Pediatric diabetic ketoacidosis

We read with interest the recent review of diagnosis and treatment of diabetic ketoacidosis by Jean-Louis Chiasson and associates.1 However, it was unclear whether the therapeutic approach was being recommended for all patients, regardless of age.

We feel that diabetic ketoacidosis should be approached and treated differently in children. In particular, the risk of cerebral edema is significantly higher in children and adolescents: the reported incidence ranges from 0.7% to 3%, and this complication is associated with substantial morbidity (21% to 35%) and mortality (20% to 25%). Although the mechanism and risk factors remain controversial, it appears that the risk is higher among those presenting with new-onset diabetes,2^,3 with lower initial partial pressure of carbon dioxide and higher initial blood urea suggesting more severe acidosis and dehydration.3 Possible aspects of treatment include rapid administration of hypotonic fluids4^,5 and use of bicarbonate.2

As a result of these factors, pediatric treatment protocols recommend more conservative fluid replacement.6^,7 Whereas Chiasson and associates1 recommend starting with 15 to 20 mL/kg of isotonic saline, for children the recommendation is 5 to 10 mL/kg in the first hour, with higher rates used only in patients with significant hemodynamic compromise. Fluid replacement should be calculated over a 48-hour period. In addition, the use of bicarbonate is not routine for all pediatric patients with pH less than 7.0, and bicarbonate may in fact increase the risk of cerebral edema in children.2 We agree with the recommendation not to give an intravenous bolus of insulin at the initiation of insulin therapy.

Many children present to emergency departments staffed by physicians who have a wealth of experience in the management of adult patients with diabetic ketoacidosis but who may not be familiar with the different management considerations required for children and adolescents with this condition. We feel it is important to increase awareness of the more conservative fluid management recommended for pediatric patients, in the hope that this may decrease the incidence of cerebral edema and improve outcomes.

Sarah Lawrence Danièle Pacaud Heather Dean Margaret Lawson Denis Daneman Pediatric Section Clinical Practice Guideline Expert Committee Canadian Diabetes Association Toronto, Ont.