title: Delayed diagnosis and issues with pump usage are the leading causes of diabetic ketoacidosis in children with diabetes living in Newfoundland and Labrador, Canada.
abstract: BACKGROUND
  Newfoundland and Labrador (NL) has a very high incidence of type 1 diabetes (T1DM) and admission rate for diabetic ketoacidosis (DKA). The purpose of this study was to identify characteristics and precipitating factors associated with pediatric DKA in this population.
  
  
  METHODS
  This was a retrospective study on children diagnosed with DKA from 2007-2011 admitted to the province's only tertiary care pediatric hospital. Demographics, biochemical characteristics, and reasons for DKA diagnosis were analyzed. Chi-square and Fisher Exact tests were performed for categorical variables; t- and non-parametric Kruskal-Wallis tests were performed for continuous variables.
  
  
  RESULTS
  A total of 90 children were admitted with DKA (39.5% newly diagnosed; 60.5% were previously diagnosed). The rate of DKA on presentation for incident cases was 22.1%. More severe cases of DKA occurred in younger, newly diagnosed patients. Almost half of preexisting diabetes cases were recurrent DKA (49.1%). The most common presenting characteristics of newly diagnosed patients were weight loss, bedwetting, polyuria, polydipsia, and neurologic symptoms. Pre-existing diabetes patients most often presented with abdominal pain and vomiting. Diagnosis of diabetes in new patients and issues related to interrupted insulin delivery in pre-existing patients using insulin pump therapy were the most common factors associated with DKA. Of the newly diagnosed patients presenting in DKA, 64% had seen a physician in the weeks leading up to diagnosis.
  
  
  CONCLUSIONS
  Pediatric patients have predictable patterns associated with a diagnosis of DKA. Most cases of DKA could be prevented with earlier diagnosis and improved education and problem-solving by families and health care providers. DKA preventative strategies are recommended and should be aimed at patients, their families, and health care professionals especially those outside of pediatric centers.
authors.affiliation: Janeway Pediatric Research Unit, Memorial University, 300 Prince Philip Drive, St. John's, A1B3V6, NL, Canada. jessicafjackman@gmail.com.
authors.forename: Jessica
authors.initials: J
authors.lastname: Jackman
authors.affiliation: Janeway Pediatric Research Unit, Memorial University, 300 Prince Philip Drive, St. John's, A1B3V6, NL, Canada. Roger.chafe@med.mun.ca.
authors.forename: Roger
authors.initials: R
authors.lastname: Chafe
authors.affiliation: Janeway Pediatric Research Unit, Memorial University, 300 Prince Philip Drive, St. John's, A1B3V6, NL, Canada. Daniel.Albrechtsons@med.mun.ca.
authors.forename: Daniel
authors.initials: D
authors.lastname: Albrechtsons
authors.affiliation: Janeway Pediatric Research Unit, Memorial University, 300 Prince Philip Drive, St. John's, A1B3V6, NL, Canada. rporter@mun.ca.|Janeway Children's Health and Rehabilitation Centre, Eastern Health, St. John's, A1B3V6, NL, Canada. rporter@mun.ca.
authors.forename: Robert
authors.initials: R
authors.lastname: Porter
authors.affiliation: Janeway Children's Health and Rehabilitation Centre, Eastern Health, St. John's, A1B3V6, NL, Canada. canugent@gmail.com.
authors.forename: Colleen
authors.initials: C
authors.lastname: Nugent
authors.affiliation: Janeway Pediatric Research Unit, Memorial University, 300 Prince Philip Drive, St. John's, A1B3V6, NL, Canada. Shahzad.Waheed@easternhealth.ca.|Janeway Children's Health and Rehabilitation Centre, Eastern Health, St. John's, A1B3V6, NL, Canada. Shahzad.Waheed@easternhealth.ca.
authors.forename: Shahzad
authors.initials: S
authors.lastname: Waheed
authors.affiliation: Janeway Pediatric Research Unit, Memorial University, 300 Prince Philip Drive, St. John's, A1B3V6, NL, Canada. lnewhook@mun.ca.|Janeway Children's Health and Rehabilitation Centre, Eastern Health, St. John's, A1B3V6, NL, Canada. lnewhook@mun.ca.
authors.forename: Leigh Anne
authors.initials: LA
authors.lastname: Newhook
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003922:Diabetes Mellitus, Type 1 / Q000150:complications / Q000188:drug therapy*; D016883:Diabetic Ketoacidosis / Q000175:diagnosis*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007260:Infusion Pumps; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use*; D007902:Length of Stay; D009523:Newfoundland and Labrador; D010343:Patient Admission
chemical_list: D007328:Insulin