Diabetic ketoacidosis (DKA) rates of 5% to 7% are occurring in non-newly diagnosed children with type 1 diabetes in the United States, United Kingdom, and Western Europe, a new study finds.

The analyses of data from nearly 50,000 patients younger than 18 years with type 1 diabetes in Austria/Germany, England/Wales, and the United States were published online August 17 in Diabetes Care by David M Maahs, MD, of the Barbara Davis Center for Childhood Diabetes, Aurora, Colorado, and colleagues.

In the three registries, females, ethnic minorities, and those with above-target HbA 1c levels were at particularly increased risk for DKA among patients, all of whom who had type 1 diabetes for at least a year.

"DKA continues to be a major problem in pediatric type 1 diabetes. Programs need to be developed and funded to target patients at high risk," Dr Maahs told Medscape Medical News.

Study coauthor Reinhard W Holl, MD, PhD, of the University of Ulm, German Center for Diabetes Research, added, "This is of course a very complex issue with many aspects besides patient education, [including] the accessibility of the healthcare system, availability of 24-hour access (for example, by telephone hotline for families with affected children), issues of insurance and reimbursement, distance between family home and emergency care as well as specialized pediatric diabetes care, [and] availability of frequent blood glucose testing."

Behaviors such as the intentional restriction of insulin by teenagers trying to lose weight may play a role, Dr Holl told Medscape Medical News.

Coauthor Justin T Warner, MD, of the department of child health, University Hospital of Wales, Cardiff, said that despite universal access to the National Health Service in England and Wales, "we still see large variability in outcomes, including DKA rates, in different parts of the country. Even when data are case-mix adjusted, there are differences in outcomes between centers delivering diabetes care, and hence, there is still a lot we have to learn to reduce this variability."

Registries Yield Numbers, but Not Explanations

Data for 2011 to 2012 were analyzed from 22,397 Austrian and German patients from the Prospective Diabetes Follow-up Registry (DPV); 16,314 English and Welsh children in the National Paediatric Diabetes Audit (NPDA); and 11,148 patients from the American Type 1 Diabetes Exchange (T1D Exchange).

The European registries are more representative of the entire type 1 diabetes populations in those countries, whereas the T1D Exchange includes only patients seen at specialty centers that emphasize team care, Dr Maahs noted.

Overall, 5.0% of the Austrian/German, 6.4% of the English/Welsh, and 7.1% of the American registry populations had experienced at least one DKA event in the prior year (DKA definitions differed slightly in the databases, but all required treatment at a healthcare facility for hyperglycemia and a pH < 7.3).

These numbers are similar to previous reports, Dr Maahs told Medscape Medical News, adding, "The continued rates and consistency across five countries is notable."

Insulin-pump use was significantly lower in the UK cohort (11.5%) compared with Austria/Germany (44.2%) and United States (56.1%) cohorts, but only in the US database was there a lower rate of DKA among pump users (odds ratio [OR], 0.84). In the other countries, there was no difference in DKA rates between pump users and those who used injections.

In a multivariate analysis, the risk for DKA was 23% higher among females than males (OR, 1.23), and 27% greater among country-specific ethnic minorities than nonminorities (OR, 1.27).

Dr Warner suggested that the use of insulin restriction to lose weight might explain the female preponderance, noting that "body image is a bigger issue among girls than boys."

Patients with HbA 1c levels of 7.5% to 8.9% were at more than twofold greater risk for DKA (OR, 2.54) compared with those meeting the pediatric target of < 7.5%, while those with HbA 1c levels of 9.0% or greater had nearly nine times the risk (OR, 8.74).

What Can Be Done?

Dr Maahs told Medscape Medical News that use of continuous glucose monitors (CGMs) was very low in all three populations, "but there is hope that increased use of CGM can improve type 1 diabetes care and reduce DKA."

Dr Holl added, "We also need more information on the psychological and social background of high-risk groups to better target prevention programs...Comparison of outcomes among different healthcare systems despite similar resources may open new ideas on how to improve long-term care in chronically ill children."

The DPV is supported through the German Bundesministerium fur Bildung und Forschung Competence Network for Diabetes Mellitus, which is integrated into the German Center for Diabetes Research. The T1D Exchange is supported through the Leona M and Harry B Helmsley Charitable Trust. The NPDA is funded by the Healthcare Quality Improvement Partnership and delivered by the Royal College of Paediatrics and Child Health. Dr Maahs is on the advisory board for Insulet. Dr Holl's nonprofit employer has received research grants from Eli Lilly, Novo Nordisk, Sanofi, and Medtronic, with no personal compensation to him. Dr Holl holds an equity fund that may contain stock from pharmaceutical companies. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online August 17, 2015. Abstract