ESPE Yearbook of Paediatric Endocrinology

Brief summary: Since 2014, children with DKA have been managed on the general ward (instead of the intensive care unit [ICU]) and with SC insulin (instead of IV insulin) at G Kuppuswamy Naidu Memorial Hospital in Coimbatore, India. This retrospective study compares the cost and outcomes of IV (2013–2014) and SC insulin treatment (2017).

In high-income countries (HICs), DKA management commonly includes IV insulin. The 2022 ISPAD Clinical Practice Consensus Guidelines primarily recommend IV insulin infusion, although SC insulin can be considered in children with minimal dehydration who are tolerating oral fluids (1). Admission to ICU should be considered for severe DKA (pH < 7.1). In the Chapter for low- and middle-income countries (LMICs), SC insulin is suggested if IV insulin cannot be safely administered (2).

In the present study, 50 episodes of DKA were treated with either IV (n=21) or SC insulin (n=29). The time to recovery was shorter (17 hours) in the SC insulin group compared to the IV insulin group (35 hours). There were no cases of cerebral edema or hypoglycemia and no fatal outcomes during the study period. The overall cost of the SC insulin approach was also more than 3 times less than the IV insulin approach. One limitation is that the group of children receiving IV insulin had a slightly more severe metabolic status compared to the group of children receiving SC insulin. Nevertheless, these results have important practical implications. First, in resource-limited settings, best use of the available resources is a priority, in particular when 2 different approaches lead to similar outcomes. Second, the majority of the DKA guidelines are developed based on data published in HICs.

It is suggested that ongoing and future training programs in pediatric diabetology offered in LMICs promote approaches that are appropriate for the level of care of a given region. At the end of the article, the authors remind the reader of a very important point: independently from the protocol itself, the best results are achieved if the medical and nursing staff have developed expertise in the management of DKA in children and if the patients are closely monitored while insulin and rehydration are provided. Indeed, dedication of the health professionals likely remains the most important determinant of treatment success.

References: 1. Glaser N, Fritsch M, Priyambada L, Rewers, A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022;23:835–856. doi: 10.1111/pedi.13406. 2. Virmani A, Brink SJ, Middlehurst A, Mohsin F, Giraudo F, Sarda A, Ajmal S, von Oettingen JE, Pillay K, Likitmaskul S, Calliari LE, Craig ME. ISPAD Clinical Practice Consensus Guidelines 2022: Management of the child, adolescent, and young adult with diabetes in limited resource settings. Pediatr Diabetes 2022;23:1529–1551. DOI: 10.1111/pedi.13456.