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Global data show an increase in the rate of diabetic ketoacidosis (DKA) at type 1 diabetes (T1D) onset during the COVID-19 pandemic, but its effect on severity remain unclear. This study assessed pre-pandemic, pandemic, and post-pandemic DKA frequency in Polish children with new-onset T1D and evaluated the pandemic's impact on DKA incidence and severity.

This multicenter national retrospective study collected an anonymized list of all new-onset T1D cases in Polish children (<18y.o.) diagnosed based on clinical presentation (diabetes diagnosed based on random blood glucose >=200mg/dl and symptoms, no suspicion of other type of diabetes).

We analyzed 7192 children with a new-onset diabetes, and after applying the predefined inclusion and exclusion criteria, 6543 cases were ultimately included in the final analysis. Overall, 54.5% presented with DKA. Frequency increased from 47.9% in 2019 to 58.6% in 2020 (p<0.0001) and decreased to 54.0% in 2022. Observed pandemic DKA (56.8%) exceeded model predictions (47.5%; p=0.0041). The additional impact of COVID-19 was estimated at a +9.4 percentage-point increase, with a 95% CI of +9.1 to 9.6%, with DKA predicted and observed rates converging by the end of the pandemic. During the pandemic, children were also more likely to present with moderate or severe DKA compared with the rest of the study period, with a subsequent decrease in severity after the pandemic.

DKA frequency increased across the study period, with a peak during the pandemic. This findings should be interpreted in the context of global epidemiological data, where the prevalence of DKA at diagnosis of type 1 diabetes remains high and varies widely between countries, reaching around 50% in some populations. Therefore, coordinated country-level actions aimed at improving awareness of early diabetes symptoms are needed to reduce the persistently high rate of DKA.