# Characterisation of diabetic ketoacidosis in children and adolescents with type 1 diabetes: a regional hospital study

## TL;DR

This study examines how children with type 1 diabetes in a regional Australian hospital present with diabetic ketoacidosis and explores treatment outcomes.

## Contribution

The study confirms the safe use of subcutaneous insulin for mild to moderate DKA in children and highlights regional management patterns.

## Key findings

- Most DKA cases in the regional hospital were managed locally with good outcomes.
- Subcutaneous insulin was safely used for mild to moderate DKA in children.
- Bicarbonate recovery could help transition to subcutaneous insulin earlier.

## Abstract

To characterise the clinical and biochemical parameters of children (0–16 years) who presented with Diabetic Ketoacidosis (DKA) at a regional hospital in Australia.

A retrospective observational study was conducted following the approval of the Ethics Committee. Data from 2018 to 2022 were collected from medical records, with a focus on patient treatment and follow-up.

A total of 72 type 1 diabetes (T1D) patients with 30 DKA presentations were identified. The mean age at DKA presentation was 11.9 +/- 3.2 years, with 42.1% having new-onset T1D. An equal number of patients presented with mild (50%) and moderate to severe DKA. Of these, 24 presentations were managed with insulin infusion, and 6 (20%) were managed with subcutaneous insulin. Following a mean ED stay of 7.93 +/- 4.8 h, 14 patients (93.3%) were transferred to the CCU or ward, and 2 were transferred to a tertiary centre. The mean HbA1c was 12.55 +/- 2.1%, with a mean recovery time of 10.4 h for pH and 6.4 h for bicarbonate. Minor complications occurred in 10% of patients (all on insulin infusion). All patients were discharged in stable condition after 2.15 +/- 1.3 days. The follow-up rate was 72.2% (13/18), with a mean HbA1c of 8.32 +/- 1.8%.

Regional hospitals witness a high frequency of children with T1D presenting with DKA as their first presentation. Targeting bicarbonate levels for acidosis correction could help facilitate an earlier transition to subcutaneous insulin and needs due consideration. This study substantiates the use of upfront subcutaneous insulin for mild to moderate DKA with good outcomes. Follow-up care remains a crucial gap that necessitates strengthening regional diabetes management teams.

Not applicable.

The online version contains supplementary material available at 10.1186/s12887-025-05824-0.

What is already known about this topic?

1. Regional areas in Australia demonstrate 1.5 times higher risk of Diabetic ketoacidosis (DKA) as the first manifestation of type 1 diabetes (T1D) as compared to the cities.

2. Although the overall incidence of T1D in Australia has remained stable in recent years, the highest increase has been in regional areas.

3. DKA is conventionally managed with insulin infusion, which is labour-intensive and may lead to complications with prolonged use.

4. The 2022 International Society of Paediatric and adolescent diabetes (ISPAD) guidelines propose subcutaneous insulin for managing mild and moderate DKA in otherwise well children, but empirical data on its application, particularly in regional areas, are limited.

What does this study add?

1. This study confirms the increased risk of DKA as the first presentation of T1D in this regional centre.

2. Most DKA patients presenting to our regional hospital are managed locally.

3. Emphasis on bicarbonate recovery as a target for acidosis correction in the guidelines could facilitate an earlier transition to SC insulin for those initiated on an insulin infusion, potentially reducing the intensive management demand at regional centres.

4. This study establishes the safe use of upfront SC insulin in managing a specific subset of paediatric DKA patients.

The online version contains supplementary material available at 10.1186/s12887-025-05824-0.