410 Archives ofDisease in Childhood 1996;75:410-415 Ketoacidosis at the diagnosis of type 1 (insulin Arch Dis Child: first published as 10.1136/adc.75.5.410 on 1 November 1996. Downloaded from dependent) diabetes mellitus is related to poor residual cell function Jorma Komulainen, Raisa Lounamaa, Mikael Knip, Eero A Kaprio, Hans K Akerblom, and the Childhood Diabetes in Finland Study Group Abstract observed to be associated with age at diagno- The determinants of the degree of meta- sis,' degree of metabolic decompensation,9 bolic decompensation at the diagnosis of mild clinical symptoms at diagnosis,2910 and type 1 (insulin dependent) diabetes melli- strict initial blood glucose control.213 Diabetic tus (IDDM) and the possible role of ketoacidosis is a serious consequence of insuf- diabetic ketoacidosis in the preservation ficient insulin secretion.'4 In addition to possi- and recovery of residual P cell function ble acute complications, it may also influence were examined in 745 Finnish children the later outcome of diabetes. and adolescents. Children younger than 2 To study the effect of age, sex, and years or older than 10 years of age were socioeconomic factors on the clinical condition found to be more susceptible to diabetic ofthe patient at the diagnosis of IDDM, and to ketoacidosis than children between 2 and find out whether metabolic decompensation at 10 years of age (<2 years: 53.3%; 2-10 diagnosis is related to subsequent endogenous years: 16.9%; >10 years: 33.3%). Children insulin secretion and impaired metabolic con- from families with poor parental trol, 745 Finnish children and adolescents, educational level had ketoacidosis more aged 0.8-14.9 years, were evaluated at the time often than those from families with high of diagnosis of IDDM and then observed for parental educational level (24.4% v two years. 16.9%). A serum C peptide concentration of0.10 nmol/l or more was associated with Methods a favourable metabolic situation. Low PATIENTS serum C peptide concentrations, high As a part ofthe Finnish nationwide 'Childhood requirement of exogenous insulin, low diabetes in Finland' study,'5 801 probands Department of prevalence ofremission, and high glycated younger than 15 years, diagnosed as having Paediatrics, Kuopio haemoglobin concentrations were ob- IDDM during the recruitment period from 1 University Hospital, http://adc.bmj.com/ served during the follow up in the group of 1986 to 30 were offered Kuopio, Finland diabetic ketoacidosis at September April 1989, J Komulainen probands having the possibility of participating in the study. Of the diagnosis of IDDM. Thus diabetic these 745 had analyses of blood pH, serum C Department of ketoacidosis at diagnosis is related to a peptide concentrations, and blood glycated Epidemiology, the decreased capacity for P cell recovery National Public Health haemoglobin levels at the time of hospital after the clinical manifestation of IDDM admission. At the time of a clinical Institute, Helsinki, in children. admission, Finland examination including assessment of con- (Arch Dis Child 1996;75:410-415) on September 28, 2021 by guest. Protected copyright. R Lounamaa sciousness and dehydration was performed, Keywords: ketoacidosis, serum C peptide, insulin dose, and the parents were asked to fill out a Department of questionnaire concerning the socioeconomic Paediatrics, University insulin dependent diabetes mellitus. of Oulu, Oulu, Finland status of the family. The subjects were then fol- M Knip lowed up in their own outpatient clinics (n = A chronic autoimmune destruction of the pan- 31) for two years. At six month intervals, the Department of creatic f cells results in decreasing endogenous recommended amount of insulin was re- Paediatrics, Peijas insulin secretion and the clinical manifestation corded, blood specimens werc taken for Hospital, Vantaa, haemoglobin and serum C peptide Finland of type 1 (insulin dependent) diabetes glycated E A Kaprio (IDDM). The clinical onset of the disease is concentrations, and a clinical examination often acute in children and adolescents, and including height and weight recording was per- The Children's diabetic ketoacidosis is present in 20-74% of formed. Hospital, II the patients.' Young age and female sex have The mean age of the probands was 8.4 years Department of been associated with an increased frequency of (range 0.8 to 14.9 years). The majority of them Paediatrics, University were males (n = 412; 55.3%). The subjects ofHelsinki, Helsinki, diabetic ketoacidosis.' However, there are only Finland limited data concerning the determinants of were divided into two groups: those with and H K Akerblom the degree of metabolic decompensation at the without diabetic ketoacidosis at diagnosis. In diagnosis of childhood IDDM. the longitudinal study the groups were com- Correspondence to: pared at the time of diagnosis and at six, 12, 18, Jorma Komulainen, It is well known that the capacity of residual Department of Paediatrics, 5 cells to secrete insulin is decreased at the and 24 months after diagnosis. Kuopio University Hospital, time of diagnosis of IDDM, often improving in PO Box 1777, FIN-7021 1 a few weeks after the initiation of exogenous LABORATORY MEASUREMENTS Kuopio, Finland. insulin treatment.8'-` The extent of improve- Capillary or venous blood pH was measured at Accepted 24 July 1996 ment in insulin secretory capacity has been the time of hospital admission. Diabetic Ketoacidosis affects residualf, cellffunction 411 ketoacidosis was defined as a blood pH of less Table 1 Data on ketoacidosis, degree ofconsciousness, and than 7.30. dehydration in study population at the diagnosis ofIDDM Arch Dis Child: first published as 10.1136/adc.75.5.410 on 1 November 1996. Downloaded from Serum C peptide concentrations were ana- No (%/) lysed in one central laboratory with a radioim- pH 7.30 or more 584 (78.4) munoassay, as described earlier,"6 by using 7.20-7.29 87 (11.7) antiserum K6 (Novo Research Institute, Bags- 7.10-7.19 40 (5.4) vaerd, Denmark). The detection limit of the 7.00-7.09 18 (2.4) <7.00 16(2.1) assay was 0.03 nmolIl. Consciousness Normal 655 (87.9) Standard methods for blood glycated hae- Impaired 90 (12.1) moglobin (HbA1) and HbA1C analysis were Dehydration No 274 (36.8) Mild 354 (47.5) used in the various hospitals (n = 31) Severe 98 (13.1) participating in the study. To make the results Unknown 19 (2.6) comparable, they were expressed as a SD score above the mean for non-diabetic subjects. impaired consciousness, while 21 (23.3%) of ASSESSMENT OF CONSCIOUSNESS AND the probands with impaired consciousness had DEHYDRATION a blood pH value of 7.30 or more. Twenty one Degree of consciousness and dehydration was (21.4%) of the children who were rated to be assessed by the clinician examining the patient severely dehydrated had a blood pH value of at the time of hospital admission. Conscious- 7.30 or more. Sixteen (2.1%) children had a ness was estimated to be either normal or blood pH value of less than 7.00. One of them impaired. Dehydration was rated to be absent, (6.2%) was considered to have normal con- mild (<8% in children younger than 12 years sciousness, and four (25.0%) were considered of age, <7% in older children), or severe (8% to be only mildly dehydrated. or more, 7% or more, respectively). Serum C peptide concentrations were ana- lysed in 697 probands (93.6%). Fourteen of them (2.0%) had an undetectable serum C DAILY INSULIN DOSE AND REMISSION peptide concentration at diagnosis, and 141 The recommended amount of insulin and the (20.2%) had a concentration of less than 0.10 weight of the proband were recorded at each nmolIl. They were considered 'low' secretors. six monthly visit, and the daily insulin dose The clinical and laboratory data of 'low' and (IU/kg/day) was calculated. Partial remission 'high' secretors are presented in table 3. was defined as an insulin dose less than 0.5 The mean age of the study population was IU/kg/day in combination with a glycated hae- 8.4 years (range 0.8 to 14.9 years). Thirty of moglobin (HbA1 or HbA1) not exceeding the the subjects (4.0%) were younger than 2.0 mean laboratory specific reference level by 4 years of age (group A), 432 of them (58.0%) SD score or more. were 2.0-10.0 years old (group B), and 283 (38.0%) were older than 10.0 years (group C). SOCIOECONOMIC FACTORS More than half (58.4%) of the subjects in the http://adc.bmj.com/ Families were divided into groups according to oldest age group were pubertal at the diagnosis parental education, taxable income, and place of IDDM. Ketoacidosis was more common in of residence. Families in which at least one of age group A (n = 16; 53.3%, p<0.001) and in the parents had an academic degree were clas- age group C (n = 72; 25.4%, p<0.01) than in sified as ones with high parental education, age group B (n = 73; 16.9%). Impaired whereas other families were classified as ones consciousness was found more often in age with low parental education. Low income was = group A (n 10; 33.3%) than in age group B on September 28, 2021 by guest. Protected copyright. considered as a reported annual income of less than FIM 90 000 ($US 18 000), medium Table 2 Laboratory data ofstudy population at time of income that of FIM 90-150 000 ($US 18- hospital admission 30 000), and high income that of more than FIM 150 000 ($US 30 000). Urban families No Mean Median SD Range had their homes in a city, town or suburb, while pH 745 7.34 7.37 0.11 6.83-7.58 rural families lived in a village or outside a B glucose (mmol/l) 739 21.6 20.2 9.6 3.2-107.0 population centre.