ISSN: 2320-5407 Int. J. Adv. Res.

13(01), 772-780

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/20256
DOI URL: http://dx.doi.org/10.21474/IJAR01/20256

RESEARCH ARTICLE
DIABETIC KETOACIDOSIS IN PEDIATRICPATIENTS: A 10-YEAR RETROSPECTIVE STUDY
COMPARING PREVIOUSLY DIAGNOSED AND NEWLY DIAGNOSED CASES AT PRESENTATION

Lamia El Fehmi1,2,3, Manal Merbouh1,2,3, Houssameddine Sarhaoui1,2,3, Youssef Mouaffak1,2,3 and Said
Younous1,2,3
1. Pediatric Intensive Care Unit, Mother and Child Hospital, Mohammed VI University Hospital Center of
Marrakech, Morocco.
2. Faculty of Medicine and Pharmacy, Cadi Ayyad University Marrakech, Morocco.
3. Childhood Health and Development Research Laboratory, Faculty of Medicine and Pharmacy, Cadi Ayyad
University Marrakech, Morocco.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background:Diabetic ketoacidosis (DKA) represents a severe
Received: 16 November 2024 metabolic disorder associated with diabetes mellitus (DM), posing a
Final Accepted: 18 December 2024 heightened risk of morbidity and mortality in children. This research
Published: January 2025 aims to evaluate the prevalence of DKA in pediatric patients and to
explore its clinical characteristics and biological consequences during
Key words:-
Diabetic Ketoacidosis, Children, Type 1 intensive care management.
Diabetes Mellitus (T1DM) Patients and Methods: A retrospective study was carried out on
children younger than 15 years who were hospitalized for DKA in the
pediatric intensive care unit of Mohammed VI University Hospital,
Marrakech, Morocco, spanning the period from January 2010 to
December 2020. A comparative analysis was performed between two
groups: patients with a known history of diabetes and those
experiencing DKA as the initial presentation of diabetes.
Results:Over a 10-year period, 240 cases of DKA were identified
among 8,222 admissions, representing 2.91% of total admissions. The
mean age of patients was 7.49 ± 4.44 years, with a higher prevalence
observed in children over 10 years old. The most common clinical
signs included polyuria-polydipsia syndrome, Kussmaul breathing,
vomiting, and altered consciousness. The most severe symptoms were
observed in children with newly diagnosed type 1 diabetes mellitus
(T1DM). The majority of patients had a favourable outcome. However,
20.6% of cases experienced complications, and one death was
recorded.
Discussion:This study highlights the significant burden of DKA in
pediatric patients, especially among those newly diagnosed with
T1DM. The high prevalence of infections as a triggering factor
emphasizes the need for improved infection management in diabetic
children. Prompt recognition and appropriate management play a key
role in mitigating the morbidity and mortality linked to DKA.
Conclusion:DKA remains a severe complication of pediatric diabetes,
with significant risks of serious consequences. Raising awareness
among healthcare providers, facilitating early detection, and adopting a

Corresponding Author:-Lamia El Fehmi 772

Address:-Pediatric Intensive Care Unit, Mother and Child Hospital, Mohammed VI
University Hospital Center of Marrakech, Morocco.
ISSN: 2320-5407 Int. J. Adv. Res. 13(01), 772-780

comprehensive approach to management are fundamental for

enhancing clinical outcomes and minimizing complications.

Copyright, IJAR, 2025,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:
Diabetic ketoacidosis (DKA) is a severe metabolic complication of diabetes mellitus (DM) that significantly
increases morbidity and mortality risks, particularly in children1. DKA is predominantly observed in newly
diagnosed cases of type 1 diabetes mellitus (T1DM), though it may also manifest in type 2 diabetes mellitus
(T2DM), albeit at a lower frequency2.DKA arises as an acute condition resulting from either partial or complete
insulin deficiency, triggering hyperglycaemia and osmotic diuresis.In the absence of insulin, cells use lipids instead
of glucose as a source of energy and leads to ketone body accumulation or ketogenesis.All these processes, lead to
dehydration and metabolic acidosis3-4.

Over the past few decades, there has been a notable global rise in the incidence of T1DM5. In Morocco, we have
limited epidemiological data concerning diabetic children.In 2021 in Morocco, T1DM in young people under 19
years of age was estimated at 43.3 thousand, with an annual increase of 5.1 thousand 6.

In developing countries, DKA-related mortality in children is higher than in western countries. This is due to the
lack of information among parents and healthcare professionals about the early symptoms of T1DM. Also, difficult
access to healthcare and poor socio-economic conditions delay diagnosis of T1DM and increase mortality of
DKA.The severity of DKA is related to hydro-electrolyticdisorders and cerebral oedema which occurs in 0.3% to
0,9% of cases and accounts for 21 to 24% of all deaths linked to DKA , not to mention the permanent neurocognitive
sequelae that can results3-7.

Aim of the study:

Given the importance of this public health problem, this study aims to assess the prevalence of DKA in our
population, examine its clinical characteristics and laboratory findings in pediatric intensive care cases, and analyze
complications following the implementation of a standardized management protocol.

Patients and Methods:

This study employed a retrospective design and was conducted in the pediatric intensive care unit of Mohammed VI
University Hospital in Marrakech, Morocco, spanning the period from January 2010 to December 2020.This study
included children younger than 15 years diagnosed with DKA, characterized by hyperglycaemia (≥ 2 g/L), ketonuria
(≥ 2 crosses on urine dipstick) or positive ketonemia (≥ 3 mmol/L), and an arterial pH below 7.3 or bicarbonate
levels under 18 mmol/L.

DKA was classified based on arterial blood gas analysis according to the severity of acidosis:
 Mild DKA: pH <7.3 or bicarbonates<18 mmol/L
 Moderate DKA: pH <7.2 or bicarbonates <10 mmol/L
 Severe DKA: pH <7.1 or bicarbonates<5 mmol/L.

The Kidney Disease Improving Global Outcomes (KDIGO) criteria were applied to identify cases of renal failure:
 Stage1: Increased serum creatinine x 1.5 – 1.9 baseline
 Stage2: Increased serum creatinine x 2 – 2.9 baseline
 Stage 3: Increased serum creatinine ≥x3baselineor initiating renal replacement therapy

Cases of isolated hyperglycaemia with no other clinical or biological signs, essentially the presence of ketonuria or
ketonemia, as well as incomplete or untraceable records, were excluded from the study.

The management of all DKA cases in this study followed the guidelines established by the International Society for
Paediatric and Adolescent Diabetes (ISPAD) 3.

Medical records were reviewed and categorized into five principal themes: epidemiological characteristics
(including age, gender, socio-economic background, and origin), clinical and paraclinical findings (symptoms and

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laboratory results), triggering factors, therapeutic interventions, and patient outcomes. Patients were classified into
two categories: those with a prior diagnosis of diabetes who developed DKA, and those experiencing DKA as the
first manifestation of diabetes. Data analysis was performed using Microsoft Excel® and SPSS Statistics for
Windows, Version 25. Continuous variables (e.g., age, symptom duration, venous glycaemia, and natremia) were
reported as mean ± standard deviation (Mean ± SD). Qualitative variables were presented as percentages or
frequencies. Comparative analyses of proportions were conducted using Pearson’s χ2-test or Fisher’s exact test,
while the independent samples t-test was employed for mean comparisons. Statistical significance was set at a 5%
threshold.

Ethical approval for this study was granted by the Institutional Ethics Committee of the Faculty of Medicine at Cadi
Ayyad University, Marrakech. Writteninformed consent wasobtainedfrom parents or legalguardians.

Epidemiology:
Over 10 years, 240 cases of DKA were observed among 8222 admissions corresponding to 2.91% of all admissions.
Of the 240 cases of DKA, 233 were included while 7 cases were excluded because of lack of records.

The average age of our patients was 7,49 ±4,44 years. 134 females (57,51%) and 99 males (42,48%) were affected.
125 children (53,64%) were from rural areas and 108(46,35%) from urban areas. It should be noted that 30,04% of
the children had visited at least 2 health institutions before being admitted to thepediatric intensive care unit (See
Table 1).

Table 1: Epidemiological characteristics of patients with DKA.

Characteristics Inaugural DM Known T1DM Total P-value
Age (years) - mean ± SD 5,11 ± 3,25 12,52 ± 1,26 7,49 ±4,44 < 0,001
Gender:
 Female 85 (36,48%) 49 (21,03%) 134 (57,51%)
 Male 0,063
73 (31,33%) 26 (11,15%) 99 (42,48%)
Origin:
 Urbain 84 (36,05%) 41 (17,59%) 108 (46,35%)
 Rural 0,830
74 (31,75%) 34 (14,59%) 125 (53,64%)
Socio-economiclevel :
 Medium 99 (42,48%) 41 (17,59%) 140 (60,08%)
 Low 0,246
49 (21,03%) 34 (14,59%) 83 (35,62%)

There was a peak in the frequency of cases among children aged over 10 years who accounted for 37.34% of cases
(n=87).In this age group, only 17 children presented with DKA for the first time, whereas 70 children were already
known to have T1DM. The second most affected group consisted of children younger than 5 years, accounting for
35.62% of cases (n=83), with all instances being inaugural DKA episodes. A statistically significant p-value
(<0.001) indicated that younger age is a risk factor for first-onset DKA (See Figure 1). Overall, inaugural DKA was
observed in 158 cases (67.81%), while all known diabetes cases corresponded to T1DM (n=75; 33.19%).

Clinical and paraclinical Data:

The mean time from symptom onset to hospital admission was 2.95 ± 1.27 days, with delays ranging from a
minimum of 1 day to a maximum of 7 days. The presentation symptoms in our patientswere:Polyuria-polydipsia
syndrome in 219 of cases (93.99%), Kussmaul dyspnoeain 198 of cases (84.98%), vomiting in 175 of cases
(75.10%), alertness disorders in 154 of cases (66.09%), abdominal pain in 137 of cases (58.80%), weight loss in
135of cases (57.93%), visual disordersin 3 cases (1.29%), and respiratory failure in 2 cases (0.86%). A significant
variation was observed between the two groups regarding symptom presentation and duration prior to
hospitalisation. Patients experiencing DKA for the first time had a prolonged delay before admission (p-value <
0.001) and exhibited more severe clinical manifestations compared to those with pre-existing diabetes (See Table 2).

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All the gas measurements taken showed a metabolic acidosis with a drop in bicarbonates. The average Ph was 7.1
with an extreme value of 6,82. Of the cases studied 48,06% showed moderate acidosis, there were also 28,32% of
mild acidosis, and 23.6% of severe acidosis.

Patients in our study had a mean kaliemia of 4,70±1,38meq/l with a tendency to hyperkalaemia (K+≥5) in 84 cases
(36.05%) versus 45 cases (19.31%)of hypokalaemia (K+<3.5)

Based on the KDIGO classification, acute kidney injury (AKI) was identified in 17 cases, accounting for 7.3% of the
study population. Among these, 5 cases (29.42%) were classified as stage 1, 10 cases (58.82%) as stage 2, and 2
cases (11.76%) as stage 3, with one patient requiring renal replacement therapy (RRT). Compared to children with
pre-existing diabetes, those experiencing their first episode of DKA exhibited significantly higher glycaemia levels
(p-value < 0.001), more severe metabolic acidosis (p-value ≤ 0.001), and increased osmolarity (p-value < 0.001)
(See Table 2).

All our patients, had undergone: CRP, blood culture and urine cytobacteriological examination (UCBE) as a matter
of course. The mean CRP in our population was 18.87±7.28 mg/l with 139 cases of elevated CRP representing
59.66% of the cases studied. Sepsis was diagnosed in 16 cases (6.87%). The most frequent germs were
staphylococcus (n=13) and Klebsiella pneumoniae (n=2). UCBE tests revealed 26 cases of urinary tract infections.

We also systematically performed chest X-rays, which showed 18 pathological cases (7.72%) with 16 cases of
pneumonia and a bronchial syndrome in 2 cases. Chest X-rays were particularly useful during the global COVID-19
pandemic for detecting interstitial syndrome. In this period, all respiratory polymerase chain reaction tests (PCR) for
SARS-COV2 (n=24) were negative. Thus, we did not detect any cases of DKA triggered by SARS-COV 2 infection
in this period.

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Table 2:Comparison of clinical and biochemical profiles between newly diagnosed and known T1DM patients:
Characteristics Inaugural DKA Known DM Total p-value
Days of symptoms-mean±SD 3,40±1,24 2,01±0,69 2.95 ±1,27 < 0,001
Polyuria-polydipsia syndromeN(%) 149 (63,98%) 70 (30,04%) 219 (93,99%) 0,773
Kussmaul dyspneaN(%) 150 (64,37%) 48 (20,60%) 198 (84,97%) < 0,001
VomitingN(%) 108 (46,35%) 67 (28,75%) 175 (75,10%) 0,001
Alertness disordersN(%) 123 (52,78%) 31 (13,30%) 154 (66,09%) < 0,001
Abdominal painN(%) 98 (42,06%) 39 (16,73%) 137 (58,79%) 0,118
Weight loss N(%) 123 (52,78%) 12 (5,15%) 135 (57,93%) < 0,001
Glycemia (g/dl) - Mean ±SD 4,75±0,74 3,73 ± 0,96 4,42 ± 0,94 < 0,001
Kalemia (meq/l) - Mean ±SD 4,70 ±1,47 4,71 ±1,19 4,70 ± 1,38 0,956
Natremia (meq/l) - Mean ±SD 135,72 ± 8,56 139,84 ± 8,52 136,84 ± 8,52 0,030
Bicarbonates (mmol/L) - Mean ± SD 6,84 ±2,34 10,77 ± 2,62 8,11 ± 3,04 < 0,001
Osmolality (mOsmol/l) - Mean ± SD 300,68 ±6,1 297,97 ± 7,06 299,81 ± 6,54 < 0,001
Days of hospital stay - Mean ± SD 3,52 ±1,05 1,82 ± 0,76 2.97 ± 1,25 < 0,001

Triggering factors:
Infections topped the list of triggers of DKA in 135 cases (57.94%). Figure 2 summarises the precipitating factors of
DKA in our study:

Management:
Therecommendations of ISPAD are based on two main components: rehydration and insulinotherapy3.In this study,
all patients underwent intravenous fluid administration prior to the initiation of insulin therapy.

We started rehydration with 0.9% isotonic sodium solution to replace the fluid deficit. Rehydration was then
maintained by5% or 10% glucose serum, depending on the blood glucose level. Sodium supplementation was
systematic for serum tonicity between 0.45% and 0.9%.

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In our study, all patients received insulin therapy with rapid-acting insulin administered intravenously with a syringe
pump at a flow rate adapted to age (between 0.05 and 0.1 IU/kg/h).This protocol allowed us to achieve good results
within the first 24 hours, with an average blood glucose of 1.95 g/l, no ketonuria and an average pH of 7.28.

Treatment also included: Correction of ionic disorders, antibiotics when indicated. RRT was performed in 1 patient
and 6 children required mechanical ventilation. None of our patients received bicarbonate alkalization.

Evolution:
The average hospital stay for our patients was 2.97 ± 1,25 days with a maximum of 7 days. The majority of patients:
185 of cases (79.4%) had a favourable outcome. However secondary complications were observed in 48 patients
(20.60%).

The following table presents the secondary complications found in our patients:(Table 3)

Table 3:Complications of patients with DKA in our study:

Complications Number of cases Pourcentage (%)
Hypokalemia 32 13,73%
Hyperkalemia 4 1.72%
Hypoglycemia 4 1.72%
Renalfailure 3 1,29%
Hemodynamicshock 2 0,86%
Hospital-acquired infections 2 0 ,86%
Death 1 0,43%

Discussion:
In recent decades, there has been a significant rise in the incidence of T1DM in children. Research has consistently
reported higher rates of DKA at the time of T1DM diagnosis, particularly in children younger than 5 years 8-9-10.This
was also the case in our study, where all children under the age of 5 years had a first episode of DKA.In fact,
younger people are more likely to have a first episode of DKA.This increased risk in younger individuals may be
attributed to challenges in expressing symptoms at an early age and a general lack of awareness among parents and
healthcare professionals regarding the early manifestations of T1DM.In our study, the twomost affected age groups
by DKA were: children over 10 years of age n= 87(37,34%), followed by children under 5 years of age n= 83
(35,62%). The increase in cases during puberty can be explained by the hormonal changes that reduce insulin action
by 30 to 50%, due to growth and sex hormones causing insulin resistance 11-12.It is also explained by the
psychological changes that can accompany puberty (denial of the disease, eating disorders, etc)in those already
known to be diabetic.

According to the literature, there is no significant predominance of one sex over the other, even in our study, there
was a slight female predominance13.

There was a clear difference in clinical presentation between those who had their first episode of the DKA and those
who already had a diagnosis of T1DM. The average duration of symptoms was significantly shorter in children with
pre-existing diabetes.In addition, children who were known to have diabetes were less likely to have alarming
symptoms (i.e alertness disorders p-value< 0,001).This highlights the importance of diabetes education. Enhancing
awareness of early T1DM symptoms among parents and healthcare professionals could help mitigate the risks of
morbidity and mortality associated with DKA. The biological implications of these differences in clinical
presentation were evident, as children with first-time DKA exhibited higher glycaemia, increased osmolality, and
more severe acidosis.

The frequency of infection as a triggering factor is still a constant fact in Africa, sometimes accountingfor over 70%
of cases. In our study,infectious causes accounted for 57.94 % of cases similar to other African countries 14-15-16. The
nature of these infections varied wildly: bronchopumonary, ear-noseand throat (ENT)infections, cutaneous, urinary,
and gynecologicalwere the most common.In our study, ENT infections accounted for 44.45% of cases with angina
in the majority.

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Poor adherence to medication includes the following: voluntary or unvoluntary discontinuation of insulin therapy,
inappropriate dosage of insulin, and dietary errors. The frequency of these factors found in 20.60% of our patients is
higher than other African studies16-17. We can thus conclude, that this factor is still frequent in developing countries.
Other triggers: situations of physical or psychological stress, certain medication such as corticosteroids, surgical
procedures.

A delayed diagnosis of diabetes is a critical factor contributing to an increased risk of DKA18. Delayed diagnosis is
related to lack of parental andphysicians’awareness. Also, referral to appropriate centres is one of the major risk
factors of delayed diagnosis and mortality in DKA19.

Treatment must be undertaken as a matter of urgency, without waiting for the results of further tests 3. It consists of 4
components: rehydration and volume resuscitation, insulin therapy, correction of hydro-electrolytic disorders, and
treatment of triggering cause. Properly administered, this treatment allows a gradual return to normal within 8 to 12
hours. Its aim should not be rapid normalization of blood glucose levels or cessation of urinary excretion of ketone
bodies, but rather interruption of hepatic production of ketone bodies by continuous administration of low doses of
insulin, and gradual correction of dehydration20.The cause of decompensation must be treated at the same time as the
ketoacidosis. In children, episodes of DKA are most often inaugural; however, precipitating causes can be found,
mainly infections and poor compliance with treatment, which may justify antibiotic treatment, and a resumption of
diabetes education or supportive psychotherapy in adolescents denying the disease 21.

Complications encountered during episodes of ketoacidosis are rare. Cerebral oedema represents a severe and
potentially life-threatening complication of DKA, predominantly affecting paediatric patients 22. Early warning signs
of cerebral oedema include headaches (especially if first experienced during treatment), irritability or behavioural
changes, followed by drowsiness and decreased level of consciousness3-23.

Treatment of cerebral oedema must be rapid and effective, as the time during which treatment with mannitol and
hyperventilation is effective is very short3. Therefore, when cerebral oedema is suspected, immediate treatment is
essential, without waiting for the results of diagnostic tools (CT scan) 24. DKA may lead to various complications,
including electrolyte imbalances such as hypokalaemia, hypoglycaemia, hypocalcaemia, hypomagnesaemia, and
severe hypophosphataemia. Acid-base disturbances, including hyperchloremic acidosis and hypochloraemic
alkalosis, are also common. Additionally, central nervous system complications may arise, such as cerebral venous
sinus thrombosis, basilar artery thrombosis, intracranial haemorrhage, and cerebral infarction…

In high-income countries, the mortality rate associated with DKA remains below 1%. However, in developing
countries, it can range between 2% and 13%25. In our study, a single fatal case was recorded, accounting for 0.43%
of the study population. The identified cause of death was severe hypoglycaemia.

Conclusion:
In summary, DKA is a severe complication in diabetic children. It can lead to serious consequences, including infant
mortality especially in children with newly diagnosed DM. Consequently, it is imperative to raise awareness of this
condition among healthcare professionals and patients. In addition, improved access to medical care and early
diagnosis can help reduce the morbidity and mortality associated with DKA in children in developing countries.

Ethics:
This study adhered to the ethical principles outlined in the Declaration of Helsinki and received approval from the
Ethics Committee of Cady Ayyad University.

Declaration of patient consent:

The authors confirm that all necessary patient consent forms have been obtained. Parental consent was secured for
the publication of images and clinical data in this journal.

Financial support and sponsorship

Nil.

Conflicts of interest
The authors declare no conflicts of interest.

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