Related Experiment Video
Updated: Jul 21, 2026
Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
A Narrative Review on Diabetic Ketoacidosis in Children
Karen K Y Leung1, Joanna Y L Tung2, Yan Tung Kelly Lee1
1Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong, China.
Insights
Diabetic ketoacidosis (DKA) management in children differs globally. Current evidence is limited on whether restrictive or permissive fluid administration is best, necessitating cautious clinical application of guidelines.
Area of Science:
- Pediatric Endocrinology
- Critical Care Medicine
Background:
- Diabetic ketoacidosis (DKA) is a severe complication in children with diabetes mellitus.
- International guidelines for DKA management vary, particularly regarding fluid administration strategies.
- Concerns about cerebral edema have historically favored restrictive fluid approaches, but recent research questions this link.
Purpose of the Study:
- To provide a narrative review on the current management of diabetic ketoacidosis in pediatric patients.
- To examine and compare international guidelines for DKA management.
- To discuss the controversy surrounding fluid administration in pediatric DKA.
Main Methods:
- A comprehensive literature search was conducted on PubMed using the term "diabetic ketoacidosis".
- The search included various study types (RCTs, trials, meta-analyses, observational studies, guidelines, reviews) in English.
- Focus was on pediatric populations (≤18 years), with a review and comparison of major clinical guidelines.
Main Results:
- Limited clinical evidence exists to definitively support either restrictive or permissive fluid management in pediatric DKA.
- Discrepancies in DKA management guidelines highlight ongoing debate, especially concerning fluid therapy.
- Recent studies challenge the causal relationship between IV fluids and DKA-related cerebral injury.
Conclusions:
- Effective DKA management requires prompt recognition, diagnosis, and integrated treatment including fluids, insulin, and close monitoring.
- The choice between restrictive and permissive fluid strategies in pediatric DKA lacks robust supporting evidence.
- Clinicians must carefully consider individual patient factors when implementing DKA management guidelines.
Background:
Diabetic ketoacidosis (DKA) is a life-threatening complication in children with diabetes mellitus. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians.
Objectives:
The purpose of this article is to provide a narrative review on the management of DKA.
Methods:
A PubMed search was performed with clinical queries using the key term "diabetic ketoacidosis". The search strategy included randomized controlled trials, clinical trials, meta-analyses, observational studies, guidelines, and reviews. The search was restricted to English literature and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines.
Results:
Selected international guidelines for DKA, namely International Society for Pediatric and Adolescent Diabetes (ISPAD), National Institute for Health and Care Excellence (NICE), British Society for Paediatric Endocrinology and Diabetes (BSPED), and South Thames Retrieval Service (STRS) were reviewed. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. This is based on the concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration. However, recent new clinical studies suggest that there is no causal relationship between intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians.
Conclusion:
The management of DKA involves early recognition, accurate diagnosis, meticulous fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal function, and neurological status. There is still limited clinical evidence to support either a restrictive or permissive approach in the fluid management of paediatric DKA patients. Clinicians should exercise caution when applying different guidelines in their clinical practice, considering the specific circumstances of individual paediatric patients.
Related Concept Videos
01:22Diabetes Mellitus: Overview and Type I Subtype
Type 1 diabetes is an autoimmune disease in which the immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas. As a result, the body is unable to produce sufficient insulin, and individuals with...
01:24Pharmacokinetics in Pediatric Patients: Drug Metabolism
01:20Pathophysiology of Diabetes
Type 1 diabetes is characterized by autoimmune-mediated destruction of pancreatic β cells, with environmental factors potentially triggering this process in genetically susceptible individuals. Despite many not having a family history, certain genes increase susceptibility, suggesting a...
01:22Complications of Diabetes Mellitus
01:25Diabetic Ketoacidosis l: Introduction
01:22Diabetic Ketoacidosis ll: Pathophysiology