Clinical and Biochemical Characteristics of Pediatric Diabetic Ketoacidosis Admissions to COVID-19 Free UAE Tertiary Center during Pandemic

The severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) was first reported in Wuhan City, China, in December 2019, and it led to serious global health crises resulted in declaring it as a pandemic on March 11, 2020, by the World Health Organization [1‒3].

Most of the countries, including United Arab Emirates (UAE), had initiated a range of public health care interventions and government regulations to mitigate the possible spread of severe acute respiratory syndrome coronavirus 2; this included a series of phased lockdowns in which physical medical services were limited only to emergencies. These regulations have led to a sudden change in lifestyle and a substantial drop in the visits to health care facilities due to the fear of contracting the virus. Such a change led to collateral effect on people with certain underlying medical conditions and those with undiscovered illness to be at risk of severe illness and acute life threating complications.

Diabetic mellitus (DM) is one of the most common chronic diseases with increasing prevalence in pediatric population. In particular, the high incidence of type 1 DM (T1DM), poor compliance and difficult control specially in pediatric age group has led to increase incidence of diabetic ketoacidosis (DKA) [4]. Several reports have indicated a surge in the number of newly diagnosed diabetes cases or worsening of the DKA severity among pediatric population during COVID-19 pandemic due to delayed diagnosis or presentation [5‒8]. No one has evaluated this information in UAE. The indirect impact of the pandemic on DKA admissions among children with T1DM in UAE is worth to be evaluated. Therefore, the aim of this study was to compare the characteristics and severity of DKA before and during the pandemic on T1DM children admitted to COVID-19-free hospital.

This is a descriptive retrospective study included all children and adolescents less than 16 years of age who were admitted with T1DM related DKA to Tawam Hospital between March 2017 and February 2021. Patients admitted between March 2020 and February 2021 (pandemic group) were compared to the previous 3 years (pre-pandemic group). We excluded patients with other types of DM such as type 2 DM or monogenic DM and who were tested positive COVID-19.

Diagnosis of T1DM was based on the criteria set by the International Society of Pediatric and Adolescent Diabetes (ISPAD) and American Diabetes Association (ADA) guidelines [9, 10] in the presence of at least one pancreatic antibody. As per the ISPAD guideline, DKA severity was classified as following: mild: venous pH <7.3 or serum bicarbonate <15 mmol/L, moderate: pH <7.2 or serum bicarbonate <10 mmol/L and severe: pH <7.1 or serum bicarbonate <5 mmol/L [9].

The data were retrieved from the electronic medical records for each admission, including number of admissions per year, demographic features, and laboratory findings (capillary pH, HCO₃, blood glucose, calculated corrected sodium, urine ketones and HbA_1c). Baseline demographic characteristics included the age, gender, nationality, family history of diabetes or autoimmune disorders, weight (wt) standard deviation score (SDS), height (Ht) SDS, body mass index (BMI) SDS, whether DM is pre-existed or newly diagnosed, and duration of DKA.

The study was approved by Al Ain District Human Research Ethics Committee (AA/AJ/787). Consent was not required because of retrospective data collection and lack of intervention.

Proportional outcomes were presented as numbers and percentages. Continuous values were expressed as mean with standard deviation or median with interquartile range (IQR) for normally and non-normally distributed variables respectively. χ² and Fisher’s Exact tests were performed for categorical variables. Two sample t test and Mann-Whitney U-Test were used to compare continuous variables with normal and nonnormal distribution respectively. p values <0.05 (two-sided) were considered statistically significant. Statistical analysis was performed using statistical software (Stata13, Stata corp LP, TX).

A total of 130 DKA episodes were included in the study; 63 were admitted during the pandemic period while 67 were admitted during the pre-pandemic period. Figure 1 shows the number of DKA admissions per month and the increase in the monthly admissions over the pandemic year compared with the pre-pandemic years.

The demographic and clinical characteristics of patients in both groups are shown in Table 1. The median (IQR) age of presentation was 11.2 (9.11–13.6) and 12.1 (6.8–12.6) years in the pandemic group and pre-pandemic group, respectively (p = 0.894). The majority of patients admitted with DKA during the pandemic year were in the group 6–11.9 years (54%), while more than half (53.7%) were at the age group 12–16 years in the pre-pandemic years (p = 0.001).

More patients with newly diagnosed diabetes were encountered during the pandemic compared to pre-pandemic years (42.9% vs. 25.4%, p = 0.035). The mean weight and BMI Z-scores ± SD were −0.27 ± 1.20 and −0.33 ± 1.65 versus 0.59 ± 1.3 and 0.61 ± 1.3 in the pandemic and pre-pandemic groups, respectively, p < 0.001 for both.

There was no difference in the clinical (dehydration, mental status) and biochemical (pH, HCO3, blood glucose, corrected sodium level) characteristics of DKA or resolution time between the two groups (see Table 2). However, the median (IQR) HbA1C was slightly higher in patients admitted during the pandemic year (11 [9.4–12.95%]) versus the pre-pandemic group (10.15 [9.27–11.80%]). Focusing on patients with newly diagnosed diabetes, again there was no significant difference between the pandemic and pre-pandemic years (Table 3).

Our study showed increase in number of DKA admissions as well as newly diagnosed T1DM during pandemic year compared to pre-pandemic years. This might be explained by the indirect impact of the COVID-19 pandemic in our region. As a government measure and one of the consequences were lockdown of Al Ain hospital, a secondary care center which is one of two large government hospitals in the eastern region, on April 2020 and relocate most of its medical services to Tawam Hospital, as a COVID-19-free hospital. On the other hand, all COVID-19 cases were forwarded to Al Ain hospital. In addition, people might feel more comfortable in seeking medical care when it is known to be a COVID-19-free center, minimizing risk of exposure.

Similar to our findings, Kamrath and colleagues [11] reported an increase in DKA which was explained by the local severity of the pandemic rather than health policy measures in Germany during pandemic which results in the delayed use of health care. In addition, an increased DKA frequency, including children with new-onset T1DM, had been reported in Saudi Arabia, potentially owing to delayed presentation [12].

In our study, the majority of patients in the pandemic group were in the age group of (6–11.9 years), however, in a German study, children younger than 6 years had the highest risk for DKA during pandemic [7]. It was more of an observational finding with no clear explanation, however, their cohort’s median age (9.9 years [IQR: 5.8–12.9 years]) was younger than our study.

In our cohort, there was no difference in characteristics of DKA episodes between the pandemic and pre-pandemic groups. This might be explained by the fact that our study was limited to a single center in our region, and we excluded all COVID-19 positive cases. Unlike our study, Kamrath and colleagues [7] showed significant increase in severity of DKA during the COVID-19 pandemic in children and adolescents due to multifactorial underlying causes which reflecting reduced medical services, fear of approaching the health care system, and more complex psychosocial factors.

Similarly, study done in Madrid confirms a significant increase in the severity of presentation of new-onset T1DM cases along with the high rate of pediatric intensive care unit admissions during the COVID-19 pandemic. It was attributed to the delayed access to health care reflecting parental/caregiver’s apprehension and desire to minimize risk of exposure to a conceivably contagious medical environment [8]. In addition, a higher proportion of incident T1DM cases presented with DKA and were admitted to the pediatric intensive care unit during pandemic had been reported by Al‐Abdulrazzaq and her colleagues in Kuwait [6].

Limitations of this study were the small sample size and being single center study, which was a COVID-19 free. Interrogation of larger, multicentered, nationally representative datasets would be beneficial for further investigation of COVID-19 impact in our region.

Understanding the direct and indirect impact of COVID-19 pandemic in pediatric diabetic population can help modify approach to such patients, as well as improve quality, utility of care and at same time avoid health system overload at most needed time. An example of this is the development of guideline in managing DM during pandemic [13] and awareness of diabetic patients and their parents about sick day management, specifically when to seek medical care.

In our COVID-19-free hospital, the pandemic and service reallocation has led to an increased rate of DKA admissions with increased number of newly diagnosed T1DM. Clinical presentation and severity were not adversely affected. However, larger, multicentered, nationally representative datasets would be beneficial for further investigation of COVID-19 impact in our region.

This study was approved by Al Ain District Human Research Ethics Committee (AA/AJ/787). It complies with the guidelines for human studies in accordance with the World Medical Association Declaration of Helsinki. Patients de-identified data used in this research was carried retrospectively. Patient gave their consent to use their data to be used for research by singing the general consent in the Medical Record System.

All authors have no conflict of interest to declare.

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Shoroogh Marei was the principal investigator; she designed the study with Noura Al Hassani. Raya Almazrouei and Walid Kaplan reviewed the methodology. Shoroogh Marei and Dalia Ra’a Said collected the data. Shoroogh Marei, Dalia Ra’a Said, and Noura Al Hassani reviewed the data. Shoroogh Marei, Noura Al Hassani, and Raya Almazrouei performed statistical analysis. Walid Kaplan and Noura Al Hassani reviewed statistical analysis results. Shoroogh Marei and Noura Al Hassani wrote the draft of the manuscript. Raya Almazrouei, Walid Kaplan, and Noura Al Hassani reviewed and edited the manuscript. All authors read and approved the final manuscript.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.