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Diabetic ketoacidosis in children
In paediatric DKA the treatment is careful fluids, continuous insulin infusion without a bolus, and potassium — and the danger special to children is cerebral oedema, which must be recognised early and treated at once.
Why it matters in the exam
The exam describes a child with polyuria, weight loss, vomiting and deep breathing (Kussmaul), sometimes as the first presentation of type 1 diabetes. The questions ask about the diagnostic criteria, the order of treatment (fluids before insulin, potassium before insulin when it is low), when glucose is added to the infusion and why bicarbonate is not given. A classic follow-up question: the child improves on the laboratory tests, then complains of headache, the heart rate falls and the blood pressure rises — cerebral oedema.
Risk factors for cerebral oedema: young age, new diagnosis, severe acidosis, low pCO2, high urea, bicarbonate use and a sodium that fails to rise as glucose falls. Treatment — mannitol or hypertonic saline — is given at once on clinical suspicion, without waiting for a CT. ISPAD 2022 raised the diagnostic bicarbonate threshold to 18 mmol/L.
Key points
- Diagnosis: glucose above 200 mg/dL, pH below 7.3 or bicarbonate below 18, ketones.
- Fluids: 10–20 mL/kg, then replacement over 24–48 hours.
- Insulin 0.05–0.1 U/kg per hour, one hour after fluids, no bolus.
- Potassium into the infusion once urine is passed; dextrose when glucose falls to 250–300 mg/dL.
- Cerebral oedema: mannitol or 3% NaCl at once; no bicarbonate.
Summary table
| Issue | Rule | Important detail |
|---|---|---|
| Diagnosis | Glucose above 200 mg/dL (11 mmol/L), venous pH below 7.3 or bicarbonate below 18 mmol/L, ketonaemia | BOHB of 3 mmol/L or more |
| Severity | Mild: pH below 7.3; moderate: below 7.2; severe: below 7.1 | Bicarbonate: below 18, 10, 5 respectively |
| Fluids | Bolus of 10–20 mL/kg of 0.9% NaCl over 20–30 minutes; then replace the deficit over 24–48 hours | In shock — a rapid 20 mL/kg bolus |
| Insulin | 0.05–0.1 U/kg per hour by infusion, one hour after fluids start | No insulin bolus |
| Potassium | Add 40 mmol/L to the infusion once potassium is known and urine is passed | If potassium is low — correct it before insulin |
| Glucose | Add dextrose when glucose falls to 250–300 mg/dL | Do not stop insulin to correct glucose |
| Cerebral oedema | Headache, falling heart rate, rising blood pressure, reduced consciousness | Mannitol 0.5–1 g/kg or 3% NaCl 2.5–5 mL/kg over 10–15 minutes |
A free exam question
בן 7 שנים, מגיע למלר"ד עקב הקאות כאבי בטן וחולשה משמעותית, בבדיקת שתן הודגמו +קטונים 4 , גלוקוז 4 , בדיקות המעבדה שלו לפני+ ואחרי 3 שעות טיפול מתאים, בטבלה שלפניך. מה צריך לעשות בשלב זה? glucose HCO3- pH לפני טיפול 9 7.15 מא"ק/ל 400 "מ"ג/ד ל אחרי טיפול 12 7.22 מא"ק/ל 240 מ"ג/ד "ל (the question as examined, in Hebrew)
- א. להתחיל במתן תוך ורידי של גלוקוז
- ב. מתן תוך ורידי bicarbonate
- ג. לעבור לאינסולין תת עורי
- ד. הורדת קצב האינסולין התוך ורידי
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Sources
- ISPAD Clinical Practice Consensus Guidelines: Diabetic ketoacidosis and hyperglycemic hyperosmolar state, 2022 — Diagnosis, fluids, insulin and cerebral injury
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Diabetes Mellitus in Children: Diabetic Ketoacidosis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.