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How many of our children with type 1 diabetes are diagnosed in their first hospital admission for diabetic keto-acidosis (DKA)? The frequency with which this happens should be a cause for considerable concern. I recently learnt, from one of my paediatric colleagues, that perhaps 20% of new cases of childhood type 1 diabetes in Wales are diagnosed in this way. We seem not to be unusual in this respect since Australian colleagues confirm that this is also true in Sydney and in Newcastle, New South Wales. More formally, a recent publication from Manchester, UK found that 27% of newly diagnosed children identified in a 6-year retrospective audit presented in keto-acidosis. And this is not a new phenomenon. Pinkney et al. reporting data from the Bart’s-Oxford Study, in 1993, found that 16% of 219 cases first presented in “severe keto-acidosis” (pH 7.10–7.35 or plasma bicarbonate 10–21mmol/l). One of these children died during that episode.