Question

Is DKA and juvenile diabetes the same? I know they both are type 1 diabetes but I don't get the difference between these two.

Answer 1

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic.

Causes

DKA happens when the signal from insulin in the body is so low that:

1. Glucose (blood sugar) can't go into cells to be used as a fuel source.
2. The liver makes a huge amount of blood sugar.
3. Fat is broken down too rapidly for the body to process.

The fat is broken down by the liver into a fuel called ketones. Ketones are normally produced when the body breaks down fat after a long time between meals. When ketones are produced too quickly and build up in the blood and urine, they can be toxic by making the blood acidic. This condition is known as ketoacidosis.

DKA is sometimes the first sign of type 1 diabetes in people who have not yet been diagnosed. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin shots, or surgery can lead to DKA in people with type 1 diabetes.

People with type 2 diabetes can also develop DKA, but it is less common and less severe. It is usually triggered by prolonged uncontrolled blood sugar, missing doses of medicines, or a severe illness or infection.

Symptoms

Common symptoms of DKA can include:

• Decreased alertness
• Deep, rapid breathing
• Dry skin and mouth
• Flushed face
• Frequent urination or thirst that lasts for a day or more
• Fruity-smelling breath
• Headache
• Muscle stiffness or aches
• Nausea and vomiting
• Stomach pain

Exams and Tests

Ketone testing may be used in type 1 diabetes to screen for early ketoacidosis. The ketone test is usually done using a urine sample or a blood sample.

Ketone testing is usually done when DKA is suspected:

• Most often, urine testing is done first.
• If the urine is positive for ketones, most often beta-hydroxybutyrate is measured in the blood. This is the most common ketone measured. The other main ketone is acetoacetate.

Other tests for ketoacidosis include:

• Arterial blood gas
• Basic metabolic panel, (a group of blood tests that measure your sodium and potassium levels, kidney function, and other chemicals and functions, including the anion gap)
• Blood glucose test
• Blood pressure measurement
• Osmolality blood test

Treatment

The goal of treatment is to correct the high blood sugar level with insulin. Another goal is to replace fluids lost through urination, loss of appetite, and vomiting if you have these symptoms.

If you have diabetes, it is likely your health care provider told you how to spot the warning signs of DKA. If you think you have DKA, test for ketones using urine strips. Some glucose meters can also measure blood ketones. If ketones are present, call your provider right away. DO NOT delay. Follow any instructions you are given.

It is likely that you will need to go to the hospital. There, you will receive insulin, fluids, and other treatment for DKA. Then providers will also search for and treat the cause of DKA, such as an infection.

Outlook (Prognosis)

Most people respond to treatment within 24 hours. Sometimes, it takes longer to recover.

If DKA is not treated, it can lead to severe illness or death.

Possible Complications

Health problems that may result from DKA include any of the following:

• Fluid buildup in the brain (cerebral edema)
• Heart stops working (cardiac arrest)
• Kidney failure

When to Contact a Medical Professional

DKA is often a medical emergency. Call your provider if you notice symptoms of DKA.

Go to the emergency room or call the local emergency number (such as 911) if you or a family member with diabetes has any of the following:

• Decreased consciousness
• Fruity breath
• Nausea and vomiting
• Trouble breathing

Prevention

If you have diabetes, learn to recognize the signs and symptoms of DKA. Know when to test for ketones, such as when you are sick.

If you use an insulin pump, check often to see that insulin is flowing through the tubing. Make sure the tube is not blocked, kinked or disconnected from the pump.

JUVENILE DIABETES

How does diabetes affect children and teens?

• Diabetes in children
• Symptoms
• Warning signs
• Complications
• Diagnosis
• Prevention

In 2017, the National Institutes of Health reported that 208,000 children and teens under 20 years had a diagnosis of either type 1 or type 2 diabetes in the United States.

Each year, they say, the prevalence of type 1 increases by 1.8 percent and type 2 by 4.8 percent.

From 2011 to 2012, 17,900 people under the age of 20 years received a diagnosis of type 1 diabetes, and 5,300 children aged 10 to 19 years received a diagnosis of type 2 diabetes.

Young people who develop diabetes have a higher risk of health challenges throughout their life.

Being able to recognize the signs and symptoms can help a child to get an early diagnosis, which in turn gives a chance of a better outcome.

Diabetes in children

Diabetes affects the body’s ability to use insulin. Rates among children are on the rise.

Type 1 and type 2 diabetes are different diseases, but they both affect the body’s use of insulin.

Type 1 diabetes in children, previously called juvenile diabetes, occurs when the pancreas is unable to produce insulin.

Without insulin, sugar cannot travel from the blood into the cells, and high blood sugar levels can result.

Treatment involves:

• lifelong insulin use and blood sugar monitoring
• diet and exercise management to help keep blood sugar levels within the target range

Type 1 often appears during childhood or adolescence, but it can start at any time.

Type 2 diabetes is less common in young children, but it can occur when insulin is not working properly. Without enough insulin, glucose can accumulate in the bloodstream.

People can often manage type 2 diabetes through:

• a change in diet
• more exercise
• maintaining a healthy weight

Sometimes the person will need medication.

The chance of getting type 2 diabetes increases as people get older, but children can also develop it.

Symptoms

Some symptoms are common to both types of diabetes.

Type 1

The most common symptoms of type 1 diabetes among children and adolescents include:

• increased thirst and urination
• hunger
• weight loss
• fatigue
• irritability
• fruity smell on the breath
• blurred vision

Girls might develop a yeast infection. Weight loss is often a common symptom before diagnosis.

Diabetes U.K. urge people to be aware of “4 Ts” in children:

• Toilet: Using the bathroom frequently, infants having heavier diapers, or bedwetting after being dry for some time
• Thirsty: Drinking more fluids than usual but being unable to quench thirst
• Tired: Feeling more tired than usual
• Thinner: Losing weight

This video provides more information on the 4 Ts:

Type 2

Symptoms of type 2 diabetes include:

• urinating more often, especially at night
• increased thirst
• tiredness
• unexplained weight loss
• itching around the genitals, possibly with a yeast infection
• slow healing of cuts or wounds
• blurred vision, as the eye’s lens becomes dry

Other signs of insulin resistance include:

• dark, velvety patches of skin, called acanthosis nigricans
• polycystic ovarian syndrome (PCOS)

Symptoms of type 1 diabetes in children tend to develop rapidly over a few weeks. Type 2 diabetes symptoms develop more slowly. It may take months or years to get a diagnosis.

Parents should take their child to the doctor if they notice any of the above symptoms.

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Warning signs

According to a 2012 survey from Diabetes U.K., only 9 percent of parents were able to identify the four main symptoms of type 1 diabetes. By 2013, this figure had increased to 14 percent.

Some children do not receive a diagnosis until their symptoms are already severe, and, in some cases, fatal.

Don’t miss the symptoms

Children and adolescents with diabetes usually experience four main symptoms, but many children will have only one or two. In some cases, they will show no signs.

If a child suddenly becomes more thirsty or tired or urinates more than usual, their parents may not consider diabetes a possibility.

Doctors too, since diabetes is less common among very young children, may attribute the symptoms to other, more common illnesses. For this reason, they may not diagnose diabetes at once.

It is important to be aware of possible signs and symptoms of diabetes in order to get a diagnosis and treatment as soon as possible.

Complications

One of the most serious consequences of undiagnosed type 1 diabetes is diabetic ketoacidosis (DKA).

Diabetic ketoacidosis (DKA)

Encouraging children to make healthful choices can reduce the risk of obesity and type 2 diabetes.

If a child does not receive a diagnosis of type 1 diabetes, or more rarely, type 2, they can develop DKA.

DKA is the leading cause of mortality in children with type 1 diabetes.

If insulin levels are very low, the body cannot use glucose for energy. Instead, it begins to break down fat for energy.

This leads to the production of chemicals called ketones, which can be toxic at high levels. A buildup of these chemicals causes DKA, where the body becomes acidic.

Early diagnosis and effective management of diabetes can prevent DKA, but this is not always possible.

A study of children aged 8 months to 16 years who had a diagnosis of type 1 diabetes found that, by the time children under the age of 2 received their diagnosis, 80 percent of them had already developed DKA.

Another investigation, published in 2008, found that among 335 children under the age of 17 with new-onset type 1 diabetes, the initial diagnosis was incorrect in more than 16 percent of cases.

Instead, they received the following diagnoses:

• respiratory system infection: 46.3 percent
• perineal candidiasis 16.6 percent
• gastroenteritis: 16.6 percent
• urinary tract infection: 11.1 percent
• stomatitis 11.1 percent
• appendicitis 3.7 percent

Researchers also found that DKA was more common among children with an incorrect, and therefore delayed, diagnosis of type 1 diabetes.

Type 2 diabetes complications

Without treatment, type 2 diabetes appears to progress faster in young people than in adults.

Younger people also seem to have a higher chance of complications, such as kidney and eye disease, earlier in life than children with type 1 diabetes.

There is also a greater risk of high blood pressure and high cholesterol levels, which raise a person’s risk for blood vessel disease.

Type 2 diabetes in children nearly always occurs with obesity, which may contribute to these higher risks. Because of this, the early detection of type 2 diabetes and attention to managing overweight in younger people is crucial.

This may include encouraging children to follow a healthful diet and get plenty of exercise.

Diagnosis

Any child with signs or symptoms of diabetes should see a doctor for screening.

This may consist of:

• a urine test to look for sugar in the urine
• a finger-prick blood test to check the child’s glucose level

The American Diabetes Association (ADA) recommend testing for children aged over 10 years who do not have symptoms of diabetes but who are overweight (over 85 percentile for body mass index or over 120 percent ideal weight for height) if they have any two of the following risk factors:

• family history of type 2 diabetes in a first- or second-degree relative
• high-risk ethnicity (Native American, African American, Latino, Asian American, or Pacific Islander)
• signs of insulin resistance
• if the mother had diabetes or gestational diabetes while pregnant with the child

The outcomes for children with type 1 and type 2 diabetes are improved greatly with early detection.

Prevention

It is not currently possible to prevent type 1 diabetes, but a child can take steps to reduce the chance of developing type 2 diabetes:

• Maintaining a healthy weight: Overweight children are at risk of developing type 2 diabetes, as they are more likely to have insulin resistance.
• Staying active: Keeping physically active reduces insulin resistance and also helps manage blood pressure.
• Limiting sugary food and drinks: Consuming lots of foods that are high in sugar can lead to weight gain. Eating a balanced, nutrient-rich diet, with plenty of vitamins, fiber and lean proteins, will lower the risk of type 2 diabetes.

Diabetic ketoacidosis results from a deficiency of circulating insulin and increased levels of the counter regulatory hormones: Glucagon, catecholamines, cortisol and growth hormone. Relative insulin deficiency occurs when the concentrations of counter-regulatory hormones markedly increase in response to stress, infection or insufficient insulin.[1] The combination of absolute or relative insulin deficiency and high counter-regulatory hormone concentrations results in an accelerated catabolic state with increased glucose production by the liver and kidney (via glycogenolysis and gluconeogenesis), and simultaneously impaired peripheral glucose utilization, which combine to result in hyperglycemia and hyperosmolarity; increased lipolysis and ketogenesis leading to ketonemia and metabolic acidosis. Hyperglycemia together with hyperketonemia cause osmotic diuresis, dehydration, and obligatory loss of electrolytes. Lactic acidosis from hypoperfusion or sepsis contributes to the acidosis. Thus DKA leads to a vicious life-threatening cycle of events ranging from hyperglycemia, hyperketonemia, osmotic diuresis, severe vomiting, dehydration, and subsequently obligatory loss of electrolytes, greater stress hormone production, and thus more severe insulin resistance. If not interrupted by exogenous insulin, fluid and electrolyte therapy, it would lead to fatal dehydration, hypoperfusion, and ultimately metabolic acidosis.

Ideally, DKA can be managed in any hospital/private unit or in a pediatric inpatient ward in case of children, with adequately trained nursing and medical personnel where lab services are available 24 h throughout the week. However, an intensive care unit (ICU)/pediatric ICU is required for children <2 years of age and in case of severe DKA characterized by compromised circulation, coma, and an increased risk of cerebral edema.

Diagnosis of DKA should be done accurately due to a possibility of a confusing clinical picture such as dehydration, meningitis, acute abdomen, pneumonia, etc. Emergency assessment can be done by following the general guidelines of Pediatric Advanced Life Support. Immediate measures are a brief history and quick diagnosis, which is essential. Initial immediate assessment or investigation includes evaluation of the severity of dehydration, level of consciousness through Glasgow Coma Scale, body weight and height if the person is mobile. Baseline investigations involve the measurement of BG levels, beta-hydroxybutyric acid, serum electrolytes and renal functions. During physical examination, physician may look for signs of dehydration, acidosis, and electrolyte imbalance, including shock, hypotension, acidotic breathing, central nervous system (CNS) status, etc.

The essential principles of DKA treatment include careful replacement of fluid deficits, correction of dehydration, correction of acidosis and hyperglycemia via insulin administration, maintenance of glucose levels at a normal range, correction of electrolyte imbalance and treatment of any precipitating cause. Successful management of DKA requires constant clinical and biochemical monitoring and timely adjustment of insulin dose, fluid and electrolyte status. Antibiotics, oxygen, and cardiac monitoring can be used if required.

Studies have shown that severe acidosis can be corrected by fluid and insulin replacement. Insulin metabolizes ketoacids and stops further production. However, HCO3 administration is shown to have no clinical benefit and may cause paradoxical CNS acidosis. Moreover, rapid correction may cause hypokalemia.

Fluid therapy is initially used for the treatment of DKA, followed by insulin therapy if required. The main objectives of fluid therapy are: Restoration of circulating volume, replacement of electrolytes, improvement of glomerular filtration and clearance of glucose and ketones from the blood. Before starting fluid therapy, the physician should check if the child was treated earlier before the current admission. During fluid therapy, water and salt deficit are replaced using 0.9% normal saline and a 10-20 mL/kg normal bolus may also be used for approximately 1-2 h. If the patient is in shock, several boluses may be given. Subsequent therapy is used for deficit replacement. Normal saline or Ringer lactate is used over a period of 4-6 h. Consequently, maintenance fluids are used. Usually, half normal saline (0.45%) with potassium chloride is given depending on the state of hydration and electrolyte levels. Fluid therapy is usually planned for a period of 48 h. However, a child may improve earlier than 48 h. Normal circulation is often achieved in 12 ± 6 h. When the child becomes stable, fluids can be given orally, and subsequently insulin can be given subcutaneously. In cases of mild DKA, no bolus is needed. The main principle of fluid therapy is to never infuse fluids more than 1.5-2 times the normal daily requirement. Moreover, constant monitoring and assessment of hydration is absolutely essential.

Potassium replacement therapy is used when the total body potassium deficit is nearly ~3-6 mmol/kg. If the patient is hypokalemic, start potassium replacement at the time of initial volume expansion and before starting insulin therapy. Otherwise, start replacing potassium after initial volume expansion and concurrent with starting insulin therapy. If the patient is hyperkalemic, defer potassium replacement therapy until urine output is documented.

In DKA, rehydration alone reduces BG. Insulin therapy is used to restore normal metabolism, to suppress lipolysis, ketogenesis and normalize BG. A low dose of intravenous (IV), insulin infusion is considered to be safe and effective. Insulin infusion should be initiated 1-2 h after starting fluid replacement therapy; that is after the patient has received initial volume expansion. The dose of insulin should usually remain at 0.05-0.1 unit/kg/h, at least until resolution of DKA viz. pH <7.30, serum HCO3 levels <15 mmol/L and beta-hydroxybutyrate levels <1 mmol/L. No IV bolus is required to be given because it may worsen hypokalemia or precipitate cerebral edema. As long as possible, the physician should minimize the time on IV insulin infusion, and optimal doses of insulin should be used to avoid severe hypokalemia. BG should be gradually lowered at a rate of 50-100 mg/dL. When BG level falls to 250 mg/dL, 5% glucose is added to IV fluid. Furthermore, 10% or 12.5% glucose may be needed while continuing insulin infusion to correct metabolic acidosis. Furthermore, 2 hourly subcutaneous or intramuscular short-acting insulin may also be used if facilities for IV infusion are not available.

However, for successful DKA management, meticulous monitoring of the patient's clinical and biochemical response using a flow chart is essential. Neurological observations, for warning signs and symptoms of cerebral edema, and capillary BG concentration should be measured on an hourly basis. Every 2-4 h serum electrolytes, blood gases, and beta-hydroxybutyrate should be measured. The physician should look for any warning signs of cerebral edema viz. restlessness, irritability, increased drowsiness, cranial nerve palsies, abnormal pupillary responses, headache, slow heart rate (HR), rising blood pressure (BP) or recurrence of vomiting.