Keytones & glucose in 4yo's urine

[amyinva]

My 4yo had a few episodes several months ago where he woke up extremely pale & lethargic. After some juice and a few hours sleep, he perked right back up and seemed normal. He hasn't had this happen for several months, but this morning he did it again. He has a cold, but nothing major that would cause that kind of lethargic weird stuff. So I tested his urine with some strips. He had very high keytones & high specific gravity so I took him to see the doctor. He had a trace amount of glucose in his urine but his blood glucose was 79. Doc says he thinks he was just wonky bc of his virus & his ears are really inflamed, & sometimes inflammation can make things a little weird. Basically, he didn't really know, and wasn't concerned bc his blood glucose was so good.

Any thought, Dr Hive? I didn't think you could get high keytones or even trace glucose in your urine for no reason..

[umsami]

I don't know. I would watch/monitor it, and if it continues…then I'd probably want to see an endocrinologist, or at least go back to the ped with that info.   

[Jean in Newcastle]

Was this a fasting urine test?  

 

Had he had any water before you tested?  Dehydration can lead to high keytones in children, I understand.  

[Sara in AZ]

I did a little research on ketones yesterday because DD, who is Type 1 diabetic, had super high glucose and was spilling moderate ketones. It's my understanding that ketones in the urine for anyone, non diabetics included, could be a sign of infection. That would jive with your son's cold and ear infection. But I've got nothing about specific gravity or the rest I the situation. Hope you get it figured out!

[amyinva]

I had already given him some OJ but the keytones were definitely lower after I pushed fluids.

[wapiti]

Specific gravity might be high just from overnight dehydration if it's a first morning sample.

 

I haven't done research on ketones in kids, though thinking out loud, I'd guess that it's possible to produce ketones overnight when the body is running on fat (for myself, that's a good thing, though certainly I don't know what the case would be for a child).  What was the level indicated by the strip?  That may provide more of a clue as to whether this is something to worry about.  It might make me wonder if his blood glucose was low enough for him to switch over to a state of nutritional ketosis (to be distinguished from the completely different ketoacidosis, which would be where levels come into play).

[Jean in Newcastle]

I had already given him some OJ but the keytones were definitely lower after I pushed fluids.

OJ should bring up his glucose levels fairly quickly so I would assume with a blood sugar of 79 after OJ that he was hypoglycemic.  That would explain the high keytones in his urine.  I'm not so sure about about trace glucose.  A virus can cause a child to become hypoglycemic.  

[Lawana]

Ketones are produced when there is a relative lack of insulin in the blood, as the body switches from using glucose to using ketone bodies for fuel. This can occur after several hours of fasting, though the ketones produced are usually small amounts. Some individuals tend to produce ketones more readily than others. As others have noted, illness can increase ketone production.

In a non-diabetic person, ketones are generally not immediately dangerous. In someone who doesn't produce enough insulin (Type 1 advanced Type 2 Diabetic), a condition called Diabetic KetoacidosiS (DKA) can be life threatening.

I am guessing that the doc felt a blood glucose of 79 was sufficient to rule out diabetes. You might consider getting a bg meter and making a few random checks yourself if it will reassure you. Are you familiar with the symptoms of diabetes?

[LMV]

The history/clinical presentation sounds like idiopathic ketotic hypoglycemia.  (Because if the blood sugar was 79 after OJ I'm presuming it was likely <60 before.) Your son is the right age for this as well.

 

Generally with these kids in the ED we give IV fluids with dextrose, draw critical labs (i.e. cortisol, GH, insulin, lactate, and a CMP) when the nurses put the IV in.  You do need to rule out endocrinologic explanations (i.e. adrenal insufficiency, panhypopit, GH deficiency), hyperinsulin syndromes, and metabolic derangements (i.e. organic acidemias, fatty acid oxidation disorders, and glycogen storage disorders so if that hasn't already been done we'll add in urine organic acids and serum carnitine and acylcarnitines.  Most of the kids without a good diagnosis we usually like it if their pediatrician will at least do an observation "admission" or if we can't get them tolerating PO and back to baseline even if they do have a good explanatory diagnosis.

 

I'm not offering medical advice but perhaps you can ask your pediatrician about idiopathic ketotic hypoglycemia and see if they want to do the rest of the workup or if they prefer to refer to endocrine and metabolism.  In general, if it is IKH you want to avoid prolonged fasts and ensure that the diet overall has adequate carbohydrates and protein.  

[sbgrace]

My son had high ketones and hypoglycemia when he was younger. That was diagnosed when he was around 3 or 3.5. I don't know if he still does, but I don't think so. I don't see the symptoms (nausea, vomiting, emotional stuff) I saw back then.

 

The pediatrician and later geneticist (our metabolics dr.) wasn't overly concerned because the ketones are protective in hypoglycemia. It's non-ketotic hypoglycemia that is very dangerous.

 

My son does have a metabolic condition affecting fatty acid metabolism and mitochondrial function. He is carnitine deficient without supplementation. We didn't know that when the hypoglycemia was diagnosed initially, though. The ketotic hypoglycemia didn't seem to alarm any of the doctors pre or post metabolic condition diagnosis. I got impression, in fact, that ketotic hypoglycemia doesn't usually indicate any other issues when it occurs in young kids. It was other things that showed he was sick.

 

Long story short, certainly follow up. But my guess is he's hypoglycemic in the mornings due to age. The doctors recommended we do uncooked cornstarch (ick) before bed. Other than that, they had no suggestions. We used to give my son a spoonful of apple or pear sauce when he first woke up. Though I don't have tests to prove it, I believe he outgrew this issue for the most part.

[amyinva]

Thank you everyone, so much, for the feedback. I will talk to our doc about these issues. I feel like I am much more informed now!

[LMV]

My son had high ketones and hypoglycemia when he was younger. That was diagnosed when he was around 3 or 3.5. I don't know if he still does, but I don't think so. I don't see the symptoms (nausea, vomiting, emotional stuff) I saw back then.

 

The pediatrician and later geneticist (our metabolics dr.) wasn't overly concerned because the ketones are protective in hypoglycemia. It's non-ketotic hypoglycemia that is very dangerous.

 

My son does have a metabolic condition affecting fatty acid metabolism and mitochondrial function. He is carnitine deficient without supplementation. We didn't know that when the hypoglycemia was diagnosed initially, though. The ketotic hypoglycemia didn't seem to alarm any of the doctors pre or post metabolic condition diagnosis. I got impression, in fact, that ketotic hypoglycemia doesn't usually indicate any other issues when it occurs in young kids. It was other things that showed he was sick.

 

Long story short, certainly follow up. But my guess is he's hypoglycemic in the mornings due to age. The doctors recommended we do uncooked cornstarch (ick) before bed. Other than that, they had no suggestions. We used to give my son a spoonful of apple or pear sauce when he first woke up. Though I don't have tests to prove it, I believe he outgrew this issue for the most part.

 

I agree that given the age and the way she described it this is most likely Idiopathic Ketotic Hypoglycemia.  However, since some kids who present this way do have an endocrine or metabolic derangement causing these symptoms (and likely to cause other problems in some cases), and other kids  may have IKH on top of other conditions, I think prudent physicians will order some additional tests to exclude the other more serious explanations.  It sounds like this is what happened with your son.

 

IKH is most common in kids between 18 months and 5 years.  So far research really hasn't come up with a great explanation/cause (hence the Idiopathic part of the name) and it is thought that these kids are probably just experiencing an "extreme of normal development".  It is also possible that these kids do have some metabolic disease we just haven't uncovered yet.  Generally as body mass increases, adequate stores exist, and individuals are able to sustain longer fasts so this becomes a non issue.  For this reason I'm always wary that IKH is the most likely diagnosis for kids who present initially over five or children who are having persisting significant symptoms much after their eighth birthday.