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For papers where a definite decision to reject could not be made based on title and abstract alone, the full text was examined.

At least two reviewers (JAUS and FMW or MJT) independently assessed all full text papers, and those not meeting the inclusion criteria by both researchers were excluded.

The 46 eligible studies included more than 24 000 children in 31 different countries.

Included studies showed considerable heterogeneity in terms of size, setting, length of study, and the proportion of children presenting in diabetic ketoacidosis (tables 1).

After duplicates were removed, the search identified 1441 papers.

One author (JAUS) excluded 1333 of these as clearly irrelevant on the basis of title and abstract.

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).

We excluded three papers after contacting the authors as it was not possible to establish the definition of diabetic ketoacidosis used.

We expressed the effect of a risk factor as an odds ratio with 95% confidence interval where possible, but where the data did not allow this we compared the mean and standard deviation of the risk factor between those individuals with and without diabetic ketoacidosis and expressed this as mean and standard error.One reviewer (JAUS) performed the search and screened the titles and abstracts to exclude papers that were clearly not relevant.A second reviewer (FMW) independently assessed a random selection of papers excluded at that stage.Studies including only highly selected groups—such as neonates or children being treated with high dose corticosteroids or receiving chemotherapy—as well as drug trials and conference proceedings were excluded.We chose to include all studies which defined diabetic ketoacidosis based on measurement of either p H or bicarbonate as this was an exploratory review not limited by time or language of publication, and we expected a range of different definitions.

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We used the Critical Appraisal Skills Programme guidelines for case control and cohort studies14 as an initial framework and classified each as key paper, satisfactory, unsure, fatally flawed, or irrelevant as in the approach of Dixon-Woods et al.15 We excluded papers classified as fatally flawed or irrelevant and discussed those classified as unsure at consensus meetings.

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