Title:A Narrative Review on Diabetic Ketoacidosis in Children
Volume: 21
Issue: 3
Author(s): Karen K.Y. Leung, Joanna Y.L. Tung, Yan T.K. Lee, Stephanie Tsang and Kam L.E. Hon*
Affiliation:
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children’s Hospital,
Hong Kong, China
- Department of Paediatrics, CUHK Medical Centre, Chinese University of Hong Kong, ShaTin, Hong
Kong, China
Keywords:
Diabetes, ketoacidosis, pediatric, intravenous fluid, cerebral edema, insulin.
Abstract:
Background: Diabetic ketoacidosis (DKA) is a life-threatening complication in children
with diabetes mellitus. There are considerable differences in the management approaches for
DKA between different countries. One of the main areas of differences between guidelines is the
administration of fluid, with most guidelines adopting a restrictive approach. The British Society
of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to
fluid administration, which has sparked controversy among some paediatricians.
Objectives: The purpose of this article is to provide a narrative review on the management of
DKA.
Methods: A PubMed search was performed with clinical queries using the key term “diabetic ketoacidosis”.
The search strategy included randomized controlled trials, clinical trials, meta-analyses,
observational studies, guidelines, and reviews. The search was restricted to English literature
and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines.
Results: Selected international guidelines for DKA, namely International Society for Pediatric and
Adolescent Diabetes (ISPAD), National Institute for Health and Care Excellence (NICE), British
Society for Paediatric Endocrinology and Diabetes (BSPED), and South Thames Retrieval Service
(STRS) were reviewed. There are considerable differences in the management approaches for
DKA between different countries. One of the main areas of differences between guidelines is the
administration of fluid, with most guidelines adopting a restrictive approach. This is based on the
concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration.
However, recent new clinical studies suggest that there is no causal relationship between
intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology
updated its guideline in 2020 to adopt a more permissive approach to fluid administration,
which has sparked controversy among some paediatricians.
Conclusion: The management of DKA involves early recognition, accurate diagnosis, meticulous
fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal
function, and neurological status. There is still limited clinical evidence to support either a restrictive
or permissive approach in the fluid management of paediatric DKA patients. Clinicians
should exercise caution when applying different guidelines in their clinical practice, considering
the specific circumstances of individual paediatric patients.
