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    1 Comment for this article
    Severe Ketoacidosis During The COVID-19 pandemic
    Devi Dayal, MD | Endocrinology and Diabetes Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.
    The article confirms the fears about an increase in severity of diabetic ketoacidosis (DKA) in children and adolescents with onset of type 1 diabetes (T1D) during the COVID-19 pandemic. The data hint at delays in access to healthcare even in a developed country like Germany. Parents’ fear of approaching healthcare services appears to be one of the major factors responsible for delayed presentations to a health facility, especially in those with severe DKA.

    The situation in the developing countries is even worse, where almost all children with onset of T1D are presenting to the hospitals in severe DKA
    (1,2). Although parental fear of exposure to COVID-19 in hospital settings and their ignorance of initial symptoms of diabetes plays some role, the main reason for severe DKA presentations is a virtual closure of medical services due to crumbled healthcare infrastructure in low-resource setups (2). I therefore strongly agree with the authors that education of public and healthcare workers is urgently needed to reduce presentations in DKA as well as severity of DKA, by emphasizing to parents they should bring sick children to hospitals without delay. β-cell antibody screening as suggested by the authors as another option is impractical during an ongoing pandemic (3).


    1. Dayal D, Gupta S, Raithatha D, Jayashree M. Missing during COVID-19 lockdown: Children with onset of type 1 diabetes [published online ahead of print, 2020 Jun 23]. Acta Paediatr. 2020;10.1111/apa.15443. doi:10.1111/apa.15443

    2. Dayal D, Gupta S, Raithatha D, Soni P, Kumar S, Baranwal A. Near-fatal experience due to delayed diagnosis of type 1 diabetes during the COVID-19 pandemic. April 28, 2020, Preprint (Version 1). Available at Research Square https://doi.org/:10.21203/rs.3.rs-25337/v1.

    3. Ziegler AG, Kick K, Bonifacio E, et al. Yield of a Public Health Screening of Children for Islet Autoantibodies in Bavaria, Germany. JAMA. 2020;323(4):339-351. doi:10.1001/jama.2019.21565
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    Research Letter
    July 20, 2020

    Ketoacidosis in Children and Adolescents With Newly Diagnosed Type 1 Diabetes During the COVID-19 Pandemic in Germany

    Author Affiliations
    • 1Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
    • 2Department of Pediatrics, Kinderkrankenhaus Amsterdamer Strasse, Cologne, Germany
    • 3Diabetes Center for Children and Adolescents, Children’s Hospital Auf der Bult, Hannover, Germany
    • 4Department of Pediatrics, Saarland University Medical Center, Homburg/Saar, Germany
    • 5Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
    • 6Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany
    • 7Institute of Epidemiology and Medical Biometry (ZIBMT), Ulm University, Ulm, Germany
    JAMA. Published online July 20, 2020. doi:10.1001/jama.2020.13445

    During the coronavirus disease 2019 (COVID-19) pandemic, a significantly lower rate of health care use has been reported, potentially leading to delayed medical care.1 Diabetic ketoacidosis is an acute life-threatening complication of a delayed diagnosis of type 1 diabetes.2 We investigated the frequency of diabetic ketoacidosis in children and adolescents at diagnosis of type 1 diabetes in Germany during the first 2 months of the COVID-19 pandemic.

    This study used data from the German Diabetes Prospective Follow-up Registry (DPV) of children and adolescents with the diagnosis of type 1 diabetes between March 13, 2020, when most kindergartens and schools were closed to reduce interpersonal contacts, through May 13, 2020. The DPV registry has a nationwide coverage of more than 90% of pediatric patients with type 1 diabetes.3 Since 2018, 217 diabetes centers (hospitals and medical practices) have transferred information from pediatric patients with newly diagnosed type 1 diabetes.