known to have DM (47.7%, n = 32). The
mean age at presentation was 11.69 ± 4.58 years (Range:
2–25 years). Venous pH of patients at presentation ranged
from 6.85 to 7.30, with a mean of 7.16 ± 0.14.
Table I also detail the frequencies of patients’ vital signs
and presenting symptoms for the total sample and divided
across known DM. Of the 67 patients, 82.1% were found to
be tachycardic (n = 55), 44.8% tachypneic (n = 30), and
20.9% were febrile on arrival to the Children’s Emergency
(n = 14). None were found to be hypotensive.The most
common symptoms were nausea and vomiting (56.7%; n =
38), followed by polyuria and polydipsia (50.7%; n = 34),
lethargy (34.3%; n = 23), and fever (22.4%; n = 15). Nearly
half of all patients had mild DKA (48.5%; n = 32; pH
7.20–7.30) while a quarter of the patients each had either
moderate (24.2%; n = 16; pH 7.10–7.19) or severe DKA
(27.3%; n = 18; pH < 7.10).The mean LOS was 95.7 hours
(range = 16–250).
Table I. Demographic and Medical Variables of the Total Sample and Across Known Diabetes Mellitus
DM= Diabetes Mellitus. DKA= Diabetic Ketoacidosis.
(N = 67)
(N = 35)
(N = 32)|
||Age ||11.69 ± 4.58 ||13.60 ± 4.15 ||9.59 ± 4.14|
||Female ||40 (59.7) ||24 (68.6) ||16 (50.0)|
||Chinese ||38 (56.7) ||17 (48.6) ||21 (65.6)|
||Malay ||13 (19.4) ||10 (28.6) ||3 (9.4)|
||Indian ||14 (20.9) ||7 (20.0) ||7 (21.9)|
||Others ||2 (3.0) ||1 (2.9) ||1 (3.1)|
||Prior Healthcare Visit ||– ||– ||25 (78.1)|
||Febrile ||14 (20.9) ||9 (25.7) ||5 (15.6)|
||Hypotensive ||0 (0) ||0 (0) ||0 (0)|
||Tachycardic ||55 (82.1) ||32 (91.4) ||23 (71.9)|
||Tachypneic ||30 (44.8) ||17 (48.6) ||10 (31.3)|
Fever ||15 (22.4) ||10 (28.6) ||5 (15.6)|
||Nausea/Vomiting ||38 (56.7) ||27 (77.1) ||11 (34.4)|
||Lethargy ||23 (34.3) ||11 (31.4) ||12 (37.5)|
||Polyuria/Polydipsia ||34 (50.7) ||5 (14.3) ||29 (90.6)|
||pH on Arrival ||6.85 ±0.14 ||6.85 ±0.13 ||6.86 ±0.15|
||Mild ||32 (47.8) ||16 (45.7) ||16 (50.0)|
||Moderate ||16 (23.9) ||10 (28.6) ||6 (18.8)|
||Severe ||18 (26.9) ||8 (22.9) ||10 (31.3)|
||Hospital Length of Stay (hours) ||95.72 ±102.74 ||96.66±101.75 ||94.69±105.44|
Data are presented either as M ±SD or as Frequency (%).
Patients with No History of DM:
Among the 32 (47.8%) patients who did not have a known
history of DM before attending the Children’s Emergency,
78.1% were found to have had a prior healthcare visit to
outpatient clinics, family physicians, private hospitals, and
other restructured hospitals before arrival (n
= 25). There
were no significant differences in the demographics, signs
and symptoms, severity of DKA, or hospital LOS between
those who had a prior healthcare visit compared to those
who did not.
Patients with a Known History of DM:
Thirty-five patients (52.2%) were known to have had a
prior diagnosis of DM before arrival at the Children’s
Emergency. Comparison between those with a known
history of DM against those with no history of DM showed
that there was a significant difference in age with known
cases of DM being older than unknown (13.60 ± 4.15 vs.
9.59 ± 4.14, p
Statistically significant differences in heart rate and
respiratory rate were also found with a higher proportion of
patients with a history of DM presenting with tachycardia
[1,67] = 4.35, p = .037) and tachypnea (x2
[1,67] = 4.53,
p = .033).
There were also statistically significant differences in
symptoms, with a higher proportion of known cases of DM
presenting with nausea or vomiting (x
[1,67] = 12.46, p<
.001) and a lower proportion presenting with polyuria or
[1,67] = 38.98, p< .001 ).
Excluding non-compliance, significant differences in
precipitating cause of DKA were also found, with a higher
proportion of known DM having pneumonia or an upper
respiratory tract infection (p
Markers of Disease Severity:
The study objective included the search for markers of
disease severity. Unsurprisingly, we found that a higher
proportion of those with severe DKA presented with
[1,66] = 7.15, p = .007). Demographics (age,
gender, ethnicity), prior diagnosis of DM, other vital signs
(heart rate, fever, blood pressure), symptoms, and known
precipitating causes were not significantly related to
Markers of Prolonged Hospital Stay:
Prolonged hospital stay was defined as >71 hours, based on
the median split of the data with the median being
excluded. Analyses revealed that there was a significant
difference in age with prolonged LOS patients being
younger at presentation (10.21 ± 4.41 vs. 13.16 ± 4.46,
 = 2.68, p = .010). There were also a higher proportion
of patients with prolonged LOS having no prior history of
DM, although this difference was marginal (x
3.52, p = .061).
Similarly, there was a marginally significant difference
with a higher proportion of prolonged LOS patients having
polyuria or polydipsia (x
[1,65] = 3.47, p = .062) and a
lower pH on presentation (7.12 ± 0.15 vs. 7.20 ± 0.12, t
= 1.95, p = .056).
The economic burden of DKA is extremely high, with an
annual cost of treating DKA in all patients at diagnosis and
during subsequent visits exceeding $1 billion.5
Newly-diagnosed patients account for a quarter of this
It has also been found in a separate study that
more than half of all paediatric patients newly diagnosed
with DM will be hospitalized and among those
hospitalized, 44% will be due to DKA.10
In Iran, 24% of
newly diagnosed Type 1 DM presented in a state of
ketoacidosis and severe DKA (pH=7.2) was observed in
54.5% of patients.11
Given the significant worldwide
economic burden of DM and that a large percentage of
newly diagnosed patients present with DKA, healthcare
education aimed at increasing awareness on paediatric DM
are warranted and have the potential to be effective.
Interestingly, a study in the United Kingdom showed that
children who were the second affected child in the family
were less likely to present in DKA than first affected
This could be due to the fact that parental
awareness regarding the management of DM and DKA
could be higher and proper counselling regarding the need
to seek early medical treatment could have been instituted.
This is particularly important as our study showed that
approximately half of all of patients who were diagnosed
with DKA did not have a prior history of DM. Therefore,
there is a significant window of opportunity at highlighting
the symptoms of DM to parents so that it can be diagnosed
early, reducing the risk of progression to DKA which is
costly to treat and carries with it greater complications and
morbidity. Other studies have also proven that DKA
prevention programs are effective. In Italy, an 8-year
community intervention program highlighting signs and
symptoms of childhood diabetes costing $23,470 led to a
reduction in the prevalence of DKA at diagnosis from 78%
to 13%. 13
Diagnosis of DKA has also proven to be difficult,
particularly in young children who may be labelled as
having pneumonia, asthma or bronchiolitis instead.4 Our
study found that the most common symptoms were nausea
and vomiting (56.7%), polyuria and polydipsia (50.7%) and
lethargy (34.3%). This is comparable to another study that
showed polyuria was observed in 96% of children at the
time of diagnosis whereas fatigue was present in 52% of
Healthcare providers should remain vigilant and
maintain a high index of suspicion for DKA in the child
with unexplained nausea and vomiting, polyuria and
polydipsia and lethargy. This is made even more important
given the fact that our study demonstrated that nearly 80%
of patients with no known history of DM had a prior
healthcare contact before arrival at Children’s Emergency.
Among patients with a known history of DM,
non-compliance to medications is an important causal event
leading to DKA. A quarter of such patients were found to
have omitted or administered suboptimal amounts of
insulin in our study. Among all patients with DKA, only
21% could be directly attributed to infective causes
(respiratory and gastro-intestinal infections). Our findings
are supported by other studies, which showed that an
inter-current illness is seldom the cause of DKA when DM
management is properly taught and families are provided
with the support of a diabetes team and a 24-hour diabetic
Severity of DKA was significantly related to patients with
tachypnea. This finding is unsurprising given the fact that
patients with severe DKA have a lower venous pH with a
consequent greater amount of respiratory compensation and
Kussmaul’s breathing. Age, gender, ethnicity, other vital
signs, symptoms on arrival to Children’s Emergency and
known history of DM were not significant predictors of
DKA severity. Our findings are in agreement with previous
studies conducted in America that demonstrated that there
was no racial or ethnic differences in DKA severity.10
the emergency physician should be wary of the tachypneic
child, which portends a worse disease. This clinical
correlation can and should be used to ascertain disease
severity even before laboratory results are available so that
early and aggressive resuscitative measures and proper
monitoring can be arranged in order to increase the
likelihood of a good outcome for the child.
Lack of healthcare insurance was also associated with
higher rates and greater severity of DKA at diagnosis.9,19-20
This is presumed to be due to the fact that uninsured
subjects tend to delay seeking medical attention. However,
in our analysis, among patients with no known history of
DM, those who sought prior medical attention before
attending Children’s Emergency did not demonstrate a
better disease outcome compared to those who did not have
a prior medical contact. We suspect that this situation is
unique to Singapore as the readily accessible transport and
healthcare network in combination with her small
geographical size prevents significant delays from acute
and emergency healthcare delivery.
Our study defined prolonged hospital stay as being more
than 71 hours, based on the median split. This duration is
comparable to the average length of hospital stay in
children from Ontario who was hospitalized with DKA.
Their average length of stay was found to be 3.2 days.21
Based on our study, younger patients were likelier to have a
prolonged hospital stay. Patients presenting with polyuria
and polydipsia, low serum pH levels and those with no
history of DM were also found to have a more prolonged
hospital stay even though this difference is marginal. We
suspect that cultural practices within Singapore could
influence the hospital LOS. This could be due to the fact
that the caregivers and family members of young patients
and those with no history of DM would require more time
to be educated regarding DM as well as the proper
administration of insulin, regular blood sugar level
monitoring as well as the warning signs of DKA and this
could be one reason for a delayed hospital discharge.
Strengths and Limitations:
We believe we are the first Asian study that examined
markers of disease severity and prolonged LOS amongst
paediatric patients with DKA. However, only 67 medical
records met the inclusion criteria (inclusion rate of 32.3%)
for our retrospective study over a 24-month period.Among
those with a prolonged hospital LOS, reasons for a delayed
hospital discharge could not be accurately elicited. The
relative lack of Asian studies, combined with the
wide-ranging clinical implications suggests that further
studies are warranted to examine reasons behind a
prolonged hospital LOS.
Our study showed that half of all paediatric patients
presenting with DKA in Singapore were not previously
known to have DM. Greater efforts aimed at highlighting
signs and symptoms of paediatric DM has the potential to
prevent and reduce the rates of DKA in Singapore. Eighty
percent of all patients with no known history of DM had a
prior healthcare contact before arrival to the Children’s
Emergency and the most common symptoms among all
patients were nausea and vomiting, polyuria and polydipsia
and lethargy. Therefore, all healthcare providers have a role
to play in maintaining a high index of suspicion in the
previously healthy child who present with the above
symptoms. Patients who had tachypnea were also found to
be at higher risk of having severe DKA. As such,
emergency personnel should be wary of the child with
suspected DKA who is also noted to be tachypneic as this
would signify a greater disease severity and would affect
their disposition and level of monitoring. Younger patients,
those without a history of DM and those with a lower
serum pH and those who present with polyuria and
polydipsia were likelier to have a prolonged hospital LOS.
Upon admission, healthcare providers and administrators
should counsel caregivers of such patients that hospital stay
could be prolonged.
The writers would like to thank the Children’s Emergency
Department of Kandang Kerbau Women’s and Children’s
Hospital, without which this study would not be possible.
This study obtained ethics approval from Singhealth
Centralised Institutional Review Board (Reference number:
2014/529/E), which also approved a waiver of consent. No
patient identifiers were collected and all information was
collected anonymously as either categorical or ordinal
variables. This study was not funded, and the authors
declared no conflict of interest.
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