Campaign for diabetic ketoacidosis prevention still effective 8 years later.

Diabetic ketoacidosis (DKA) in children with type 1 diabetes at onset is considered an increased risk factor of death and is generally related to a long duration of misdiagnosed hyperglycemia-associated symptoms (1). Shortening this latency period could be a winning preventive strategy. In the period of 1991–1997, we investigated this hypothesis in the province of Parma and demonstrated that, thanks to a school and physician campaign centered on the earliest symptom of diabetes (nocturnal enuresis in a “dry” child) as reported by 89% of parents, it was possible to prevent DKA (2). The key success of this campaign was due to a poster showing a child sleeping (potentially wetting the bed) as well as five attractive messages for parents: “Does your child drink and urinate more than usual? Has he started wetting the bed again?… Make sure he does not have high blood glucose levels… Call your Pediatrician today. Children can also have diabetes.” Eight years after the publication of the results from this campaign, newly diagnosed type 1 diabetes from the same area was retrospectively investigated in order to verify whether the campaign was still effective. From 1 January 1999 to 31 December 2006, 167 children with newly diagnosed type 1 diabetes were admitted to our department. Of these children, 32 (22 girls 7.8 ± 1.6 years of age) were from the province of Parma, where a prevention program for DKA had been promoted (group 1) and 42 (19 girls 8.2 ± 1.4 years of age) were from the two nearby provinces (group 2, control) in which no campaign had been performed. Moderate (pH <7.2, bicarbonate <10 mmol/l) or severe (pH <7.1, bicarbonate <5 mmol/l) DKA was found in 5 (15.6%) and 34 (80.9%; P < 0.002) children in groups 1 and 2, respectively. The DKA episodes in group 1 were observed in 2004 (n = 1), 2005 (n = 1), and 2006 (n = 3). No patients with DKA from group 1 were admitted in the period of 1999–2003. The duration of symptoms before diagnosis was 4.5 ± 3.5 and 16.0 ± 8.0 days (P < 0.0001) in groups 1 and 2, respectively. Almost all parents from both groups reported an unusual enuresis in their children, but only the parents (81%) from group 1 promptly consulted a pediatrician following the messages displayed in the poster. Today's data show that the campaign for DKA prevention is still effective in Parma's province 8 years after it was promoted and confirm that enuresis is the most important warning symptom for the early diagnosis of type 1 diabetes. DKA episodes observed in the patients from group 1 in the period of 2004–2006 are a sign that the campaign should be periodically renewed (possibly every 5 years) in order to maintain effectiveness.