Increased Presentation of Diabetic Ketoacidosis and Changes in Age and Month of Type 1 Diabetes at Onset during the COVID-19 Pandemic in Spain

Abstract

Objective: To assess the impact of the COVID-19 pandemic and lockdown measures on the presenting characteristics (age at diagnosis, severity, monthly distribution) of newly diagnosed type 1 diabetes in Spanish children. Research Design and Methods: An ambispective observational multicenter study was conducted in nine Spanish tertiary-level hospitals between January 2015 and March 2021. Inclusion criteria: new cases of type 1 diabetes in children (0–14 years) recording age, sex, date of diagnosis, presence of diabetic ketoacidosis (DKA) at onset, and severity of DKA. Data were compared before and during the pandemic. Results: We registered 1444 new cases of type 1 diabetes in children: 1085 in the pre-pandemic period (2015–2019) and 359 during the pandemic (2020–March 2021). There was a significant increase in the group aged ≤4 years in the pandemic period (chi-squared = 10.986, df 2, p = 0.0041). In 2020–2021, cases of DKA increased significantly by 12% (95% CI: 7.2–20.4%), with a higher percentage of moderate and severe DKA, although this increase was not significant. In 2020, there was a sharp decrease in the number of cases in March, with a progressive increase from May through November, higher than in the same months of the period 2015–2019, highlighting the increase in the number of cases in June, September, and November. The first three months of 2021 showed a different trend to that observed both in the years 2015–2019 and in 2020, with a marked increase in the number of cases. Conclusions: A change in monthly distribution was described, with an increase in DKA at onset of type 1 diabetes. No differences were found in severity, although there were differences in the age distribution, with an increase in the number of cases in children under 4 years of age.

Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic

“…In this systematic review and meta-analysis, in 17 studies including 38 149 children and adolescents with newly diagnosed type 1 diabetes, 13, 23, 24, 27, 31, 32, 38, 39, 49-51, 53, 55, 58-60, 63 we found that the incidence rate of type 1 diabetes was 1.14 times higher in the first year and 1.27 times higher in the second year after the onset of the COVID-19 pandemic compared with before the pandemic. In 15 studies including a total of 4324 children and adolescents with DKA, 27,29,36,37,[40][41][42][44][45][46][47]49,50,54,65 we also found that the incidence rate of DKA at diagnosis was 1.26 times higher in the first year after the onset of the COVID-19 pandemic compared with before the pandemic. The magnitude of increase in the incidence rate of type 1 diabetes that we observed after the onset of the pandemic was greater than the expected 3% to 4% annual increase in the incidence rate based on prepandemic temporal trends in Europe.…”

“…After the abstract review, we retrieved 81 full-text articles to determine eligibility. Forty-two records met the full inclusion criteria . The manual search of the included studies’ reference lists did not yield additional studies.…”

“…Twenty-four studies (57.1%) reported DKA incidence at diagnosis. 3, 5, 6, 8, 9, 12, 14, 18, 19, 22, 25, 27-31, 34, 35, 37, 38, 40, 42, 48, 49 Incident cases of type 1 and type 2 diabetes were reported in 36 studies (85.7%) 12,23,24,[27][28][29][30][31][32][33][35][36][37][38][39][40][41][42][44][45][46][47][48][49][50][51][52][53][54][55][56][58][59][60][61]63 and 9 studies (21.4%), 3,33,34,39,43,45,46,55,62 respectively. Two studies (4.8%) did not distinguish between diabetes types.…”

“…24, 28-30, 33, 35-37, 40-42, 44-48, 54, 57, 61, 64 Of these, 15 (75.0%) reported an increase in the number of incident cases of type 1 diabetes during the first 12 months of the pandemic compared with during the 12 months before the pandemic. 33,[35][36][37][40][41][42][44][45][46][47][48]54,61,64 Type 2 Diabetes…”

“…In a random-effects meta-analysis of pooled data from 15 studies (35.7%) including a total of 4324 children and adolescents with DKA, the incidence rate of DKA was higher during the pandemic period compared with the prepandemic period (IRR, 1.26; 95% CI, 1.17-1.36) (Figure 2C). 27,29,36,37,[40][41][42][44][45][46][47]49,50,54,65 Between-study heterogeneity was minimal (I 2 = 0%).…”