University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In children with type I diabetes, are there modifiable risk factors that can predict which patients are at higher risk for acute complications?

Clinical Bottom Lines

1. Incidence of DKA increases with age in girls. However, age in girls is inversely related to the incidence of severe hypoglycemia.
2. Factors increasing the risk of DKA in children older than 13 include higher insulin dose, increased HbA1c, underinsurance, and psychiatric disorders in girls. In children under 13 years-old, only higher insulin dose and HbA1c are risk factors for DKA.
3. Factors increasing the risk of severe hypoglycemia in children older than 13 include longer duration of diabetes, higher HbA1c, underinsurance and psychiatric disorders. In children under 13 years-old, only increased duration of disease and underinsurance increase risk.

Summary of Key Evidence

1. This study was designed as a cohort of 1243 diabetic children, ages 0 to 19, looking at risk factors associated with DKA and severe hypoglycemia.¹
2. Inclusion criteria required diagnosis of diabetes with continuous insulin treatment, ages 0 to 19 years, resident of the Denver metropolitan area, and at least one outpatient visit to the Barbara Davis Center for Childhood Diabetes.
3. Results:

   Risk factors for DKA Age < 13	Risk factors for DKA Age > 13
   - Increased HbA1C [RR 1.68 per 1% increase] - Increased insulin dose [RR 1.4 per 0.2 units/kg/day increase]	- Increased HbA1c [RR 1.43 per 1% increase] - Increased insulin dose [RR 1.13 per 0.2 units/kg/day increase] - Underinsurance [p<0.001] - Psychiatric disorders in girls [RR 3.22]
   Risk factors for Recurrent DKA Age < 13	Risk factors for Recurrent DKA Age > 13
   - Increased HbA1C [OR 1.81 per 1% increase] - Increased insulin dose [OR 1.62 per 0.2 units/kg/day increase]	- Increased HbA1c [OR 1.64 per 1% increase] - Increased insulin dose [OR 1.63 per 0.2 units/kg/day increase] - Underinsurance [p<0.002] - Psychiatric disorders [p<0.001]
   Risk factors for Severe Hypoglycemia Age < 13	Risk factors for Severe Hypoglycemia Age > 13
   - Increased duration of disease [RR 1.39 per 5-year increment] - Underinsurance [p<0.008]	- Increased duration of disease [RR 1.34 per 5-year increment] - Underinsurance [p<0.005] - Decreased HbA1c [RR 1.22 per 1% decrease] - Psychiatric disorders [RR 1.56]
   Risk factors for Recurrent Severe Hypoglycemia; Age < 13	Risk factors for Recurrent Severe Hypoglycemia; Age > 13
   - None	- Increased duration of disease [RR 1.54 per 5-year increment] - Underinsurance [p<0.03]

   
   

Additional Comments

• Problematic aspects to this study include a 13.8% loss to follow up and restriction of population to the Denver Metropolitan area with at least one visit to the Barbara Davis Center for Childhood Diabetes.
• Advantageous aspects, on the other hand, include a cohort study, large sample size, exclusion of complications following the first year of diagnosis, clearly defined outcome measures, and computerized database for information collection.
• Results of this study allow practitioners to identify those patients at high risk for acute complications and intervene on modifiable risk factors when possible.
• Perhaps further studies should be done looking at different interventions with patient found to have risk factors that impact the incidence of DKA and severe hypoglycemia.

Citation

1. Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes. JAMA 2002;287:2511-8.

CAT Author: Jennifer Vredeveld, MD

CAT Appraisers: John Frohna, MD

Date appraised: September 6, 2006