With the improvement in medical care, Type 1 diabetes can be easily recognized if it is considered by the physician during the assessment of a sick child. The availability of biochemical testing will help the primary care provider to determine the severity of the disease and direct the management of the patient. However, since very young child do not always show clear symptoms, more time has to be be spent to elicit the important information from parents or caregivers. This approach will help to make the diagnosis before any serious metabolic derangements take place.
Previous studies from different areas of Saudi Arabia reported higher rates of DKA at the onset of the disease ranging from 55-77% compared to our study (46.7%).[16
The lower rates of DKA noticed in the current study compared to the previous reports may be due to better awareness of the disease by the community and easy access to health care.
In the present study, it was found that younger children presented later to the hospital than older children. This might be due to the absence – in most cases – of the classical symptoms of polyuria, polydipsia and weight loss noticeable in older children. Moreover, abdominal pain was less apparent in young children than older ones. This delay contributed to the severity of the disease in this group as shown by the higher frequency of DKA compared to older children (31.4% compared to 15.3) respectively.
It is to be noted here that, despite presenting a more severe disease the younger children had a significantly lower HbA1c% denoting a shorter period of uncontrolled glycemia, compared to the older children, thus compounding the insidious onset of DKA in younger children
It is well known that T1DM in children, often presents with ketosis as the metabolic changes are rapid in this type of diabetes.[17
] In the present study, almost a third (31.4%) of the younger patients presented with ketosis, which was double that of the older children (15.3%).
The lack of awareness of the parents as well as the nonspecific early signs and symptoms might be responsible for this discrepancy between the two groups.[7
] The longer duration of signs and symptoms as well as the profound metabolic disturbances, and the rapid loss of more fluid by young children resulted in the significantly higher number of young children who showed signs of dehydration and ketoacidosis.[18
URT infections are known to be one of the triggers of ketoacidosis in diabetic patients.[19
] It was a significant presenting finding in the younger children compared to the older group in our study. This might sometimes mask and delay the diagnosis especially at primary health care centers. The biochemical test results show that the older children had a significantly higher RBS. However, both figures, in fact, are so high that the difference between them is of little consequence even if statistically significant.
It has been also noted that with the onset of dehydration in diabetic children, the glumerular filtration rate (GFR) decreases resulting in decreased clearance of glucose and ketones from the circulation. This increases the likelihood of DKA.[20
] The acidosis, however, as witnessed by the significantly lower pH and higher ABE in the young children especially when compounded by a significantly higher degree of dehydration carries a special risk of serious complications.
Although this study has a limitation of not including all cases in the region, as some were treated in other institutions, it can be considered an indicator of the clinical picture of children affected with T1DM.
Early recognition of the condition in young children should be sought by improving the awareness of the community as well as the primary care physicians to the possibility of T1DM in the high risk group especially after prolonged vague symptoms of infection. For known diabetics, an early biochemical testing might be of help towards early diagnosis.