AIMS/HYPOTHESIS: The aim of this work was to evaluate geographical variability and trends in the prevalence of diabetic ketoacidosis (DKA), between 2006 and 2016, at the diagnosis of childhood-onset type 1 diabetes in 13 countries over three continents. METHODS: An international retrospective study on DKA at diagnosis of diabetes was conducted. Data on age, sex, date of diabetes diagnosis, ethnic minority status and presence of DKA at diabetes onset were obtained from Australia, Austria, Czechia, Denmark, Germany, Italy, Luxembourg, New Zealand, Norway, Slovenia, Sweden, USA and the UK (Wales). Mean prevalence was estimated for the entire period, both overall and by country, adjusted for sex and age group. Temporal trends in annual prevalence of DKA were estimated using logistic regression analysis for each country, before and after adjustment for sex, age group and ethnic minority status. RESULTS: During the study period, new-onset type 1 diabetes was diagnosed in 59,000 children (median age [interquartile range], 9.0 years [5.5-11.7]; male sex, 52.9%). The overall adjusted DKA prevalence was 29.9%, with the lowest prevalence in Sweden and Denmark and the highest in Luxembourg and Italy. The adjusted DKA prevalence significantly increased over time in Australia, Germany and the USA while it decreased in Italy. Preschool children, adolescents and children from ethnic minority groups were at highest risk of DKA at diabetes diagnosis in most countries. A significantly higher risk was also found for females in Denmark, Germany and Slovenia. CONCLUSIONS/INTERPRETATION: DKA prevalence at type 1 diabetes diagnosis varied considerably across countries, albeit it was generally high and showed a slight increase between 2006 and 2016. Increased awareness of symptoms to prevent delay in diagnosis is warranted, especially in preschool children, adolescents and children from ethnic minority groups.

Centre of Epidemiology and Biostatistics Polytechnic University of Marche Via Tronto 10 a 60020 Ancona Italy

DECCP Clinique Pédiatrique Centre Hospitalier Luxembourg Luxembourg

Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden

Department of Child Health University Hospital of Wales Cardiff UK

Department of Endocrinology Starship Children's Health Auckland New Zealand

Department of Paediatric Diabetes John Hunter Children's Hospital Faculty of Medicine University of Newcastle Newcastle NSW Australia

Department of Paediatric Endocrinology Diabetes and Metabolic Diseases UMC University Children's Hospital and Faculty of Medicine Ljubljana Slovenia

Department of Pediatric and Adolescent Medicine Medical University of Vienna Vienna Austria

Department of Pediatrics 1 Medical University of Innsbruck Innsbruck Austria

Department of Pediatrics 2nd Faculty of Medicine Charles University Prague and Motol University Hospital Prague Czechia

Department of Pediatrics Aarhus University Hospital Aarhus Denmark

Department of Pediatrics and Adolescent Medicine Copenhagen University Hospital Herlev Denmark

Department of Pediatrics NU Hospital Group Uddevalla Sweden

Department of Pediatrics Ryhov County Hospital Jönköping Sweden

Departments of Nutrition and Medicine University of North Carolina Chapel Hill NC USA

Division of Paediatric and Adolescent Medicine Oslo University Hospital Oslo Norway

Division of Pediatric Diabetology Department of Women's and Children's Health Salesi Hospital Ancona Italy

Division of Population Medicine School of Medicine Cardiff University Cardiff UK

German Center for Diabetes Research Munich Neuherberg Germany

Institute of Clinical Medicine University of Oslo Oslo Norway

Institute of Epidemiology and Medical Biometry ZIBMT University of Ulm Albert Einstein Allee 41 89081 Ulm Germany

Lifecourse Epidemiology of Adiposity and Diabetes Center Colorado School of Public Health University of Colorado Anschutz Medical Campus Aurora CO USA

Paediatrics Robinson Research Institute The University of Adelaide Adelaide SA Australia

Sahlgrenska Academy Institute of Clinical Sciences Gothenburg University Gothenburg Sweden

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EDENT1FI Master Protocol for screening of presymptomatic early-stage type 1 diabetes in children and adolescents

Impact of the COVID-19 pandemic on long-term trends in the prevalence of diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes: an international multicentre study based on data from 13 national diabetes registries