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We aimed to examine 25-yr trends in the incidence, age at diagnosis, seasonal variation, and frequency of diabetic ketoacidosis among children and adolescents with newly diagnosed type 1 diabetes mellitus in Serbia, before, during, and after the COVID-19 pandemic. This nationwide, multicentre, study included all individuals aged ≤ 19 yr diagnosed with T1DM between 2000 and 2024 across 15 paediatric centres in Serbia. Clinical characteristics were compared using parametric and non-parametric tests, as appropriate. A total of 4,335 new T1DM cases were registered. The incidence increased significantly from 9.7 per 100,000 in 2000 to 25.5 per 100,000 in 2021 (annual percent change (APC) 3.12%, p < 0.001). Among children aged 0-14 yr, incidence rose until 2016 (APC 4.14%, p = 0.01), followed by a plateau through 2024, suggesting possible stabilization in younger age groups. Monthly variations in the frequency of newly diagnosed T1DM cases did not reach statistical significance (p = 0.876). Overall, 42.4% of patients presented with DKA, with a marked rise during the COVID-19 pandemic (47.7%) and persistently higher post-pandemic levels compared with pre-pandemic years. Over 25 yr, Serbia experienced a steady increase in paediatric T1DM incidence with recent stabilization among younger children. DKA remains persistently high in post pandemic years.