Pediatric Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) in a child is hyperglycemia, ketosis and acidosis. All three come from insulin deficiency. Most children with DKA have new-onset type 1 diabetes, and for that group DKA is the most common first presentation. Your goal has two parts. Restore perfusion and volume first. Then correct the acidosis and ketosis with insulin, without causing cerebral injury.

Why Kids Are Different

• Cerebral edema: Rare, but life-threatening. It mostly shows up in the first hours of treatment. In the PECARN FLUID trial, clinically apparent cerebral injury occurred in 0.9% of DKA episodes.
• Fluid and insulin are linked: insulin lowers serum osmolality slowly. Pace fluid and insulin together. Fluid restriction alone is not the way to do it.
• Smaller reserve: a child has less in the tank. Kids carry a higher volume-to-weight ratio, so a small loss in liters is a big percentage of their body. Weigh the child when you can.
• Dosing is per kg: insulin, fluid and every other drug are weight-based. Never use an adult fixed dose.

Think DKA in any child with polyuria, polydipsia, vomiting, abdominal pain, Kussmaul respirations, fruity breath or altered mental status. Be most suspicious when the child already has type 1 diabetes.

Diagnostic Criteria (ISPAD)

Severity

Severity comes from pH, bicarbonate and mental status. This page does not list the ISPAD cut-points. Use your local DKA severity protocol.

Red Flags

• Decreasing level of consciousness, or any new confusion or irritability (cerebral edema can be missed in the first hours)
• Signs of shock: prolonged capillary refill, cool or mottled skin, weak pulses
• Vomiting that prevents oral intake, or ongoing severe abdominal pain
• Glucose not falling, or potassium not measured before insulin

Fluids come first. Insulin starts after fluid resuscitation has begun. Not with the first bolus. And only once potassium is known and not low. The bolus and rehydration rates below follow the ISPAD 2022 summary and the PECARN FLUID trial. Confirm them with local protocol.

0–60 Minutes

1. Check glucose and potassium: measure before insulin. Point-of-care glucose is the first step; a venous blood gas and electrolytes follow. (Paramedic/RN/CCT, per local protocol)
2. Give the bolus: with shock, 20 mL/kg isotonic crystalloid rapidly, then reassess. Without shock, 10–20 mL/kg per protocol, then reassess before the next bolus.
3. Read the potassium before insulin: below 3.5 mmol/L, replace potassium first and hold insulin. 3.5–5.5 mmol/L, potassium goes into the fluid once urine output is confirmed. Above 5.5 mmol/L, withhold potassium until the child voids. Continuous ECG throughout. See the potassium chloride page.

1–48 Hours

1. Rehydrate: PECARN FLUID assumed a 5% deficit. It replaced that deficit evenly over 48 hours, alongside maintenance fluid (Holliday-Segar, 4-2-1 mL/kg/hr). That was the trial protocol, not a guideline dose. Watch the total rate. Do not exceed the protocol rate.
2. Choose fluid by sodium: 0.9% saline or a balanced crystalloid is started; once glucose is near 250 mg/dL and corrected sodium is normal or high, 0.45% saline or a balanced crystalloid may be used (per a 2026 meta-analysis summarizing ISPAD and ADA guidance).
3. Start insulin: regular insulin IV infusion at 0.05–0.1 units/kg/hr with no bolus. ISPAD advises against a bolus. In a 2026 randomized trial (n = 70), 0.05 units/kg/hr was non-inferior to 0.1 units/kg/hr for the glucose fall. The lower rate is a reasonable choice when glucose is falling quickly, or per protocol.
4. Add dextrose: when glucose falls to about 250 mg/dL, add dextrose (5%, or a higher concentration per protocol if glucose still falls too fast) to the fluid so insulin can continue, and titrate to glucose.

Cerebral edema is rare, and it is life-threatening. In the Glaser NEJM 2001 case-control study, the children who developed it arrived with lower PaCO₂ and higher blood urea nitrogen. Bicarbonate treatment was the only treatment variable still linked to it, at a relative risk of 4.2. Treat it right away once you suspect it. Do not wait for imaging.

Signs to Act On

• Deteriorating or abnormal mental status after treatment starts, including an abnormal response to pain
• Sustained fall in heart rate, with hypertension and irregular respiration (the Cushing triad)
• Headache, new vomiting, irritability, lethargy, incontinence in a child who is continent, diastolic blood pressure above 90 mmHg, or cranial nerve palsy

Treat the clinical picture. Do not use the Muir criteria to delay treatment. This page does not reproduce the major/minor classification.

Osmotherapy and Positioning

• Raise the head 15–30°. Avoid hypotension and hypoxia, and protect the airway. Don't hyperventilate, and avoid hypocapnia.
• Trim maintenance fluid to avoid overhydration. Osmotherapy should not wait for imaging.
• Mannitol 0.5–1 g/kg IV over 10–15 minutes, which may be repeated after 30 minutes, is the dose from a 2025 systematic review. The FDA label is approved for pediatric use to reduce intracranial pressure: 0.25 g/kg IV over at least 30 minutes, repeated every 6–8 hours. The label says the optimal pediatric dose has not been defined. The review dose is above the label dose, so use it only with medical direction and local protocol.
• 3% saline 2–5 mL/kg IV over 10–20 minutes, repeated if needed, is the range on the E3 3% saline page. A 2025 review gives 3–5 mL/kg over 10–15 minutes. ISPAD gives its own range. This page does not reconcile the two, so use the local protocol range.

Every dose runs per kg of measured weight. Get the weight first. Doses vary by protocol; follow local protocols and medical direction.

Insulin, dextrose, potassium chloride and hypertonic saline are the high-alert drugs on this page. Mannitol is dosed by weight as well.

Reassess mental status, perfusion and vital signs at least hourly. Document the GCS every hour. Check glucose and electrolytes often, and draw a venous blood gas as ordered. Write down fluid intake and output.

Transition to Subcutaneous Insulin

• Wait until DKA has resolved and the child can eat and drink. Only then move to subcutaneous insulin.
• Give the first subcutaneous dose and the overlap per protocol. Keep the IV infusion running through the overlap. Do not stop IV insulin first.

Disposition

• Any cerebral edema, shock, persistent acidosis or altered mental status means transfer to a pediatric-capable center or PICU.
• A child with DKA and altered mental status needs a PICU bed. For perfusion targets, see the pediatric shock page.

Infants and Children Under 2 Years

• The mannitol label warns that children under 2 years, neonates most of all, face a higher risk of fluid and electrolyte problems.
• A small child has little blood, so bolus volumes have to be exact. Use weight-based volumes only.

Known Type 1 Diabetes

• Ask about missed insulin doses, illness and insulin pump failure. Any one of them can be what set this off.
• SGLT2 inhibitors can cause DKA with a lower glucose. A normal glucose does not rule it out.

Adolescents

• Put adolescents on the pediatric DKA pathway, unless local policy sets an age cut-off for adult protocols. Adult fixed doses and boluses do not apply.
• Hyperosmolar hyperglycemic state can overlap with DKA. Check osmolality and mental status.
• An older adolescent may be pregnant. Check pregnancy status, and involve obstetric care.

• Destination: A pediatric-capable ED or PICU. Altered mental status or shock goes to the highest level of pediatric care available.
• Transport: Monitor continuously, elevate the head, and avoid hypotension and hypoxia. Avoid routine intubation or sedation. Kussmaul breathing is the child's compensation for acidosis. If intubation is required, match the pre-intubation minute ventilation and avoid hypocapnia.
• Handoff: Use IMIST-AMBO or MIST. Include the glucose trend, the potassium, the fluid volume given and the last mental status check.