title: Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review.
abstract: OBJECTIVE
  To identify the factors associated with diabetic ketoacidosis at diagnosis of type 1 diabetes in children and young adults.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  PubMed, EMBASE, Web of Science, Scopus, and Cinahl and article reference lists.
  
  
  METHODS
  Cohort studies including unselected groups of children and young adults presenting with new onset type 1 diabetes that distinguished between those who presented in diabetic ketoacidosis and those who did not and included a measurement of either pH or bicarbonate in the definition of diabetic ketoacidosis. There were no restrictions on language of publication.
  
  
  RESULTS
  46 studies involving more than 24,000 children in 31 countries were included. Together they compared 23 different factors. Factors associated with increased risk were younger age (for <2 years old v older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35 (2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection (odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74 (1.10 to 2.77)). Protective factors were having a first degree relative with type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)), higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43 to 0.94) in two studies), and higher background incidence of type 1 diabetes (correlation coefficient -0.715). The mean duration of symptoms was similar between children presenting with or without diabetic ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0) respectively), and up to 38.8% (285/735) of children who presented with diabetic ketoacidosis had been seen at least once by a doctor before diagnosis.
  
  
  CONCLUSIONS
  Multiple factors affect the risk of developing diabetic ketoacidosis at the onset of type 1 diabetes in children and young adults, and there is potential time, scope, and opportunity to intervene between symptom onset and development of diabetic ketoacidosis for both parents and clinicians.
authors: General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 0SR, UK. jau20@cam.ac.uk
authors: Juliet A
authors: JA
authors: Usher-Smith
authors: Matthew J
authors: MJ
authors: Thompson
authors: Stephen J
authors: SJ
authors: Sharp
authors: Fiona M
authors: FM
authors: Walter
mesh_terms: D000293:Adolescent; D000367:Age Factors; D015992:Body Mass Index; D002648:Child; D002675:Child, Preschool; D003241:Consanguinity; D057210:Delayed Diagnosis; D003922:Diabetes Mellitus, Type 1 / Q000175:diagnosis* / Q000208:ethnology / Q000209:etiology; D016883:Diabetic Ketoacidosis / Q000175:diagnosis* / Q000208:ethnology / Q000209:etiology; D003951:Diagnostic Errors; D005260:Female; D005334:Fever / Q000150:complications; D006801:Humans; D007223:Infant; D007239:Infections / Q000150:complications; D007348:Insurance, Health; D008297:Male; D010290:Parents; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D010375:Pedigree; D012111:Residence Characteristics; D012307:Risk Factors; D012621:Seasons; D012737:Sex Factors; D012959:Socioeconomic Factors; D013997:Time Factors; D055815:Young Adult