Diabetic ketoacidosis in children continues to be an important cause of morbidity and mortality, especially in developing economies as a result of
malnutrition, a high rate of
infections, and delay in seeking timely medical care.
Malnutrition also increases the risk of
diabetic ketoacidosis-related complications. The objective of this study was to assess the nutritional status of patients presenting with
diabetic ketoacidosis and correlate it with the incidence of complications at presentation and those encountered during the course of illness.
DESIGN: Prospective study.
SETTING: Pediatric emergency and intensive care units, Advanced Pediatrics Centre, PGIMER, Chandigarh, India.
PATIENTS: Thirty-three children between 1 month and 12 yrs of age presenting with
diabetic ketoacidosis between July 2008 and June 2009 were enrolled consecutively and assessed for nutritional status by anthropometric parameters (
body weight, crown-heel length/height, mid-upper arm circumference, triceps and subscapular skin fold thicknesses), biochemical parameters (
serum albumin,
zinc,
magnesium,
vitamin A levels), and preillness dietary history (by pretested Food Frequency Questionnaire). Patients were classified as malnourished or normally nourished based on the weight for age criteria matched for Indian standards. The incidence of complications (
electrolyte imbalances,
hypoglycemia,
sepsis,
cerebral edema, etc.) and outcome in terms of survival or death in both the groups were compared with Student's t-test for parametric data, Mann-Whitney U test for nonparametric data, and chi-square test for categorical variables.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Anthropometric assessment showed that 11 of 33 (33.3%) were malnourished. Preillness dietary history revealed that 16 (48.5%) were calorie- and
protein-deficient (known diabetic n = 7; new onset n = 9), whereas 11 (33.3%) were only calorie-deficient (known diabetic n = 2).
Hypoalbuminemia was seen in 21 (63.6%), hypovitaminosis A in eight (24.2%), and low
zinc levels in three (9%). The malnourished and normally nourished groups were similar with respect to demographics, precipitating factors, severity of
diabetic ketoacidosis, treatment received, and outcome. However, the incidence and severity of
therapy-related
hypokalemia (100% vs. 72.7%; p = .05) and
hypoglycemia (63.6 vs. 13.6%; p = .004) were significantly higher in the former as compared with the latter. The mean ± SD admission serum
potassium levels were similar in both the groups (3.4 ± 0.8 mEq/L in the malnourished vs. 3.5 ± 0.7 mEq/L in the normally nourished) with the malnourished group showing a significant fall at 6 hrs after start the of
diabetic ketoacidosis protocol (2.8 ± 0.8 mEq/L vs. 3.6 ± 0.7 mEq/L; p = .033), although the mean rate and dose of
insulin infusion were similar. The fall in
blood glucose (mean ± SD mg/dL) at 12, 24, and 36 hrs after onset of the
diabetic ketoacidosis protocol was also significantly greater in the malnourished group as compared with the normally nourished
diabetic ketoacidosis (195 ± 69.1 and 272.61 ± 96.3, p = .02; 171 ± 58.5 and 257 ± 96.3, p = .05; and 153.75 ± 49.6 and 241.71 ± 76.3, p = .04, respectively). The incidence of
hypophosphatemia, hypomagnesemia,
cerebral edema,
renal failure,
sepsis, and
septic shock was similar in both the groups. There were two deaths, both resulting from complicating
cerebral edema and
renal failure and unrelated to the nutritional status of the patients.
CONCLUSIONS: