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Background: Raising the awareness of childhood diabetes symptoms can reduce the frequency of diabetic ketoacidosis (DKA) at onset of type 1 diabetes (T1D). However, data on the effectiveness of such interventions are limited. The aim of the study was to describe trends of DKA at onset of childhood T1D during 2005-2014 and assess the impact of a diabetes awareness campaign launched late 2010. Methods: Data of children < 12 years presented with DKA at diagnosis were analyzed according to age, gender and year of diagnosis. The frequency and severity of DKA before and during the 4 years campaign were compared. Results: During 2005-2014, 44.9% (243/541) of children diagnosed with T1D presented with DKA. Of these, 22.7% had pH < 7.1. In both genders DKA was higher in children < 6 years (47.8% vs. 40%; p < 0.01) and more severe in < 3 years old compared to older children (30% vs. 20%; p < 0.01). Following the awareness campaign DKA rate dropped from 48% in 2010 to 39% in 2014 and 15.8% had severe DKA compared to 26.1% in 2005-2010 (p < 0.01). This trend was observed in both genders and across age groups. In children < 3 years the reduction in DKA frequency and severity was not statistically significant (p = 0.15 and p = 0.42, respectively). Conclusions: In NWSA, the frequency and severity of DKA at onset of childhood T1D were reduced following 4 years awareness campaign; but the rate is still high. Maintaining the campaign may result in further improvement following a longer period of observation. [ABSTRACT FROM AUTHOR]