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Rehydration is Often Inadequate for Children Who are Overweight and Have Diabetic Ketoacidosis (DKA)

November 3, 2023

Editor’s Note: Dr. Julie Evans (she/her) is a resident physician in pediatrics at the University of Virginia. She is interested in general pediatrics and global health. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

In 2018, the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in Diabetic Ketoacidosis (FLUID) trial set out to recommend what type of fluid, how much, and how quickly children in diabetic ketoacidosis (DKA) can be adequately rehydrated. .

The researchers were able, through this trial that used fluid volumes based on each child’s weight, to determine that fluid rate and sodium content of the fluid had no association with short- or long-term neurological injuries in children. However, this study did not investigate whether these rates and volumes were appropriate for children who have been diagnosed as being obese or overweight.

Dr. Kathleen M. Brown from Children’s National Medical Center and colleagues in the PECARN FLUID group, completed a secondary analysis of the PECARN FLUID trial database to determine whether children with obesity or overweight are at increased risk for neurological injuries if they receive fluid rehydration based on weight. Their results are being early released in Pediatrics this week in an article entitled, “Rehydration Rates and Outcomes in Overweight Children with Diabetic Ketoacidosis” (10.1542/peds.2023-062004).

The authors hypothesized that for children with obese and overweight:

  • Clinicians would be hesitant to give bolus fluid volumes based on the child’s weight at the PECARN FLUID protocol
  • Lesser volumes would result in longer duration to recovery
  • Lesser volumes would result in more complications due to insufficient electrolyte replacement

The PECARN FLUID trial participants were randomized to 1 of 4 IV fluid treatment protocols. The protocols used either half normal or normal saline, and a rapid or slow rehydration rate. Volume of fluid rehydration was weight based, and the maximum amount was based on a weight of 100 kilograms. For this study, patients with a body mass index (BMI) in the 85th-95th percentile were considered overweight, and those with BMI over the 95th percentile were considered obese.

The authors analyzed data from 1,277 DKA episodes, and only 7 youth weighed more than 100kg.

The authors found that:

  • Patients with obesity received significantly less than protocol determined amount of fluid when compared to children in the overweight and normal BMI groups at both 12 and 24 hours.
  • Children with overweight and obesity received a slower rate of rehydration than the protocol dictated compared with the children in the normal BMI group.
  • These differences persisted when adjusted for age, new onset diabetes vs previous diagnosis, and DKA severity.
  • Increased risk of mental status decline and cerebral injury were similar between all BMI groups.
  • Higher rates of hypophosphatemia were observed in children with obesity. This was thought to represent the lack of phosphate in bolus fluids.
  • There was no difference between groups in relation to other electrolyte abnormalities.

Based on the findings of this article, clinicians should treat children with DKA with obesity and overweight the same as they would those with a normal BMI - with proper fluid rehydration volume based on weight. Fluid administration using weight-based calculations will not put these patients at increased risk for cerebral injury and may be able to prevent hypophosphatemia.

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