Pediatric Diabetic Ketoacidosis

In a child or adolescent with diabetes symptoms, vomiting, abdominal pain, hyperventilation, dehydration, or altered consciousness, measure point-of-care glucose and blood β-hydroxybutyrate promptly. DKA requires hyperglycemia with plasma glucose >200 mg/dL, acidosis defined by pH <7.3 or bicarbonate <15 mmol/L, and β-hydroxybutyrate >3 mmol/L or urine ketones at least 2+.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE DKA can occur with normal glucose in patients already taking insulin; symptoms plus elevated ketones warrant urgent hospital assessment regardless of glucose.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

At diagnosis obtain glucose, blood ketones, pH and pCO2, bicarbonate, sodium, potassium, urea, creatinine, and body weight; document mental status, perfusion, vital signs, respiratory pattern, emesis, and clinical dehydration.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE Assess for infection or another precipitant when fever or hypothermia, hypotension, refractory acidosis, or lactic acidosis is present.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

For clinically dehydrated children without shock, give 0.9% sodium chloride 10 mL/kg intravenously over 30 minutes. Reassess perfusion before considering a second 10 mL/kg bolus and discuss additional boluses with the senior pediatric clinician. For hypotensive shock with a weak, thready pulse, give 10 mL/kg 0.9% sodium chloride promptly.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

Calculate the first 48-hour fluid plan using estimated deficit plus maintenance. Assume 5% dehydration in mild-to-moderate DKA with pH ≥7.1 and 10% dehydration in severe DKA with pH <7.1; replace the deficit evenly over 48 hours. Use Holliday-Segar maintenance, capped at 75 kg, and subtract non-shock initial boluses from the estimated deficit.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

Begin a soluble insulin infusion 1-2 hours after fluid therapy begins at 0.05-0.1 units/kg/hour; do not give an IV insulin bolus. Disconnect an insulin pump when IV insulin begins. If hypokalemia is present initially, provide potassium before starting insulin; if previously using basal insulin, continuing subcutaneous basal insulin can be considered in consultation with a diabetes specialist.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

Record capillary glucose, vital signs, fluid input/output, and modified Glasgow Coma Scale at least hourly. In children <2 years and those with severe DKA, assess consciousness and heart rate every 30 minutes. Use continuous ECG monitoring during IV therapy to identify hypokalemia-associated abnormalities.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE Obtain laboratory glucose, pH/pCO2, sodium, potassium, urea, and β-hydroxybutyrate at 2 hours after treatment begins and at least every 4 hours thereafter.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

A physician should perform direct reassessment at diagnosis and at least every 4 hours, more frequently for severe DKA, age <2 years, or clinical concern. At each review, reassess neurologic status, vital signs, laboratory data, ECG, and cumulative fluid balance.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

If β-hydroxybutyrate is not declining by 6-8 hours, consider increasing insulin to 0.1 units/kg/hour or higher. Do not transition from IV to subcutaneous insulin until ketosis is resolving, the patient is alert, and oral fluids are tolerated without nausea or vomiting.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

Before discharge after DKA in established diabetes, review the likely precipitant directly with the child or adolescent and caregivers. Insulin omission, lack of uninterrupted insulin access, intercurrent illness, and psychosocial stressors are major recurrence risks.PubMed+1PubMedType 1 Diabetes in Children and Adolescents - PMC - NIHnice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE The diabetes team should provide individualized written sick-day instructions covering glucose and blood ketone monitoring, insulin adjustment, fluid and food intake, and thresholds for urgent contact or evaluation; revisit this plan at least annually.nice org uknice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE

Provide blood β-hydroxybutyrate strips and a meter, and advise ketone testing during illness or hyperglycemia. Blood ketone monitoring has practical advantages in young children and may identify metabolic deterioration earlier than urine testing.PubMedPubMedType 1 Diabetes in Children and Adolescents - PMC - NIH

Assess recurrent DKA for nonadherence sensitively and evaluate psychosocial well-being. Pediatric diabetes care should include access to multidisciplinary education, nutrition, mental health, and 24-hour clinical advice, with ongoing family involvement that is developmentally appropriate.PubMed+2PubMed14. Children and Adolescents: Standards of Care in Diabetes ...PubMedType 1 Diabetes in Children and Adolescents - PMC - NIHnice org ukRecommendations | Diabetes (type 1 and type 2) in children and young people: diagnosis and management | Guidance | NICE