The Pandemic (Covid-19) and Pediatric Diabetic Ketoacidosis: The Lessons We Have Learned
Main Article Content
Abstract
In this review, we aim to outline the world’s experience with pediatric diabetic ketoacidosis (DKA) during and after the recent pandemic due to Covid-19. Although most of the literature during the pandemic illustrated the devastation wreaked on adults with diabetes, it took its toll on the pediatric population as well. Here we describe the incidence, prevalence, global impact, and varied presentations of Covid-19 related DKA. We opine on the mechanism of action or pathophysiology of pandemic related DKA, from direct viral effects to indirect mechanisms, such as inability to seek medical help and/or fear of seeking help at medical establishments that crucially kept children away from care only to present in worse states of chronic disease. The silver lining was the advent of telehealth and treatment of DKA in non-traditional settings that ironically broadened the scope of care. Lastly, we review areas in need of future study so that we are better prepared as pediatric clinicians for the next pandemic to protect the children in a more thorough and durable fashion. There are numerous lessons we have learned from this that we can apply now in our daily practice to improve the care we give to our patients.
Article Details
How to Cite
LITTLEJOHN, Elizabeth; HAGEMAN, Joseph.
The Pandemic (Covid-19) and Pediatric Diabetic Ketoacidosis: The Lessons We Have Learned.
Medical Research Archives, [S.l.], v. 12, n. 10, oct. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5785>. Date accessed: 31 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i10.5785.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. COVID-19 and Diabetes: The Tale of Two Pandemics; Elizabeth Littlejohn, MD, MS and Rebecca Schein, MD; Pediatric Annals; Volume 53Issue 7Jul 2024 : July 1, 2024 | pp.e242–e243; https://doi.org/10.3928/19382359-20240502-01.
2. Rahmati M, Yon DK, Lee SW, et al. New-onset type 1 diabetes in children and adolescents as post acute sequelae of SARS-CoV-2 infection: A systematic review and meta-analysis of cohort studies. J Med Virol. 2023;95(6):e28833. doi:10.1002/jmv.28833.
3. Chao LC, Vidmar AP, Georgia S. Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic [published correction appears in Diabetes Care. 2021 Dec;44(12):2812. doi: 10.2337/dc21-er12]. Diabetes Care. 2021;44(6):1451-1453. doi:10.2337/dc20-2733.
4. Jalilova A, Ata A, Demir G, et al. The Effect of the SARS-CoV-2 Pandemic on Presentation with Diabetic Ketoacidosis in Children with New Onset Type 1 Diabetes Mellitus. J Clin Res Pediatr Endocrinol. 2023;15(3):264-267. doi:10.4274/jcrpe.galenos.2023.2022-11-4.
5. Ho J, Rosolowsky E, Pacaud D, Huang C, Lemay JA, Brockman N, Rath M, Doulla M. Diabetic ketoacidosis at type 1 diabetes diagnosis in children during the COVID-19 pandemic. Pediatr Diabetes. 2021 Jun;22(4):552-557. doi: 10.1111/pedi.13205. Epub 2021 Mar 27. PMID: 33745226; PMCID: PMC8251027.
6. Elgenidy A, Awad AK, Saad K, et al. Incidence of diabetic ketoacidosis during COVID-19 pandemic: a meta-analysis of 124,597 children with diabetes. Pediatr Res. 2023;93(5):1149-1160. doi:10.1038/s41390-022-02241-2.
7. Cherubini V, Marino M, Scaramuzza AE, et al. The Silent Epidemic of Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes in Children and Adolescents in Italy During the COVID-19 Pandemic in 2020 [published correction appears in Front Endocrinol (Lausanne). 2022 Aug 04;13:977211. doi: 10.3389/fendo.2022.977211]. Front Endocrinol (Lausanne). 2022;13:878634. Published 2022 Jun 17. doi:10.3389/fendo.2022.878634.
8. Qeadan F, Tingey B, Egbert J, et al. The associations between COVID-19 diagnosis, type 1 diabetes, and the risk of diabetic ketoacidosis: A nationwide cohort from the US using the Cerner Real-World Data. PLoS One. 2022;17(4):e0266809. Published 2022 Apr 19. doi:10.1371/journal.pone.0266809.
9. Lavik AR, Ebekozien O, Noor N, Alonso GT, Polsky S, Blackman SM, Chen J, Corathers SD, Demeterco-Berggren C, Gallagher MP, Greenfield M, Garrity A, Rompicherla S, Rapaport R, Yayah Jones NH. Trends in Type 1 Diabetic Ketoacidosis During COVID-19 Surges at 7 US Centers: Highest Burden on non-Hispanic Black Patients. J Clin Endocrinol Metab. 2022 Jun 16;107(7):1948-1955. doi: 10.1210/clinem/dgac158. PMID: 35380700; PMCID: PMC8992309.
10. Lawrence C, Seckold R, Smart C, et al. Increased paediatric presentations of severe diabetic ketoacidosis in an Australian tertiary center during the COVID-19 pandemic. Diabet Med. 2021;38(1):e14417. doi:10.1111/dme.14417.
11. Abdou M, Hassan MM, Hassanein SA, Elsebaie EH, Shamma RA. Presentations, Complications, and Challenges Encountered During Management of Type 1 Diabetes in Egyptian Children During COVID-19 Pandemic: A Single-Center Experience. Front Endocrinol (Lausanne). 2022;13:814991. Published 2022 Mar 11. doi:10.3389/fendo.2022.814991.
12. Donbaloğlu Z, Tuhan H, Tural Kara T, et al. The Examination of the Relationship Between COVID-19 and New-Onset Type 1 Diabetes Mellitus in Children. Turk Arch Pediatr. 2022;57(2):222-227. doi:10.5152/TurkArchPediatr.2022.21284.
13. Chambers MA, Mecham C, Arreola EV, Sinha M. Increase in the Number of Pediatric New-Onset Diabetes and Diabetic Ketoacidosis Cases During the COVID-19 Pandemic. Endocr Pract. 2022;28(5):479-485. doi:10.1016/j.eprac.2022.02.005.
14. Ebekozien O, Agarwal S, Noor N, et al. Inequities in Diabetic Ketoacidosis Among Patients With Type 1 Diabetes and COVID-19: Data From 52 US Clinical Centers. J Clin Endocrinol Metab. 2021;106(4):e1755-e1762. doi:10.1210/clinem/dgaa920.
15. Nagl K, Waldhör T, Hofer SE, et al. Alarming Increase of Ketoacidosis Prevalence at Type 1 Diabetes-Onset in Austria-Results From a Nationwide Registry. Front Pediatr. 2022;10:820156. Published 2022 Feb 14. doi:10.3389/fped.2022.820156.
16. Alaqeel A, Aljuraibah F, Alsuhaibani M, et al. The Impact of COVID-19 Pandemic Lockdown on the Incidence of New-Onset Type 1 Diabetes and Ketoacidosis Among Saudi Children. Front Endocrinol (Lausanne). 2021;12:669302. Published 2021 Apr 1. doi:10.3389/fendo.2021.669302.
17. Salmi H, Heinonen S, Hästbacka J, et al. New-onset type 1 diabetes in Finnish children during the COVID-19 pandemic. Arch Dis Child. 2022;107(2):180-185. doi:10.1136/archdischild-2020-321220.
18. Lee YL, Nasir FFWA, Selveindran NM, Zaini AA, Lim PG, Jalaludin MY. Paediatric new onset type 1 diabetes and diabetic ketoacidosis during the COVID-19 pandemic in Malaysia. Diabetes Res Clin Pract. 2023;205:110981. doi:10.1016/j.diabres.2023.110981.
19. Elbarbary NS, Dos Santos TJ, de Beaufort C, Agwu JC, Calliari LE, Scaramuzza AE. COVID-19 outbreak and pediatric diabetes: Perceptions of health care professionals worldwide. Pediatr Diabetes. 2020;21(7):1083-1092. doi:10.1111/pedi.13084.
20. Goldman S, Pinhas-Hamiel O, Weinberg A, et al. Alarming increase in ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the first wave of the COVID-19 pandemic in Israel. Pediatr Diabetes. 2022;23(1):10-18. doi:10.1111/pedi.13296.
21. Leiva-Gea I, Fernández CA, Cardona-Hernandez R, et al. Increased Presentation of Diabetic Ketoacidosis and Changes in Age and Month of Type 1 Diabetes at Onset during the COVID-19 Pandemic in Spain. J Clin Med. 2022;11(15):4338. Published 2022 Jul 26. doi:10.3390/jcm11154338.
22. Vorgučin I, Savin M, Stanković Đ, et al. Incidence of Type 1 Diabetes Mellitus and Characteristics of Diabetic Ketoacidosis in Children and Adolescents during the First Two Years of the COVID-19 Pandemic in Vojvodina. Medicina (Kaunas). 2022;58(8):1013. Published 2022 Jul 28. doi:10.3390/medicina58081013.
23. Fisler G, Izard SM, Shah S, Lewis D, Kainth MK, Hagmann SHF, Belfer JA, Feld LM, Mastroianni F, Kvasnovsky CL, Capone CA, Schneider J, Sweberg T, Schleien C, Taylor MD; Northwell COVID-19 Research Consortium. Characteristics and risk factors associated with critical illness in pediatric COVID-19. Ann Intensive Care. 2020 Dec 19;10(1):171. doi: 10.1186/s13613-020-00790-5. PMID: 33340348; PMCID: PMC7749393.
24. Parappil P, Ghimire S, Saxena A, et al. New-onset diabetic ketoacidosis with purpura fulminans in a child with COVID-19-related multisystem inflammatory syndrome. Infect Dis (Lond). 2022;54(7):522-528. doi:10.1080/23744235.2022.2050423.
25. Amaral LB, Carlesse F, Rossato L. Pediatric mucormycosis associated with COVID-19: A systematic review of clinical cases. Enferm Infecc Microbiol Clin (Engl Ed). 2024;42(6):321-326. doi:10.1016/j.eimce.2023.11.006.
26. Kostopoulou E. The Interplay Between COVID-19 and Pediatric Endocrine Disorders. What have we Learned After More than Three Years of the Pandemic? Horm Metab Res. 2024;56(3):181-192. doi:10.1055/a-2152-4590.
27. Varol F, Ozyilmaz LGB, Sahin EG, Can YY, Altas U, Cam H. Does the severity of diabetic ketoacidosis in children with type 1 diabetes change during the COVID-19 pandemic? A single-center experience from a pediatric intensive care unit. North Clin Istanb. 2022;9(5):429-435. Published 2022 Oct 20. doi:10.14744/nci.2022.09634.
28. Shimony H, Miller L, Reich P, et al. Pediatric diabetes mellitus hospitalizations and COVID-19 pandemic response measures. Diabetes Res Clin Pract. 2024;207:111060. doi:10.1016/j.diabres.2023.111060.
29. Howard MB, Basu S, Sherwin E, Cohen JS. Triple threat: new presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias. Am J Emerg Med. 2021;49:437.e5-437.e8. doi:10.1016/j.ajem.2021.04.045
30. Duong-Quy S, Huynh-Truong-Anh D, Le-Thi-Hong N, et al. Acute Respiratory Distress Syndrome Associated with Multisystem Inflammatory Syndrome in a Child with Covid-19 and Diabetic Ketoacidosis: A Case Report. Pulm Ther. 2022;8(3):333-342. doi:10.1007/s41030-022-00192-x.
31. Vasconez WA, Bustamante Escobar CL, Agarwal N, Solano JP, Sanchez JE. Severe Diabetic Ketoacidosis in a Child with Type-1 Diabetes, Asthma, and COVID-19. J Pediatr Intensive Care. 2021;10(3):232-234. doi:10.1055/s-0040-1713164.
32. Tseng YS, Tilford B, Sethuraman U, Cashen K. Combined Hyperglycemic Hyperosmolar Syndrome and Diabetic Ketoacidosis Associated with COVID-19 in a Pediatric Patient. Case Rep Crit Care. 2021 Nov 27;2021:6429710. doi: 10.1155/2021/6429710. PMID: 38442727; PMCID: PMC8627355.
33. Alizadeh, Faraz & O'Halloran, Amanda & Alghamdi, Areej & Chen, Charlotte & Trissal, Maria & Traum, Avram & Decourcey, Danielle. (2020). Toddler With New Onset Diabetes and Atypical Hemolytic Uremic Syndrome in the Setting of COVID-19. Pediatrics. 147. 10.1542/peds.2020-016774.
34. Azova S, Liu E, Wolfsdorf J. Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic. Pediatr Diabetes. 2023;2023:5123197. doi:10.1155/2023/5123197.
35. Agathis NT, Womack LS, Webber BJ, et al. Children, adolescents, and young adults hospitalized with COVID-19 and diabetes in summer 2021. Pediatr Diabetes. 2022;23(7):961-967. doi:10.1111/pedi.13396.
36. Liu X, Yu Q, Li L, Wei S, Zeng J, Jiang J. Acute pancreatitis associated with diabetic ketoacidosis in a child with COVID-19 infection. BMC Infect Dis. 2023;23(1):381. doi:10.1186/s12879-023-08371-0.
37. Mohammad Ashraf H, Sunderajan T, Pierre L, Kondamudi N, Adeyinka A. Aversion to Hospital Admission Due to Fear of COVID Infection Leading to Fatality From Diabetic Ketoacidosis. Cureus. 2021;13(12):e20251; doi:10.7759/cureus.20251.
38. Agarwal A, Bansal D, Nallasamy K, Jayashree M, William V. Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt. Pediatric Health Med Ther. 2023 Sep 4;14:281-288. doi: 10.2147/PHMT.S384104. PMID: 37691882; PMCID: PMC10488656.
39. Foster T, Haller M, Atkinson M, Schatz D; Delayed diagnosis of diabetic ketoacidosis and associated mortality during the COVID-19 pandemic; Journal of Diabetes. 2021 Jun; 10; 837-839; doi.org/10.1111/1753-0407.13208.
40. Modarelli R, Balikcioglu PG, Hendrix G, DeRusso M, Ozment C. The Perfect Storm: Rapid Progression of Diabetic Ketoacidosis in Pediatric Diabetes in the Setting of COVID-19. AACE Clin Case Rep. 2021;7(6):357-359. doi:10.1016/j.aace.2021.05.007.
41. Dżygało K, Nowaczyk J, Szwilling A, Kowalska A. Increased frequency of severe diabetic ketoacidosis at type 1 diabetes onset among children during COVID-19 pandemic lockdown: an observational cohort study. Zwiększona częstość występowania ciężkiej cukrzycowej kwasicy ketonowej u dzieci z cukrzycą typu 1 w czasie pandemii COVID-19: kohortowe badanie obserwacyjne. Pediatr Endocrinol Diabetes Metab. 2020;26(4):167-175. doi:10.5114/pedm.2020.101003.
42. Alaqeel A, Aljuraibah F, Alsuhaibani M, et al. The Impact of COVID-19 Pandemic Lockdown on the Incidence of New-Onset Type 1 Diabetes and Ketoacidosis Among Saudi Children. Front Endocrinol (Lausanne). 2021;12:669302. Published 2021 Apr 1. doi:10.3389/fendo.2021.669302.
43. Wu Z, Wang J, Ullah R, et al. Covid 19 and diabetes in children: advances and strategies. Diabetol Metab Syndr. 2024;16(1):28. Published 2024 Jan 29. doi:10.1186/s13098-024-01267-2.
44. Keiner ES, Slaughter JC, Datye KA, Cherrington AD, Moore DJ, Gregory JM. COVID-19 Exacerbates Insulin Resistance During Diabetic Ketoacidosis in Pediatric Patients With Type 1 Diabetes. Diabetes Care. 2022;45(10):2406-2411. doi:10.2337/dc22-0396.
45. Toomey V, Klein MJ, Vidmar AP, Chao LC, Pineda J, Bhalla A. Association Between COVID-19 and Severity of Illness for Children With Hyperglycemic Crisis. Hosp Pediatr. 2023;13(9):794-801. doi:10.1542/hpeds.2023-007195.
46. Iughetti L, Trevisani V, Cattini U, et al. COVID-19 and Type 1 Diabetes: Concerns and Challenges. Acta Biomed. 2020;91(3):e2020033. Published 2020 Sep 7. doi:10.23750/abm.v91i3.10366.
47. Montefusco L, Pastore I, Lunati ME, Fiorina P. Increased Risk of Diabetes and Diabetic Ketoacidosis Associated With COVID-19. Diabetes. 2023;72(5):560-561. doi:10.2337/db22-0908.
48. McCluskey CK, Zee-Cheng JE, Klein MJ, et al. The Temporal Relationship Between Local School Closure and Increased Incidence of Pediatric Diabetic Ketoacidosis. Front Pediatr. 2022;10:812265. Published 2022 Mar 11. doi:10.3389/fped.2022.812265.
49. Margolis MG, Weizman S, Lazar L, et al. Clinical and immunological characteristics of children diagnosed with-Type 1 diabetes during the COVID-19 pandemic. Diabet Med. 2024;41(5):e15250. doi:10.1111/dme.15250.
50. Kamrath C, Rosenbauer J, Eckert AJ, et al. Incidence of COVID-19 and Risk of Diabetic Ketoacidosis in New-Onset Type 1 Diabetes. Pediatrics. 2021;148(3):e2021050856. doi:10.1542/peds.2021-050856.
51. Kiral E, Kirel B, Havan M, Keskin M, Karaoglan M, Yildirim A, Kangin M, Talay MN, Urun T, Altug U, Kesici S, Tufan E, Kacmaz E, Bozan G, Azapagasi E, Uysal Yazici M, Ozturk Z, Yesilbas O, Karaguzel G, Kaya G, Barlas U, Duyu M, Boyraz M, Sevketoglu E, Akcay N, Hancili S, Guven A, Dursun O, Ulgen Tekerek N, Ozcifci G, Yazici P, Turanli E, Kendirli T, Kahveci F, Yetimakman AF, Citak A, Şik G, Bingol I, Aygun F, Durak C, Yilmaz R, Bugrul F, Sari Y, Tekguç H, Albayrak H, Yener N, Agin H, Soydan E, Yildizdas D, Dilek SO, Yalindag N, Incekoy-Girgin F, Alacakir N, Tutunculer F, Arslanaoglu MO, Aydin C, Bilgin M, Simsek E, Dinleyici EC. Increased Severe Cases and New-Onset Type 1 Diabetes Among Children Presenting With Diabetic Ketoacidosis During First Year of COVID-19 Pandemic in Turkey. Front Pediatr. 2022 Jun 29;10:926013. doi: 10.3389/fped.2022.926013. PMID: 35844756; PMCID: PMC9277100.
52. Priyambada L, Wolfsdorf JI, Brink SJ, et al. ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin. Pediatr Diabetes. 2020;21(8):1394-1402. doi:10.1111/pedi.13118.
53. Zucchini S, Scozzarella A, Maltoni G. Multiple influences of the COVID-19 pandemic on children with diabetes: Changes in epidemiology, metabolic control and medical care. World J Diabetes. 2023 Mar 15;14(3):198-208. doi: 10.4239/wjd.v14.i3.198. PMID: 37035223; PMCID: PMC10075036.
54. Jethwani P, Saboo B, Jethwani L, Kesavadev J, Kalra S, Sahay R, Agarwal S, Hasnani D. Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions. Int J Diabetes Dev Ctries. 2020 Sep;40(3):335-339. doi: 10.1007/s13410-020-00865-w. Epub 2020 Sep 15. PMID: 32952333; PMCID: PMC7490475.
2. Rahmati M, Yon DK, Lee SW, et al. New-onset type 1 diabetes in children and adolescents as post acute sequelae of SARS-CoV-2 infection: A systematic review and meta-analysis of cohort studies. J Med Virol. 2023;95(6):e28833. doi:10.1002/jmv.28833.
3. Chao LC, Vidmar AP, Georgia S. Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic [published correction appears in Diabetes Care. 2021 Dec;44(12):2812. doi: 10.2337/dc21-er12]. Diabetes Care. 2021;44(6):1451-1453. doi:10.2337/dc20-2733.
4. Jalilova A, Ata A, Demir G, et al. The Effect of the SARS-CoV-2 Pandemic on Presentation with Diabetic Ketoacidosis in Children with New Onset Type 1 Diabetes Mellitus. J Clin Res Pediatr Endocrinol. 2023;15(3):264-267. doi:10.4274/jcrpe.galenos.2023.2022-11-4.
5. Ho J, Rosolowsky E, Pacaud D, Huang C, Lemay JA, Brockman N, Rath M, Doulla M. Diabetic ketoacidosis at type 1 diabetes diagnosis in children during the COVID-19 pandemic. Pediatr Diabetes. 2021 Jun;22(4):552-557. doi: 10.1111/pedi.13205. Epub 2021 Mar 27. PMID: 33745226; PMCID: PMC8251027.
6. Elgenidy A, Awad AK, Saad K, et al. Incidence of diabetic ketoacidosis during COVID-19 pandemic: a meta-analysis of 124,597 children with diabetes. Pediatr Res. 2023;93(5):1149-1160. doi:10.1038/s41390-022-02241-2.
7. Cherubini V, Marino M, Scaramuzza AE, et al. The Silent Epidemic of Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes in Children and Adolescents in Italy During the COVID-19 Pandemic in 2020 [published correction appears in Front Endocrinol (Lausanne). 2022 Aug 04;13:977211. doi: 10.3389/fendo.2022.977211]. Front Endocrinol (Lausanne). 2022;13:878634. Published 2022 Jun 17. doi:10.3389/fendo.2022.878634.
8. Qeadan F, Tingey B, Egbert J, et al. The associations between COVID-19 diagnosis, type 1 diabetes, and the risk of diabetic ketoacidosis: A nationwide cohort from the US using the Cerner Real-World Data. PLoS One. 2022;17(4):e0266809. Published 2022 Apr 19. doi:10.1371/journal.pone.0266809.
9. Lavik AR, Ebekozien O, Noor N, Alonso GT, Polsky S, Blackman SM, Chen J, Corathers SD, Demeterco-Berggren C, Gallagher MP, Greenfield M, Garrity A, Rompicherla S, Rapaport R, Yayah Jones NH. Trends in Type 1 Diabetic Ketoacidosis During COVID-19 Surges at 7 US Centers: Highest Burden on non-Hispanic Black Patients. J Clin Endocrinol Metab. 2022 Jun 16;107(7):1948-1955. doi: 10.1210/clinem/dgac158. PMID: 35380700; PMCID: PMC8992309.
10. Lawrence C, Seckold R, Smart C, et al. Increased paediatric presentations of severe diabetic ketoacidosis in an Australian tertiary center during the COVID-19 pandemic. Diabet Med. 2021;38(1):e14417. doi:10.1111/dme.14417.
11. Abdou M, Hassan MM, Hassanein SA, Elsebaie EH, Shamma RA. Presentations, Complications, and Challenges Encountered During Management of Type 1 Diabetes in Egyptian Children During COVID-19 Pandemic: A Single-Center Experience. Front Endocrinol (Lausanne). 2022;13:814991. Published 2022 Mar 11. doi:10.3389/fendo.2022.814991.
12. Donbaloğlu Z, Tuhan H, Tural Kara T, et al. The Examination of the Relationship Between COVID-19 and New-Onset Type 1 Diabetes Mellitus in Children. Turk Arch Pediatr. 2022;57(2):222-227. doi:10.5152/TurkArchPediatr.2022.21284.
13. Chambers MA, Mecham C, Arreola EV, Sinha M. Increase in the Number of Pediatric New-Onset Diabetes and Diabetic Ketoacidosis Cases During the COVID-19 Pandemic. Endocr Pract. 2022;28(5):479-485. doi:10.1016/j.eprac.2022.02.005.
14. Ebekozien O, Agarwal S, Noor N, et al. Inequities in Diabetic Ketoacidosis Among Patients With Type 1 Diabetes and COVID-19: Data From 52 US Clinical Centers. J Clin Endocrinol Metab. 2021;106(4):e1755-e1762. doi:10.1210/clinem/dgaa920.
15. Nagl K, Waldhör T, Hofer SE, et al. Alarming Increase of Ketoacidosis Prevalence at Type 1 Diabetes-Onset in Austria-Results From a Nationwide Registry. Front Pediatr. 2022;10:820156. Published 2022 Feb 14. doi:10.3389/fped.2022.820156.
16. Alaqeel A, Aljuraibah F, Alsuhaibani M, et al. The Impact of COVID-19 Pandemic Lockdown on the Incidence of New-Onset Type 1 Diabetes and Ketoacidosis Among Saudi Children. Front Endocrinol (Lausanne). 2021;12:669302. Published 2021 Apr 1. doi:10.3389/fendo.2021.669302.
17. Salmi H, Heinonen S, Hästbacka J, et al. New-onset type 1 diabetes in Finnish children during the COVID-19 pandemic. Arch Dis Child. 2022;107(2):180-185. doi:10.1136/archdischild-2020-321220.
18. Lee YL, Nasir FFWA, Selveindran NM, Zaini AA, Lim PG, Jalaludin MY. Paediatric new onset type 1 diabetes and diabetic ketoacidosis during the COVID-19 pandemic in Malaysia. Diabetes Res Clin Pract. 2023;205:110981. doi:10.1016/j.diabres.2023.110981.
19. Elbarbary NS, Dos Santos TJ, de Beaufort C, Agwu JC, Calliari LE, Scaramuzza AE. COVID-19 outbreak and pediatric diabetes: Perceptions of health care professionals worldwide. Pediatr Diabetes. 2020;21(7):1083-1092. doi:10.1111/pedi.13084.
20. Goldman S, Pinhas-Hamiel O, Weinberg A, et al. Alarming increase in ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the first wave of the COVID-19 pandemic in Israel. Pediatr Diabetes. 2022;23(1):10-18. doi:10.1111/pedi.13296.
21. Leiva-Gea I, Fernández CA, Cardona-Hernandez R, et al. Increased Presentation of Diabetic Ketoacidosis and Changes in Age and Month of Type 1 Diabetes at Onset during the COVID-19 Pandemic in Spain. J Clin Med. 2022;11(15):4338. Published 2022 Jul 26. doi:10.3390/jcm11154338.
22. Vorgučin I, Savin M, Stanković Đ, et al. Incidence of Type 1 Diabetes Mellitus and Characteristics of Diabetic Ketoacidosis in Children and Adolescents during the First Two Years of the COVID-19 Pandemic in Vojvodina. Medicina (Kaunas). 2022;58(8):1013. Published 2022 Jul 28. doi:10.3390/medicina58081013.
23. Fisler G, Izard SM, Shah S, Lewis D, Kainth MK, Hagmann SHF, Belfer JA, Feld LM, Mastroianni F, Kvasnovsky CL, Capone CA, Schneider J, Sweberg T, Schleien C, Taylor MD; Northwell COVID-19 Research Consortium. Characteristics and risk factors associated with critical illness in pediatric COVID-19. Ann Intensive Care. 2020 Dec 19;10(1):171. doi: 10.1186/s13613-020-00790-5. PMID: 33340348; PMCID: PMC7749393.
24. Parappil P, Ghimire S, Saxena A, et al. New-onset diabetic ketoacidosis with purpura fulminans in a child with COVID-19-related multisystem inflammatory syndrome. Infect Dis (Lond). 2022;54(7):522-528. doi:10.1080/23744235.2022.2050423.
25. Amaral LB, Carlesse F, Rossato L. Pediatric mucormycosis associated with COVID-19: A systematic review of clinical cases. Enferm Infecc Microbiol Clin (Engl Ed). 2024;42(6):321-326. doi:10.1016/j.eimce.2023.11.006.
26. Kostopoulou E. The Interplay Between COVID-19 and Pediatric Endocrine Disorders. What have we Learned After More than Three Years of the Pandemic? Horm Metab Res. 2024;56(3):181-192. doi:10.1055/a-2152-4590.
27. Varol F, Ozyilmaz LGB, Sahin EG, Can YY, Altas U, Cam H. Does the severity of diabetic ketoacidosis in children with type 1 diabetes change during the COVID-19 pandemic? A single-center experience from a pediatric intensive care unit. North Clin Istanb. 2022;9(5):429-435. Published 2022 Oct 20. doi:10.14744/nci.2022.09634.
28. Shimony H, Miller L, Reich P, et al. Pediatric diabetes mellitus hospitalizations and COVID-19 pandemic response measures. Diabetes Res Clin Pract. 2024;207:111060. doi:10.1016/j.diabres.2023.111060.
29. Howard MB, Basu S, Sherwin E, Cohen JS. Triple threat: new presentation with diabetic ketoacidosis, COVID-19, and cardiac arrhythmias. Am J Emerg Med. 2021;49:437.e5-437.e8. doi:10.1016/j.ajem.2021.04.045
30. Duong-Quy S, Huynh-Truong-Anh D, Le-Thi-Hong N, et al. Acute Respiratory Distress Syndrome Associated with Multisystem Inflammatory Syndrome in a Child with Covid-19 and Diabetic Ketoacidosis: A Case Report. Pulm Ther. 2022;8(3):333-342. doi:10.1007/s41030-022-00192-x.
31. Vasconez WA, Bustamante Escobar CL, Agarwal N, Solano JP, Sanchez JE. Severe Diabetic Ketoacidosis in a Child with Type-1 Diabetes, Asthma, and COVID-19. J Pediatr Intensive Care. 2021;10(3):232-234. doi:10.1055/s-0040-1713164.
32. Tseng YS, Tilford B, Sethuraman U, Cashen K. Combined Hyperglycemic Hyperosmolar Syndrome and Diabetic Ketoacidosis Associated with COVID-19 in a Pediatric Patient. Case Rep Crit Care. 2021 Nov 27;2021:6429710. doi: 10.1155/2021/6429710. PMID: 38442727; PMCID: PMC8627355.
33. Alizadeh, Faraz & O'Halloran, Amanda & Alghamdi, Areej & Chen, Charlotte & Trissal, Maria & Traum, Avram & Decourcey, Danielle. (2020). Toddler With New Onset Diabetes and Atypical Hemolytic Uremic Syndrome in the Setting of COVID-19. Pediatrics. 147. 10.1542/peds.2020-016774.
34. Azova S, Liu E, Wolfsdorf J. Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic. Pediatr Diabetes. 2023;2023:5123197. doi:10.1155/2023/5123197.
35. Agathis NT, Womack LS, Webber BJ, et al. Children, adolescents, and young adults hospitalized with COVID-19 and diabetes in summer 2021. Pediatr Diabetes. 2022;23(7):961-967. doi:10.1111/pedi.13396.
36. Liu X, Yu Q, Li L, Wei S, Zeng J, Jiang J. Acute pancreatitis associated with diabetic ketoacidosis in a child with COVID-19 infection. BMC Infect Dis. 2023;23(1):381. doi:10.1186/s12879-023-08371-0.
37. Mohammad Ashraf H, Sunderajan T, Pierre L, Kondamudi N, Adeyinka A. Aversion to Hospital Admission Due to Fear of COVID Infection Leading to Fatality From Diabetic Ketoacidosis. Cureus. 2021;13(12):e20251; doi:10.7759/cureus.20251.
38. Agarwal A, Bansal D, Nallasamy K, Jayashree M, William V. Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt. Pediatric Health Med Ther. 2023 Sep 4;14:281-288. doi: 10.2147/PHMT.S384104. PMID: 37691882; PMCID: PMC10488656.
39. Foster T, Haller M, Atkinson M, Schatz D; Delayed diagnosis of diabetic ketoacidosis and associated mortality during the COVID-19 pandemic; Journal of Diabetes. 2021 Jun; 10; 837-839; doi.org/10.1111/1753-0407.13208.
40. Modarelli R, Balikcioglu PG, Hendrix G, DeRusso M, Ozment C. The Perfect Storm: Rapid Progression of Diabetic Ketoacidosis in Pediatric Diabetes in the Setting of COVID-19. AACE Clin Case Rep. 2021;7(6):357-359. doi:10.1016/j.aace.2021.05.007.
41. Dżygało K, Nowaczyk J, Szwilling A, Kowalska A. Increased frequency of severe diabetic ketoacidosis at type 1 diabetes onset among children during COVID-19 pandemic lockdown: an observational cohort study. Zwiększona częstość występowania ciężkiej cukrzycowej kwasicy ketonowej u dzieci z cukrzycą typu 1 w czasie pandemii COVID-19: kohortowe badanie obserwacyjne. Pediatr Endocrinol Diabetes Metab. 2020;26(4):167-175. doi:10.5114/pedm.2020.101003.
42. Alaqeel A, Aljuraibah F, Alsuhaibani M, et al. The Impact of COVID-19 Pandemic Lockdown on the Incidence of New-Onset Type 1 Diabetes and Ketoacidosis Among Saudi Children. Front Endocrinol (Lausanne). 2021;12:669302. Published 2021 Apr 1. doi:10.3389/fendo.2021.669302.
43. Wu Z, Wang J, Ullah R, et al. Covid 19 and diabetes in children: advances and strategies. Diabetol Metab Syndr. 2024;16(1):28. Published 2024 Jan 29. doi:10.1186/s13098-024-01267-2.
44. Keiner ES, Slaughter JC, Datye KA, Cherrington AD, Moore DJ, Gregory JM. COVID-19 Exacerbates Insulin Resistance During Diabetic Ketoacidosis in Pediatric Patients With Type 1 Diabetes. Diabetes Care. 2022;45(10):2406-2411. doi:10.2337/dc22-0396.
45. Toomey V, Klein MJ, Vidmar AP, Chao LC, Pineda J, Bhalla A. Association Between COVID-19 and Severity of Illness for Children With Hyperglycemic Crisis. Hosp Pediatr. 2023;13(9):794-801. doi:10.1542/hpeds.2023-007195.
46. Iughetti L, Trevisani V, Cattini U, et al. COVID-19 and Type 1 Diabetes: Concerns and Challenges. Acta Biomed. 2020;91(3):e2020033. Published 2020 Sep 7. doi:10.23750/abm.v91i3.10366.
47. Montefusco L, Pastore I, Lunati ME, Fiorina P. Increased Risk of Diabetes and Diabetic Ketoacidosis Associated With COVID-19. Diabetes. 2023;72(5):560-561. doi:10.2337/db22-0908.
48. McCluskey CK, Zee-Cheng JE, Klein MJ, et al. The Temporal Relationship Between Local School Closure and Increased Incidence of Pediatric Diabetic Ketoacidosis. Front Pediatr. 2022;10:812265. Published 2022 Mar 11. doi:10.3389/fped.2022.812265.
49. Margolis MG, Weizman S, Lazar L, et al. Clinical and immunological characteristics of children diagnosed with-Type 1 diabetes during the COVID-19 pandemic. Diabet Med. 2024;41(5):e15250. doi:10.1111/dme.15250.
50. Kamrath C, Rosenbauer J, Eckert AJ, et al. Incidence of COVID-19 and Risk of Diabetic Ketoacidosis in New-Onset Type 1 Diabetes. Pediatrics. 2021;148(3):e2021050856. doi:10.1542/peds.2021-050856.
51. Kiral E, Kirel B, Havan M, Keskin M, Karaoglan M, Yildirim A, Kangin M, Talay MN, Urun T, Altug U, Kesici S, Tufan E, Kacmaz E, Bozan G, Azapagasi E, Uysal Yazici M, Ozturk Z, Yesilbas O, Karaguzel G, Kaya G, Barlas U, Duyu M, Boyraz M, Sevketoglu E, Akcay N, Hancili S, Guven A, Dursun O, Ulgen Tekerek N, Ozcifci G, Yazici P, Turanli E, Kendirli T, Kahveci F, Yetimakman AF, Citak A, Şik G, Bingol I, Aygun F, Durak C, Yilmaz R, Bugrul F, Sari Y, Tekguç H, Albayrak H, Yener N, Agin H, Soydan E, Yildizdas D, Dilek SO, Yalindag N, Incekoy-Girgin F, Alacakir N, Tutunculer F, Arslanaoglu MO, Aydin C, Bilgin M, Simsek E, Dinleyici EC. Increased Severe Cases and New-Onset Type 1 Diabetes Among Children Presenting With Diabetic Ketoacidosis During First Year of COVID-19 Pandemic in Turkey. Front Pediatr. 2022 Jun 29;10:926013. doi: 10.3389/fped.2022.926013. PMID: 35844756; PMCID: PMC9277100.
52. Priyambada L, Wolfsdorf JI, Brink SJ, et al. ISPAD Clinical Practice Consensus Guideline: Diabetic ketoacidosis in the time of COVID-19 and resource-limited settings-role of subcutaneous insulin. Pediatr Diabetes. 2020;21(8):1394-1402. doi:10.1111/pedi.13118.
53. Zucchini S, Scozzarella A, Maltoni G. Multiple influences of the COVID-19 pandemic on children with diabetes: Changes in epidemiology, metabolic control and medical care. World J Diabetes. 2023 Mar 15;14(3):198-208. doi: 10.4239/wjd.v14.i3.198. PMID: 37035223; PMCID: PMC10075036.
54. Jethwani P, Saboo B, Jethwani L, Kesavadev J, Kalra S, Sahay R, Agarwal S, Hasnani D. Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions. Int J Diabetes Dev Ctries. 2020 Sep;40(3):335-339. doi: 10.1007/s13410-020-00865-w. Epub 2020 Sep 15. PMID: 32952333; PMCID: PMC7490475.