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Insulin pump therapy is associated with higher rates of mild diabetic ketoacidosis compared to injection therapy: A 2‐year Swedish national survey of children and adolescents with type 1 diabetes

Open access
Wersäll, Johan H., Adolfsson, Peter, Forsander, Gun, Hanas, Ragnar·2022·Pediatric Diabetes
DOI 10.1111/pedi.13377PMC PMC9796597
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Abstract

OBJECTIVES: Diabetic ketoacidosis (DKA) in type 1 diabetes (T1D) can occur during both insulin pump therapy (continuous subcutaneous insulin infusion, CSII) and insulin injection therapy (multiple daily injections, MDI). The primary aim of this study was to compare CSII and MDI regarding DKA frequency. A secondary aim was to compare metabolic derangement between CSII and MDI at hospital admission for DKA. RESEARCH DESIGN AND METHODS: Children 0-17.99 years with established T1D admitted for DKA in Sweden from February 1, 2015 to January 31, 2017 were invited to participate. Data regarding demographics, laboratory data, CSII or MDI, and access to ketone meters and CGM were provided through questionnaires and medical records. The Swedish National Diabetes Registry (SWEDIABKIDS) was used to compare the distribution of CSII and MDI in the national population with the population admitted for DKA, using the chi-square goodness-of-fit test. Distribution of CSII and MDI was then categorized in clinical severity grades for mild (pH 7.20-7.29), moderate (pH 7.10-7.29) and severe DKA (pH <7.10). RESULTS: The distribution of CSII at DKA admission was significantly larger than in the national pediatric population with T1D (74.7% vs. 59.7%, p = 0.002). CSII was overrepresented in mild DKA (85.2% vs. with CSII, p < 0.001), but not in moderate/severe DKA (57.9% with CSII, p = 0.82). Mean HbA1c at hospital admission was 73.9 mmol/mol with CSII and 102.7 mmol/mol with MDI. CONCLUSIONS: CSII was associated with higher risk of mild DKA than MDI. MDI was associated with markedly higher HbA1c levels than CSII at hospital admission for DKA.

AI snapshot

Written from the paper’s full text.

TL;DR

In a 2-year Swedish national survey of children with established type 1 diabetes admitted for DKA, insulin pump therapy (CSII) was overrepresented relative to the national pediatric T1D population, but this excess was confined to mild DKA. Children on MDI who developed DKA had markedly higher HbA1c at admission than those on CSII.

Key findings

  • Among 99 first DKA admissions, 74/99 (74.7%) used CSII versus 59.7% CSII in the national SWEDIABKIDS pediatric T1D population (p = 0.002).
  • CSII was overrepresented in mild DKA (pH 7.20–7.29): 52/61 (85.2%) versus 59.7% nationally (p < 0.001); moderate/severe DKA combined showed no overrepresentation (22/38, 57.9% versus 59.7%, p = 0.82).
  • Mean HbA1c at hospital admission was 73.9 mmol/mol with CSII and 102.7 mmol/mol with MDI; HbA1c >70 mmol/mol was seen in 18/19 (94.7%) MDI cases versus 27/55 (49.1%) CSII cases.
  • Median pH at admission was 7.25 with CSII and 7.16 with MDI (p < 0.001); in adjusted multivariable regression, only insulin treatment mode had a significant effect on pH, with CSII associated with higher pH (p = 0.028).

Methods

  • National prospective study including all children 0–17.99 years with established T1D admitted for DKA in Sweden from February 1, 2015 to January 31, 2017; there were no exclusion criteria, all pediatric centers agreed to participate, and only the first DKA episode was included for children with multiple events.
  • Data came from questionnaires completed by parents/caregivers and children ≥15 years and by the attending physician or nurse, supplemented by medical records; SWEDIABKIDS provided national CSII/MDI distribution and patient-years.
  • Analyses used chi-square goodness-of-fit to compare DKA CSII/MDI distribution with the national population, Mann–Whitney U tests for pH and HbA1c, and univariate/multivariable regression adjusting for sex, age, ketone meter access, and CGM; DKA severity was graded as mild (pH 7.20–7.29), moderate (pH 7.10–7.19), and severe (pH <7.10).

Limitations

  • The paper states that total treatment time from CSII start to DKA admission was impossible to obtain from SWEDIABKIDS, which would have permitted more precise relative risk estimation, and that socioeconomic or ethnic data were not included in analyses.
  • The text makes evident possible under-ascertainment of mild DKA if some children self-treated at home and were not admitted; seven small hospitals reported no DKA cases, CSII/MDI usage data were unavailable for the entire study period for children who turned 18 before January 31, 2017, and the observational design lacked randomization.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1111/pedi.13377

Cites

34 of 34 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

7 of 23 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Hybrid Closed Loop systems that might decrease the risk of DKA were not standard features of CSII treatment at the time of study inclusion.

    “Hybrid Closed Loop systems that might decrease the risk of DKA were not standard features of CSII treatment at the time of study inclusion. 22 , 23 , 26”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [22] Breton MD, Kanapka LG, Beck RW, et al. A randomized trial of closed‐loop control in children with type 1 diabetes. N Engl J Med. 2020; 383(9): 836‐ 845. 32846062 PMC7920146 source

      The Trial Design and Patients section describes closed-loop control as a separate assigned treatment; control patients used their existing pumps or pumps with a predictive low-glucose suspend feature. This supports the distinction between closed-loop control and the pump treatment used in this trial, but does not establish what was standard in CSII treatment at the citing study’s inclusion date. The Adverse Events section reports no DKA in either group, so this trial cannot show a reduction in DKA risk. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites [23] Lee MH, Paldus B, Krishnamurthy B, et al. The clinical case for the integration of a ketone sensor as part of a closed loop insulin pump system. J Diabetes Sci Technol. 2019; 13(5): 967‐ 973. 30628470 PMC6955455 source
    • cites [26] Tauschmann M, Thabit H, Bally L, et al. Closed‐loop insulin delivery in suboptimally controlled type 1 diabetes: a multicentre, 12‐week randomised trial. Lancet. 2018; 392(10155): 1321‐ 1329. 30292578 PMC6182127 source

      The Introduction says the first hybrid closed-loop system entered clinical use in 2017, and Methods > Procedures distinguishes hybrid closed-loop therapy from standard insulin pump therapy in this trial. The paper does not establish that hybrid closed-loop systems decrease DKA risk or whether they were standard features at the citing study’s time of inclusion. Results report one DKA event in the closed-loop group, attributed to infusion-set failure. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Findingown data

    CSII was not overrepresented in moderate/severe DKA (57.9% vs 59.7%, p = 0.82).

    “but not in moderate/severe DKA (57.9% with CSII, p = 0.82)”
    • Also stated in: § Analyses of study data · plain
      “When severe and moderate DKA were combined, moderate/severe DKA had a distribution of CSII similar to the national population (57.9% vs. 59.7%, p = 0.82, chi‐square goodness‐of‐fit test, Figure 3).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The DKA cases captured in the study are representative of all DKA cases in Sweden during the study period with respect to insulin delivery mode.
    • Rests on an assumption: Treatment mode recorded at admission (CSII or MDI) accurately reflects the patient's insulin delivery mode at the time of DKA.
    • Rests on an assumption: The national population distribution of CSII and MDI based on treatment months in SWEDIABKIDS is proportional to patient-years and thus valid for comparison.
  • Findingown data

    CSII was overrepresented in mild DKA (85.2% vs 59.7%, p < 0.001).

    “CSII was overrepresented in mild DKA (85.2% vs. with CSII, p < 0.001)”
    • Also stated in: § Analyses of study data · plain
      “Children with mild DKA (pH 7.20–7.29) had a significantly larger distribution of CSII than the national pediatric T1D population (85.2% vs. 59.7%, p < 0.001, chi‐square goodness‐of‐fit test, Figure 3).”
    • Also stated in: § CONCLUSIONS · plain
      “However, this overrepresentation of CSII was seen in mild DKA.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The DKA cases captured in the study are representative of all DKA cases in Sweden during the study period with respect to insulin delivery mode.
    • Rests on an assumption: Treatment mode recorded at admission (CSII or MDI) accurately reflects the patient's insulin delivery mode at the time of DKA.
    • Rests on an assumption: The national population distribution of CSII and MDI based on treatment months in SWEDIABKIDS is proportional to patient-years and thus valid for comparison.
  • Findingown data

    The distribution of CSII at DKA admission was significantly larger than in the national pediatric population with T1D (74.7% vs 59.7%, p = 0.002).

    “The distribution of CSII at DKA admission was significantly larger than in the national pediatric population with T1D (74.7% vs. 59.7%, p = 0.002).”
    • Also stated in: § Analyses of study data · plain
      “There was a significant difference between the observed and the expected distributions of CSII and MDI in the population of DKA admissions (χ = 9.317, p = 0.002, chi‐square goodness‐of‐fit test, Figure 2).”
    • Also stated in: § CONCLUSIONS · plain
      “Compared with the distribution of CSII in the national pediatric population with T1D, the distribution of CSII was significantly higher in children admitted to hospital for DKA.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The DKA cases captured in the study are representative of all DKA cases in Sweden during the study period with respect to insulin delivery mode.
    • Rests on an assumption: Treatment mode recorded at admission (CSII or MDI) accurately reflects the patient's insulin delivery mode at the time of DKA.
    • Rests on an assumption: The national population distribution of CSII and MDI based on treatment months in SWEDIABKIDS is proportional to patient-years and thus valid for comparison.
  • Findingown data

    HbA1c levels >70 mmol/mol at admission for DKA were seen in 18/19 (94.7%) of children with MDI and 27/55 (49.1%) of children with CSII.

    “HbA1c levels >70 mmol/mol at admission for DKA were seen in 18/19 (94.7%) of children with MDI and 27/55 (49.1%) of children with CSII.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: HbA1c measured at hospital admission for DKA reflects usual glycemic control prior to the DKA episode.
  • Classified as probably not a substantial claim. 26
  • May combine two claims. 13

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Better glycemic control has been shown in several studies with CGM.

    “Besides advantages in increasing comfort, for example by enabling uninterrupted physical activity and minimizing the need for capillary glucose tests, better glycemic control has been shown in several studies. 7 , 13 , 19 , 20 , 21”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [7] Cardona‐Hernandez R, Schwandt A, Alkandari H, et al. Glycemic outcome associated with insulin pump and glucose sensor use in children and adolescents with type 1 diabetes. Data from the International Pediatric Registry SWEET. Diabetes Care. 2021; 44(5): 1176‐ 1184. 33653821 source
    • cites [13] Bratke H, Margeirsdottir HD, Assmus J, Njolstad PR, Skrivarhaug T. Does current diabetes technology improve metabolic control? A cross‐sectional study on the use of insulin pumps and continuous glucose monitoring devices in a Nationwide pediatric population. Diabetes Ther. 2021; 12(9): 2571‐ 2583. 34389930 PMC8385028 source
    • cites [19] DeSalvo DJ, Miller KM, Hermann JM, et al. Continuous glucose monitoring and glycemic control among youth with type 1 diabetes: international comparison from the T1D exchange and DPV initiative. Pediatr Diabetes. 2018; 19(7): 1271‐ 1275. 29923262 PMC6175652 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    DKA is associated with significant risk of acute morbidity and mortality, may cause long-term morbidity, and entails a substantial healthcare cost.

    “Since DKA is associated with significant risk of acute morbidity and mortality, may cause long‐term morbidity, and entails a substantial healthcare cost, it is nonetheless imperative to keep the incidence rate of DKA as low as possible. 27 , 28 , 29”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [27] Aye T, Mazaika PK, Mauras N, et al. Impact of early diabetic ketoacidosis on the developing brain. Diabetes Care. 2019; 42(3): 443‐ 449. 30573652 PMC6385695 source

      The Introduction describes DKA as a leading acute cause of morbidity and mortality in youth with type 1 diabetes and associates it with long-term adverse cognitive effects. The Conclusions also say that a single moderate or severe episode in young children can potentially have long-term effects. The paper does not substantiate the claim about substantial healthcare cost (searched: healthcare costs, hospitalization, economic cost, cost). (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [28] Ghetti S, Kuppermann N, Rewers A, et al. Cognitive function following diabetic ketoacidosis in children with new‐onset or previously diagnosed type 1 diabetes. Diabetes Care. 2020; 43(11): 2768‐ 2775. 32962981 PMC7576431 source

      The Conclusions (page not provided) describe brain injury as a serious DKA complication and report cognitive deficits that may persist or worsen, supporting the morbidity portions of the claim, particularly in children with type 1 diabetes. Our copy does not establish the claimed mortality risk or substantial healthcare cost. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [29] Donzeau A, Piffaretti C, Jossens A, et al. Time trend in excess mortality in children with type 1 diabetes from 1987 to 2016 in mainland France. Pediatr Diabetes. 2021; 23: 38‐ 44. 34881493 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    This study should be interpreted in relation to international rates of DKA in children with T1D, which are higher than in Sweden.

    “This study should be interpreted in relation to international rates of DKA in children with T1D, which are higher than in Sweden. 34 , 35”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [34] Cengiz E, Xing D, Wong JC, et al. Severe hypoglycemia and diabetic ketoacidosis among youth with type 1 diabetes in the T1D exchange clinic registry. Pediatr Diabetes. 2013; 14(6): 447‐ 454. 23469984 PMC4100244 source

      The Results > DKA section reports that 9.9% of participants in a US registry had at least one DKA event within 12 months. The Discussion places that figure alongside rates from other studies but says those rates are difficult to compare; it gives no Swedish rate or comparison showing that international rates are higher than Sweden’s. (LLM, conf=0.81)

      Experimental — accuracy not yet measured
    • cites [35] Maahs DM, Hermann JM, Holman N, et al. Rates of diabetic ketoacidosis: international comparison with 49,859 pediatric patients with type 1 diabetes from England, Wales, the U.S., Austria, and Germany. Diabetes Care. 2015; 38(10): 1876‐ 1882. 26283737 source

  • May combine two claims.

    Findingown data

    Mean HbA1c at hospital admission was 73.9 mmol/mol with CSII and 102.7 mmol/mol with MDI.

    “Mean HbA1c at hospital admission was 73.9 mmol/mol with CSII and 102.7 mmol/mol with MDI.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: HbA1c measured at hospital admission for DKA reflects usual glycemic control prior to the DKA episode.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    There were 118 DKA cases calculated from SWEDIABKIDS during the study period.

    “Including only the first DKA event in patients with multiple events, there were 118 DKA cases calculated from Swediabkids during the study period February 1, 2015 to January 31, 2017.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In adjusted multivariable regression analyses, only insulin treatment mode had a significant effect on pH, with CSII being associated with a higher mean pH value than MDI (p = 0.028, CI -0.103 to -0.006).

    “In adjusted multivariable regression analyses, only insulin treatment mode had a significant effect on pH, with CSII being associated with a higher mean pH value than MDI (p = 0.028, CI −0.103 to −0.006).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    In SWEDIABKIDS, among 7832 children with treatment mode registered, treatment time was 84,130 months (59.7%) with CSII and 56,755 months (40.3%) with MDI during the study period.

    “Treatment mode (CSII or MDI) was registered during at least one routine visit in 7832 children, in whom the treatment time was 84,130 months (59.7%) with CSII and 56,755 months (40.3%) with MDI (Figure 1).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The national population distribution of CSII and MDI based on treatment months in SWEDIABKIDS is proportional to patient-years and thus valid for comparison.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Regarding CGM, 39/70 (55.7%) of CSII users and 7/25 (28.0%) of MDI users had CGM at admission.

    “Regarding CGM, 39/70 (55.7%) of the CSII users and 7/25 (28.0%) of the MDI users had CGM at admission.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Access to ketone meters and CGM reported in questionnaires is accurate.

  • May combine two claims.

    Findingown data

    CGM use in children with DKA was only 58% for CSII and 29% for MDI, compared to an overall figure of 80%-90% in SWEDIABKIDS during the study period.

    “CGM use in children with DKA was only 58% for CSII and 29% for MDI, compared to an overall figure of 80%–90% in SWEDIABKIDS during the study period.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Access to ketone meters and CGM reported in questionnaires is accurate.

  • May combine two claims.

    Findingown data

    Of the 99 DKA cases included, 74/99 (74.7%) were CSII and 25/99 (25.3%) were MDI.

    “Of these, there were 74/99 (74.7%) cases with CSII and 25/99 (25.3%) cases with MDI treatment (Table 1 and Figure 1).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Treatment mode recorded at admission (CSII or MDI) accurately reflects the patient's insulin delivery mode at the time of DKA.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    No significant interactions were found between the independent variables.

    “No significant interactions were found between the independent variables.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Studies have shown mixed results regarding DKA incidence rates when comparing CSII with MDI, with CSII associated with higher, lower, or practically equal DKA incidence rates compared with MDI in various populations.

    “However, studies have shown mixed results regarding DKA incidence rates when comparing CSII with MDI. CSII has been associated with higher, 10 , 11 lower, 7 , 8 or practically equal 12 , 13 DKA incidence rates compared with MDI in various populations.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [10] Brorsson AL, Viklund G, Ortqvist E, Lindholm OA. Does treatment with an insulin pump improve glycaemic control in children and adolescents with type 1 diabetes? A retrospective case‐control study. Pediatr Diabetes. 2015; 16(7): 546‐ 553. 25327782 source

      Checked before — its earlier verdict is held back until a new check runs.

    • cites [11] Hanas R, Lindgren F, Lindblad B. A 2‐yr national population study of pediatric ketoacidosis in Sweden: predisposing conditions and insulin pump use. Pediatr Diabetes. 2009; 10(1): 33‐ 37. 18761647 source
    • cites [7] Cardona‐Hernandez R, Schwandt A, Alkandari H, et al. Glycemic outcome associated with insulin pump and glucose sensor use in children and adolescents with type 1 diabetes. Data from the International Pediatric Registry SWEET. Diabetes Care. 2021; 44(5): 1176‐ 1184. 33653821 source

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Premisecitation

    Access to blood ketone tests at home is recommended by many authors since these tests may reduce hospitalizations for DKA.

    “In addition, access to blood ketone tests at home is recommended by many authors since these tests may reduce hospitalizations for DKA. 14 , 15 , 16”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [14] Vanelli M, Mastrorilli C, Fainardi V, et al. Clinical utility of beta‐hydroxybutyrate measurement in the management of physiological ketosis at home in children under 5. Acta Bio‐Med: Atenei Parmensis. 2019; 90(2): 215‐ 220. PMC6776208 31124998 source

      Checked before — its earlier verdict is held back until a new check runs.

    • cites [15] Laffel LM, Wentzell K, Loughlin C, Tovar A, Moltz K, Brink S. Sick day management using blood 3‐hydroxybutyrate (3‐OHB) compared with urine ketone monitoring reduces hospital visits in young people with T1DM: a randomized clinical trial. Diabetic Med. 2006; 23(3): 278‐ 284. 16492211 source
    • cites [16] Klocker AA, Phelan H, Twigg SM, Craig ME. Blood beta‐hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in type 1 diabetes: a systematic review. Diabetic Med. 2013; 30(7): 818‐ 824. 23330615 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    pH values at hospital admission were compared between CSII and MDI using Mann-Whitney U test and univariate and multivariable regression analyses, adjusting for sex, age, and access to ketone meters and CGM, with robust estimation of variance.

    “pH values at hospital admission were compared between CSII and MDI using the Mann–Whitney U test and univariate and multivariable regression analyses, adjusting for sex, age, and access to ketone meters and CGM, with robust estimation of the variance for the multivariable analysis. 31”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [31] Dudgeon P. Some improvements in confidence intervals for standardized regression coefficients. Psychometrika. 2017; 82(4): 928‐ 951. 28290108

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    DKA incidence rates in children with established T1D are relatively low in Sweden from an international perspective, with annual incidences of hospital admission for DKA below 1% in the total national T1D pediatric population.

    “DKA incidence rates in children with established T1D are relatively low in Sweden from an international perspective, with annual incidences of hospital admission for DKA below 1% in the total national T1D pediatric population. 4”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Annual Report of the Swedish National Paediatric Diabetes Registry (SWEDIABKIDS). 2020; Accessed February 2022. https://www.ndr.nu/pdfs/Arsrapport_Swediabkids_2020.pdf.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All pediatric centers caring for children with diabetes agreed to participate prior to the inclusion period.

    “All pediatric centers caring for children with diabetes agreed to participate prior to the inclusion period.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    CGM utilizes subcutaneous sensors for continuous monitoring of glucose levels with a high degree of accuracy.

    “CGM utilizes subcutaneous sensors for continuous monitoring of glucose levels with a high degree of accuracy. 17 , 18”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [17] Bailey TS, Chang A, Christiansen M. Clinical accuracy of a continuous glucose monitoring system with an advanced algorithm. J Diabetes Sci Technol. 2015; 9(2): 209‐ 214. 25370149 PMC4604574 source

      Checked before — its earlier verdict is held back until a new check runs.

    • cites [18] Laffel L. Improved accuracy of continuous glucose monitoring systems in pediatric patients with diabetes mellitus: results from two studies. Diabetes Technol Ther. 2016; 18(Suppl 2): S223. 26784126 PMC4717517

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    There were no exclusion criteria.

    “There were no exclusion criteria.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The study is part of a two-year national prospective study, including all children 0-17.99 years with both new-onset and established T1D admitted to hospital for DKA in Sweden from February 1, 2015 to January 31, 2017.

    “This study is part of a two‐year national prospective study, including all children 0–17.99 years with both new‐onset and established T1D admitted to hospital for DKA in Sweden from February 1, 2015 to January 31, 2017.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisereasoning

    Interruption of insulin administration via CSII results in quicker ketogenesis than missed doses with MDI, where a long-acting insulin provides an insulin depot.

    “Interruption of insulin administration via CSII results in quicker ketogenesis than missed doses with MDI, where a long‐acting insulin provides an insulin depot.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Approval for this study was granted from the regional research ethics committee in Vastra Gotaland, Gothenburg, Sweden (registration number 748-14), who granted permission for the conduction of the study nationally.

    “Approval for this study was granted from the regional research ethics committee in Vastra Gotaland, Gothenburg, Sweden (registration number 748‐14), who granted permission for the conduction of the study nationally.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    CGM has been associated with lower frequencies of DKA in several international studies.

    “CGM has been associated with lower frequencies of DKA in several international studies. 7”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Cardona‐Hernandez R, Schwandt A, Alkandari H, et al. Glycemic outcome associated with insulin pump and glucose sensor use in children and adolescents with type 1 diabetes. Data from the International Pediatric Registry SWEET. Diabetes Care. 2021; 44(5): 1176‐ 1184. 33653821 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Another limitation is the lack of socioeconomic or ethnic data in statistical analyses.

    “Another limitation is the lack of socioeconomic or ethnic data in statistical analyses.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    A strength with this study is that it is a national population-based design that included all children 0-17.99 years with T1D admitted to hospital for DKA during 2 years.

    “A strength with this study is that it is a national population‐based design that included all children 0–17.99 years with T1D admitted to hospital for DKA during 2 years.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All included individuals consented to take part in the study, either by their caregivers or by caregivers and the child if above the age of 15 years.

    “All included individuals consented to take part in the study, either by their caregivers or by caregivers and the child if above the age of 15 years.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    The significant overrepresentation of CSII among hospital admissions for mild DKA could reflect a management problem in this group.

    “The significant overrepresentation of CSII among hospital admissions for mild DKA could reflect a management problem in this group. 36”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Dogan ADA, Jorgensen UL, Gjessing HJ. Diabetic ketoacidosis among patients treated with continuous subcutaneous insulin infusion. J Diabetes Sci Technol. 2017; 11(3): 631‐ 632. 27595713 PMC5505411

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    If a child had experienced multiple episodes of DKA during the study period, only the first episode was included in the study.

    “If a child had experienced multiple episodes of DKA during the study period, only the first episode was included in the study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    A lower DKA incidence in Sweden might reflect increased awareness among patients and caregivers.

    “A lower DKA incidence in Sweden might reflect increased awareness among patients and caregivers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A limitation in this study is that the total treatment time since the start of CSII treatment until DKA admission was impossible to obtain from SWEDIABKIDS.

    “A limitation in this study is that the total treatment time since the start of CSII treatment until DKA admission was impossible to obtain from SWEDIABKIDS.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    A high-quality national register (SWEDIABKIDS) was used to compare the background pediatric population with T1D.

    “Furthermore, a high‐quality national register (SWEDIABKIDS) was used to compare the background pediatric population with T1D.”
    Quote in the paperSubstantial claim
30 of 30

  • The paper relies on this without support.

    The DKA cases captured in the study are representative of all DKA cases in Sweden during the study period with respect to insulin delivery mode.

    “When including only the first hospital admission for DKA in children with multiple DKA events, the study captured 99/118 (84%) of all patients with DKA compared to Swediabkids.”

  • The paper relies on this without support.

    Treatment mode recorded at admission (CSII or MDI) accurately reflects the patient's insulin delivery mode at the time of DKA.

    “Parents/caregivers, together with their children if 15 years of age or above, filled out a questionnaire regarding demographic data, insulin treatment mode (CSII or MDI), access to capillary ketone meters, and CGM use at the time of admission.”

  • The paper relies on this without support.

    The national population distribution of CSII and MDI based on treatment months in SWEDIABKIDS is proportional to patient-years and thus valid for comparison.

    “Data on patient‐years with CSII or MDI were derived from the current type of insulin treatment registered in SWEDIABKIDS during routine outpatient visits.”

  • The paper relies on this without support.

    HbA1c measured at hospital admission for DKA reflects usual glycemic control prior to the DKA episode.

    “HbA1c levels were compared between CSII and MDI in DKA using the Mann–Whitney U test.”

  • The paper relies on this without support.

    Access to ketone meters and CGM reported in questionnaires is accurate.

    “Parents/caregivers, together with their children if 15 years of age or above, filled out a questionnaire regarding demographic data, insulin treatment mode (CSII or MDI), access to capillary ketone meters, and CGM use at the time of admission.”
5 of 5

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract gives a different pH range for moderate DKA

    Minor

    The abstract defines moderate DKA as pH 7.10-7.29, which overlaps its mild category. The methods define moderate DKA as pH 7.10-7.19.

  • Discussion CGM percentages differ from reported study results

    Minor

    The discussion states CGM use among children with DKA was 58% for CSII and 29% for MDI, whereas the results give 39/70 (55.7%) and 7/25 (28.0%), respectively. Neither discussion percentage is the rounded value of its reported result.

  • Mild-DKA MDI HbA1c standard deviation is incompatible with its range

    Minor

    For mild DKA with MDI, the reported HbA1c% SD is 3.0, although every reported value lies between 9.0% and 11.1%. Even a two-observation sample spanning that entire range could have an SD of at most about 1.49%.

  • Overall MDI minimum pH excludes a subgroup value

    Minor

    The table gives 6.96 as the minimum pH for all MDI cases, but 6.95 as the minimum for the moderate/severe MDI subgroup.

4 of 4

Cites

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Related

Authors
Wersäll, J. H., Adolfsson, P., Forsander, G., & Hanas, R.
Affiliations
  • Sahlgrenska University Hospital (SE)
  • Hallands sjukhus Kungsbacka (SE)
  • Institute of Clinical Sciences Sahlgrenska Academy at University of Gothenburg Gothenburg Sweden
Corresponding author
Wersäll, Johan H.
ORCID
Venue
Pediatric Diabetes
Publisher
Wiley
Published
2022-06-17
Volume
23
Issue
7
Pages
1038-1044
ISSN
  • 1399-543X (ISSN-L)
  • 1399-5448
DOI
10.1111/pedi.13377
PMC
PMC9796597
OpenAlex
W4281730061
Cited by
21
References
34
Citations by year
2026: 5 · 2025: 6 · 2024: 8 · 2023: 2
FWCI
2.84
Type
journal article
Language
en
Open access
Licence
Locations
  • Pediatric Diabetes (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
Keywords
insulin pump therapy, multiple daily insulin injections, diabetic ketoacidosis, type 1 diabetes, children and adolescents, HbA1c, continuous glucose monitoring, DKA severity, insulin delivery method
MeSH terms
Adolescent, Child, Diabetes Mellitus, Type 1, Glycated Hemoglobin, Humans, Hypoglycemic Agents, Injections, Subcutaneous, Insulin, Insulin Infusion Systems, Ketones, Sweden, Diabetic Ketoacidosis

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-11-06.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-11-06.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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