The Temporal Relationship Between Local School Closure and Increased Incidence of Pediatric Diabetic Ketoacidosis.

Casey K Mccluskey,Kenneth E Remy,Matthew C Scanlon,Janine E Zee-Cheng,Christopher L Carroll,Alexandre T Rotta,Steven L Shein,Margaret J Klein

doi:10.3389/fped.2022.812265

Abstract

ImportanceThe incidence of pediatric diabetic ketoacidosis (DKA) increased early in the COVID-19 pandemic, but the relative contribution of behavioral changes and viral-related pathophysiology are unknown.ObjectiveTo evaluate the relationship between school closure date and onset of increased DKA to help clarify the etiology of the increased incidence.DesignA multi-center, quality-controlled Pediatric Intensive Care Unit (PICU) database was used to identify the number of admissions to a participating PICU with DKA on each calendar day from 60 days before local school closure to 90 days after, and compared to baseline data from the same periods in 2018–2019. Interrupted time series and multiple linear regression analyses were used to identify admission rates that differed significantly between 2020 and baseline.SettingEighty-one PICUs in the United StatesParticipants: Children ages 29 days to 17 years admitted to a PICU with DKAExposures: Statewide school closureMain outcome/measure: Rate of admission to the PICU for DKA.ResultsThere were 1936 admissions for children with DKA in 2020 and 1795 admissions/year to those same PICUs in 2018-2019. Demographics and clinical outcomes did not differ before school closure, but pandemic-era patients were less often white and had longer hospital length of stay in the post-school closure period. The difference between 2020 admissions and 2018-2019 admissions was not different than zero before school closure, and significantly higher than zero after school closure, but was significantly increased in 2020 at >30 days after school closure (p = 0.039).Conclusions/RelevanceAn increase in pediatric DKA admissions began one month after school closures. Given that behavioral changes started near school closure dates and viral activity peaked weeks after, this suggests that behavioral factors may not be the primary etiology and it is possible that SARS-CoV-2 infection may have direct effects on pediatric DKA.

Highlights

Higher incidence of diabetic ketoacidosis (DKA) early in the COVID-19 pandemic was reported in the United Kingdom and in the United States (US) [1, 2], but the relative contributions of societal influences and viral infection are unclear
We evaluated the relationship between school closure date and the number of children admitted with DKA to Pediatric Intensive Care Units (PICUs) across the US
We found an increased incidence of pediatric DKA beginning approximately one month after local school closure

Summary

Introduction

Higher incidence of diabetic ketoacidosis (DKA) early in the COVID-19 pandemic was reported in the United Kingdom and in the United States (US) [1, 2], but the relative contributions of societal influences (e.g., reduced access to medical care, hesitancy to seek care) and viral infection are unclear. Prior studies have compared the incidence of pediatric DKA in a discrete epoch (e.g., March–April 2020) to preceding years [1, 2]. Vaccination rates, sick visits to the pediatrician, and emergency room utilization all decreased concurrently with school closures and other measures aiming to mitigate the pandemic, suggesting that DKA rates should increase near that time if primarily driven by behavioral changes [3–6]. A more delayed increase in DKA would be expected if viral factors predominate, since COVID-19 incidence peaked weeks after school closures [7]. We evaluated the relationship between school closure date and the number of children admitted with DKA to Pediatric Intensive Care Units (PICUs) across the US

Methods

Results

Conclusion