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Pediatric Diabetic Ketoacidosis Clinical Presentation

  • Author: William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH; Chief Editor: Timothy E Corden, MD  more...
Updated: Apr 25, 2014


When diabetic ketoacidosis occurs as a first presentation of diabetes, symptoms are likely to develop over several days, with progressive dehydration and ketosis. In a small child wearing diapers and with naturally high fluid intake, polyuria and polydipsia are easily missed. When diabetes is developing, the stress and symptoms of another illness may precipitate diabetic ketoacidosis, as well as mask the underlying problem.

Diabetic ketoacidosis can develop very rapidly in a patient with established diabetes, particularly when insulin therapy has been forgotten, deliberately omitted, or disrupted, as with children on continuous subcutaneous insulin infusions or using the newer analogue insulins. Under these circumstances, diabetic ketoacidosis may present with relatively normal blood glucose levels (ie, 250 mg/dL, 15 mmol/L) or less.


Symptoms of hyperglycemia include the following:

  • Polyuria - Increased volume and frequency of urination
  • Polydipsia - Thirst is often extreme, with children waking at night to consume large quantities of any available drink
  • Nocturia and secondary enuresis in a previously continent child
  • Weight loss - May be dramatic due to breakdown of protein and fat stores
  • Muscle pains and cramps

Acidosis and dehydration

Symptoms of acidosis and dehydration include the following:

  • Abdominal pain that may be severe enough to present as a surgical emergency; for children with a failure of continuous subcutaneous insulin infusion, this may be the first presenting sign, along with vomiting
  • Shortness of breath that may be mistaken for primary respiratory distress
  • Confusion and coma in the absence of recognized head injury [1]

Cerebral edema

Presentation of cerebral edema varies; most cases occur 4-12 hours after initiation of treatment. Typically, the child appears to be improving until a sudden deterioration occurs, with increasing coma; fixed, dilated pupils; and, finally, respiratory arrest. Other patients may have a progressively worsening coma. Children may occasionally present with signs of cerebral edema before treatment begins. Regular monitoring of neurologic status to detect early changes, together with prompt corrective treatment, is important to avoid death or damage.

Clinical signs of developing cerebral edema can be divided into 3 main categories. One diagnostic criteria, 2 major criteria, or 1 major and 2 minor criteria have a sensitivity of 92% and false-positive rate of 4%.[34]

Diagnostic criteria

  • Abnormal motor or verbal response to pain
  • Decorticate or decerebrate posture
  • Cranial nerve palsy (especially III, IV, and VI)
  • Abnormal neurogenic breathing pattern (eg, Cheyne-Stokes), apneusis

Major criteria

  • Altered mentation, fluctuating level of consciousness
  • Sustained and inappropriate bradycardia
  • Age-inappropriate incontinence

Minor criteria

  • Vomiting
  • Headache
  • Abnormally drowsy
  • Diastolic hypertension (>90 mm Hg)

Additional symptoms

Patients with diabetic ketoacidosis may also have the following symptoms:

  • Vomiting
  • Signs of intercurrent infection (eg, urinary tract infection, respiratory tract infection)
  • Weakness and nonspecific malaise that may precede other symptoms of hyperglycemia

Physical Examination

Dehydration may be observed in patients with diabetic ketoacidosis. The degree of dehydration is often reported to be approximately 5-10% but easily can be overestimated (see Table 1, below). One report suggested that children with severe ketoacidosis are rarely more than 8% dehydrated.[5] Clinical signs such as dry mouth, sunken eyes, and decreased skin turgor, are present from about 3% dehydration. Little correlation with hydration status was found in diabetic ketoacidosis patients when using single biochemical or clinical markers.[35]

Table 1. Clinical Assessment of Dehydration (Open Table in a new window)

  Mild (< 3%) Moderate


Severe (8%) and

Shock (>10%)

Appearance Thirsty, alert Thirsty, lethargic Drowsy, cold
Tissue turgor Normal Absent Absent
Mucous membranes Moist Dry Very dry
Blood pressure Normal Normal or low Low for age
Pulse Normal Rapid Rapid and weak
Eyes Normal Sunken Grossly sunken
Anterior fontanelle Normal Sunken Grossly sunken

Other symptoms can include the following:

  • Blood pressure - Usually normal until terminal stages of illness
  • Tachycardia - May be present
  • Capillary refill - Initially maintained, but a combination of increasing acidosis and dehydration cause poor tissue perfusion
  • Kussmaul breathing or deep sighing respiration - A mark of acidosis; these symptoms may be mistaken for status asthmaticus, pneumonia, and even hysterical hyperventilation
  • Ketone odor - Patient may have a smell of ketones on the breath, although many people cannot detect this smell
  • Impaired consciousness - Occurs in approximately 20% of patients
  • Coma - May be present in 10% of patients
  • Abdominal tenderness - May occur; tenderness is usually nonspecific or epigastric in location; bowel sounds may be reduced or absent in severe cases

Rapid onset of diabetic ketoacidosis that presents with relatively low blood glucose levels, vomiting, and abdominal pain can occur in children using short-acting and long-acting insulin analogues or continuous subcutaneous insulin infusions.

Contributor Information and Disclosures

William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH Consultant Paediatric Diabetologist, The Great North Children's Hospital, The Royal Victoria Infirmary; Honorary Clinical Lecturer, University of Newcastle upon Tyne; Honorary Clinical Lecturer, University of Durham, UK

William H Lamb, MD, MBBS, FRCP(Edin), FRCP, FRCPCH is a member of the following medical societies: British Medical Association, Royal College of Physicians, Royal College of Paediatrics and Child Health, British Society of Paediatric Endocrinology and Diabetes, International Society for Pediatric and Adolescent Diabetes

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Eli Lily and Company.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.


G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.


The author would like to thank Debbie Matthews and Tim Cheetham for reading the manuscript and for all of their support.

  1. Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediatr Diabetes. 2006 Feb. 7(1):11-5. [Medline].

  2. Harris GD, Fiordalisi I. Physiologic management of diabetic ketoacidemia. A 5-year prospective pediatric experience in 231 episodes. Arch Pediatr Adolesc Med. 1994 Oct. 148(10):1046-52. [Medline].

  3. Wolfsdorf J, Craig ME, Daneman D, et al. Diabetic ketoacidosis. Pediatr Diabetes. 2007 Feb. 8(1):28-43. [Medline].

  4. Marshall SM, Walker M, Alberti KGMM. Diabetic Ketoacidosis and Hyperglycaemic non-ketotic coma. Alberti, Zimmet, Defronzo eds. International Textbook of Diabetes Mellitus. 1997. 1215-30.

  5. Fagan MJ, Avner J, Khine H. Initial fluid resuscitation for patients with diabetic ketoacidosis: how dry are they?. Clin Pediatr (Phila). 2008 Nov. 47(9):851-5. [Medline].

  6. Durr JA, Hoffman WH, Sklar AH, et al. Correlates of brain edema in uncontrolled IDDM. Diabetes. 1992 May. 41(5):627-32. [Medline].

  7. Hale PM, Rezvani I, Braunstein AW, et al. Factors predicting cerebral edema in young children with diabetic ketoacidosis and new onset type I diabetes. Acta Paediatr. 1997 Jun. 86(6):626-31. [Medline].

  8. Mel JM, Werther GA. Incidence and outcome of diabetic cerebral oedema in childhood: are there predictors?. J Paediatr Child Health. 1995 Feb. 31(1):17-20. [Medline].

  9. Silver SM, Clark EC, Schroeder BM, Sterns RH. Pathogenesis of cerebral edema after treatment of diabetic ketoacidosis [published erratum appears in Kidney Int 1997 May;51(5):1662]. Kidney Int. 1997 Apr. 51(4):1237-44. [Medline].

  10. Okuda Y, Adrogue HJ, Field JB, et al. Counterproductive effects of sodium bicarbonate in diabetic ketoacidosis. J Clin Endocrinol Metab. 1996 Jan. 81(1):314-20. [Medline].

  11. Glaser N. Cerebral injury and cerebral edema in children with diabetic ketoacidosis: could cerebral ischemia and reperfusion injury be involved?. Pediatr Diabetes. 2009 Dec. 10(8):534-41. [Medline].

  12. Musey VC, Lee JK, Crawford R. Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis. Diabetes Care. 1995 Apr. 18(4):483-9. [Medline].

  13. Thompson CJ, Cummings F, Chalmers J, Newton RW. Abnormal insulin treatment behaviour: a major cause of ketoacidosis in the young adult. Diabet Med. 1995 May. 12(5):429-32. [Medline].

  14. Morris AD, Boyle DI, McMahon AD, et al. Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. The DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland. Medicines Monitoring Unit. Lancet. 1997 Nov 22. 350(9090):1505-10. [Medline].

  15. Smaldone A, Honig J, Stone PW, et al. Characteristics of California children with single versus multiple diabetic ketoacidosis hospitalizations (1998-2000). Diabetes Care. 2005 Aug. 28(8):2082-4. [Medline]. [Full Text].

  16. Holstein A, Abel C, Zumwalde I. Recurrent severe diabetic ketoacidosis due to intoxication with synthetic drugs ('Ecstasy' and 'Speed'). Intensivmedizin und Notfallmedizin. 1997. 34(1):46-50.

  17. Rewers A, Klingensmith G, Davis C, et al. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics. 2008 May. 121(5):e1258-66. [Medline].

  18. Smith CP, Firth D, Bennett S, et al. Ketoacidosis occurring in newly diagnosed and established diabetic children. Acta Paediatr. 1998 May. 87(5):537-41. [Medline].

  19. Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes. JAMA. 2002 May 15. 287(19):2511-8. [Medline].

  20. Levy-Marchal C, Patterson CC, Green A. Geographical variation of presentation at diagnosis of type I diabetes in children: the EURODIAB study. European and Dibetes. Diabetologia. 2001 Oct. 44 Suppl 3:B75-80. [Medline].

  21. Edge JA, Dunger DB. Variations in the management of diabetic ketoacidosis in children. Diabet Med. 1994 Dec. 11(10):984-6. [Medline].

  22. Neu A, Hofer SE, Karges B, Oeverink R, Rosenbauer J, Holl RW. Ketoacidosis at diabetes onset is still frequent in children and adolescents: a multicenter analysis of 14,664 patients from 106 institutions. Diabetes Care. 2009 Sep. 32(9):1647-8. [Medline]. [Full Text].

  23. Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. 2011 Jul 7. 343:d4092. [Medline].

  24. Fritsch M, Rosenbauer J, Schober E, Neu A, Placzek K, Holl RW. Predictors of diabetic ketoacidosis in children and adolescents with type 1 diabetes. Experience from a large multicentre database. Pediatr Diabetes. 2011 Jun. 12(4 Pt 1):307-12. [Medline].

  25. Delamater AM, Shaw KH, Applegate EB, et al. Risk for metabolic control problems in minority youth with diabetes. Diabetes Care. 1999 May. 22(5):700-5. [Medline]. [Full Text].

  26. Cohn BA, Cirillo PM, Wingard DL, et al. Gender differences in hospitalizations for IDDM among adolescents in California, 1991. Implications for prevention. Diabetes Care. 1997 Nov. 20(11):1677-82. [Medline].

  27. Quinn M, Fleischman A, Rosner B, et al. Characteristics at diagnosis of type 1 diabetes in children younger than 6 years. J Pediatr. 2006 Mar. 148(3):366-71. [Medline].

  28. Ghetti S, Lee JK, Sims CE, Demaster DM, Glaser NS. Diabetic ketoacidosis and memory dysfunction in children with type 1 diabetes. J Pediatr. 2010 Jan. 156(1):109-14. [Medline].

  29. Edge JA, Ford-Adams ME, Dunger DB, et al. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. 1999 Oct. 81(4):318-23. [Medline]. [Full Text].

  30. Neu A, Willasch A, Ehehalt S, et al. Ketoacidosis at onset of type 1 diabetes mellitus in children--frequency and clinical presentation. Pediatr Diabetes. 2003 Jun. 4(2):77-81. [Medline].

  31. Warner DP, McKinney PA, Law GR, Bodansky HJ. Mortality and diabetes from a population based register in Yorkshire 1978-93. Arch Dis Child. 1998 May. 78(5):435-8. [Medline]. [Full Text].

  32. Hoffman WH, Locksmith JP, Burton EM, et al. Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis. J Diabetes Complications. 1998 Nov-Dec. 12(6):314-20. [Medline].

  33. Holsclaw DS Jr, Torcato B. Acute pulmonary edema in juvenile diabetic ketoacidosis. Pediatr Pulmonol. 1997 Dec. 24(6):438-43. [Medline].

  34. Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care. 2004 Jul. 27(7):1541-6. [Medline].

  35. Sottosanti M, Morrison GC, Singh RN, Sharma AP, Fraser DD, Alawi K, et al. Dehydration in children with diabetic ketoacidosis: a prospective study. Arch Dis Child. 2012 Feb. 97(2):96-100. [Medline].

  36. Brandenburg MA, Dire DJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. 1998 Apr. 31(4):459-65. [Medline].

  37. Wiggam MI, O'Kane MJ, Harper R, et al. Treatment of diabetic ketoacidosis using normalization of blood 3- hydroxybutyrate concentration as the endpoint of emergency management. A randomized controlled study. Diabetes Care. 1997 Sep. 20(9):1347-52. [Medline].

  38. Noyes KJ, Crofton P, Bath LE, et al. Hydroxybutyrate near-patient testing to evaluate a new end-point for intravenous insulin therapy in the treatment of diabetic ketoacidosis in children. Pediatr Diabetes. 2007 Jun. 8(3):150-6. [Medline].

  39. Fiordalisi I, Novotny WE, Holbert D, Finberg L, Harris GD. An 18-yr prospective study of pediatric diabetic ketoacidosis: an approach to minimizing the risk of brain herniation during treatment. Pediatr Diabetes. 2007 Jun. 8(3):142-9. [Medline].

  40. Puttha R, Cooke D, Subbarayan A, Odeka E, Ariyawansa I, Bone M. Low dose (0.05 units/kg/h) is comparable with standard dose (0.1 units/kg/h) intravenous insulin infusion for the initial treatment of diabetic ketoacidosis in children with type 1 diabetes-an observational study. Pediatr Diabetes. 2009 Jul 6. [Medline].

  41. Butkiewicz EK, Leibson CL, O'Brien PC, Palumbo PJ, Rizza RA. Insulin therapy for diabetic ketoacidosis. Bolus insulin injection versus continuous insulin infusion. Diabetes Care. 1995 Aug. 18(8):1187-90. [Medline].

  42. Della Manna T, Steinmetz L, Campos PR, Farhat SC, Schvartsman C, Kuperman H. Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care. 2005 Aug. 28(8):1856-61. [Medline].

  43. Green SM, Rothrock SG, Ho JD, et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med. 1998 Jan. 31(1):41-8. [Medline].

  44. Hale PJ, Crase J, Nattrass M. Metabolic effects of bicarbonate in the treatment of diabetic ketoacidosis. Br Med J (Clin Res Ed). 1984 Oct 20. 289(6451):1035-8. [Medline].

  45. White H, Cook D, Venkatesh B. The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury. Anesth Analg. 2006 Jun. 102(6):1836-46. [Medline].

  46. Vanelli M, Chiari G, Ghizzoni L, et al. Effectiveness of a prevention program for diabetic ketoacidosis in children. An 8-year study in schools and private practices. Diabetes Care. 1999 Jan. 22(1):7-9. [Medline]. [Full Text].

  47. [Guideline] Miller SG. Family therapy for recurrent diabetic ketoacidosis: Treatment guidelines. Family Systems Medicine. 1996. 14(3):303-14.

  48. Douglas D. Isotonic Fluids Helpful in Diabetic Ketoacidosis in Kids: Study. Medscape. Apr 4 2013. Available at Accessed: April 16, 2013.

  49. White PC, Dickson BA. Low Morbidity and Mortality in Children with Diabetic Ketoacidosis Treated with Isotonic Fluids. J Pediatr. 2013 Mar 15. [Medline].

Glasgow Coma Scale, modified for age of verbal response.
A graphical representation of the electrocardiographic changes of hypokalemia.
A graphical representation of the electrocardiographic changes of hyperkalemia (due to overcorrection of potassium loss).
Diabetic ketoacidosis treatment and results chart (page 1 of 4).
Diabetic ketoacidosis treatment and results chart (page 2 of 4).
Diabetic ketoacidosis treatment and results chart (page 3 of 4).
Diabetic ketoacidosis treatment and results chart (page 4 of 4).
Carbs for Kids-Count Them In: The Constant Carbohydrates Diet.
Diabetes Sick Day Rules.
Taking Diabetes Back to School.
Table 1. Clinical Assessment of Dehydration
  Mild (< 3%) Moderate


Severe (8%) and

Shock (>10%)

Appearance Thirsty, alert Thirsty, lethargic Drowsy, cold
Tissue turgor Normal Absent Absent
Mucous membranes Moist Dry Very dry
Blood pressure Normal Normal or low Low for age
Pulse Normal Rapid Rapid and weak
Eyes Normal Sunken Grossly sunken
Anterior fontanelle Normal Sunken Grossly sunken
Table 2. Suggested Daily Maintenance Fluid Replacement Rates
Weight Infusion rate
0-12.9 kg 80 mL/kg/24 h
13-19.9 kg 65 mL/kg/24 h
20-34.9 kg 55 mL/kg/24 h
35-59.9 kg 45 mL/kg/24 h
Adult (>60 kg) 35 mL/kg/24 h
Table 3. Infusion Rates of Potassium Chloride
Serum/Plasma K+ (mEq/L) Potassium Chloride (KCL) Dose in Infusion Fluids
< 2.5 mEq/L Carefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h
2.5-3.5 mEq/L 40 mEq/L
3.5-5 mEq/L 20 mEq/L
5-6 mEq/L 10 mEq/L (optional)
Over 6 mEq/L Stop K+ and repeat level in 2 h
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