What to do if a child has urine ketones but appears fine?

Management of Urine Ketones in a Child Who Appears Well

When a child has urine ketones but appears clinically well, monitor blood glucose levels and assess for symptoms of hyperglycemia, while ensuring adequate hydration and considering insulin administration according to the child's Diabetes Medical Management Plan (DMMP) if the child has diabetes. 1

Assessment of Ketones in Children

Understanding Ketone Bodies

• Ketones are produced by the liver when glucose is not readily available as an energy source
• Three main ketone bodies exist:
  • Acetoacetate (detected in urine tests)
  • Beta-hydroxybutyrate (predominant in blood, better indicator of ketosis)
  • Acetone (least abundant, causes "fruity" breath odor) 2, 3

Interpreting Ketone Levels

• Normal ketone levels: <0.5 mmol/L in blood
• Physiological ketosis: 0.3-4 mmol/L
• Pathological ketosis/DKA: >7-8 mmol/L 2

Clinical Decision Algorithm

Step 1: Determine if the child has diabetes

• If the child has known diabetes:

  • Check blood glucose levels immediately using a glucometer or CGM 1
  • Review the child's DMMP for specific instructions 1

• If the child does not have known diabetes:

  • Check blood glucose if available
  • Assess for symptoms of new-onset diabetes (polyuria, polydipsia, weight loss)

Step 2: Assess hydration status

• Look for clinical signs of dehydration:

  • Dry mucous membranes
  • Decreased skin turgor
  • Sunken eyes
  • Decreased urine output

• Note: Clinical assessment of dehydration may not accurately reflect actual dehydration in diabetic ketoacidosis 4

Step 3: Evaluate for potential causes of ketosis

For children with diabetes:

• Inadequate insulin dosing
• Missed insulin doses
• Illness or infection
• Prolonged fasting

For children without diabetes:

• Prolonged fasting/decreased oral intake
• Gastroenteritis with vomiting
• Low carbohydrate diet (ketosis can occur with <20-30g carbs daily) 2
• Prolonged exercise

Step 4: Management based on findings

For children with diabetes:

• If blood glucose >250 mg/dL with ketones:

  • Administer insulin according to the child's DMMP 1
  • Ensure adequate hydration with sugar-free fluids
  • Monitor blood glucose and ketones every 2-4 hours 2
  • Contact healthcare provider if ketones persist or the child's condition worsens

• If blood glucose is normal or low with ketones:

  • Provide carbohydrates and fluids
  • Monitor blood glucose levels
  • Consider other causes of ketosis

For children without diabetes:

• If the child appears well with normal vital signs:
  • Encourage oral hydration with fluids containing electrolytes
  • Provide carbohydrates if the child can tolerate oral intake
  • Monitor for resolution of ketones

Important Considerations

Preferred Ketone Testing Method

• Blood ketone measurement is preferred over urine ketones for more accurate assessment 2, 5
• Blood tests measure beta-hydroxybutyrate, the predominant ketone in pathological states
• Urine tests only detect acetoacetate and can give false positives 3

When to Seek Immediate Medical Attention

• Development of altered mental status
• Persistent vomiting
• Inability to maintain hydration
• Worsening clinical status despite interventions
• Blood ketone levels >1.2 mmol/L (associated with higher risk of hospital admission) 6

Common Pitfalls to Avoid

• Relying solely on urine ketones to monitor treatment response 2
• Assuming ketones always indicate diabetes (ketones can occur with fasting, low-carb diets, or prolonged exercise) 7
• Giving juice or carbohydrates to a hyperglycemic child with diabetes (this can worsen hyperglycemia) 1
• Failing to recognize that ketonemia takes longer to clear than hyperglycemia 2

By following this structured approach, you can appropriately manage a child with urine ketones who appears clinically well while monitoring for any signs of deterioration that would require more urgent intervention.