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Papers in which it was unclear whether the inclusion criteria were met were assessed by a third researcher (MJT or FMW), and where either the definition of diabetic ketoacidosis was not given or we were unable to interpret the data presented adequately we contacted the authors for clarification.

Quality assessment was conducted independently by at least two reviewers (JAUS and FMW or MJT).

When studies recruited children over more than one time period and it was possible to separate all the data into different time periods, we used only the most recent period.

In all other cases we combined the data from all time periods.

A further eight papers were identified through citation searching.

One paper compared the severity of type 1 diabetes at presentation in south east Sweden and Lithuania and so is reported as two studies.18 The analysis is therefore based on 46 studies.

The current criteria for diagnosis published by the International Society for Paediatric and Adolescent Diabetes is blood glucose An electronic literature search of Pub Med, EMBASE, Web of Science, Scopus, and Cinahl up to March 2011 was performed using a combination of subject headings and free text incorporating “diabetic ketoacidosis” , “diabetes and ketoacidosis” , and “diagnosis” limited to infants, children, or adolescents (see appendix on for complete search strategy).The most common reasons for exclusion were that the papers included only a measure of the frequency of diabetic ketoacidosis and no further clinical details or it was not possible to separate the data for children with new onset diabetes (fig 1).

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