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May 31, 2004

Diagnosis and Symptoms, Other

Question from Saskatoon, Saskatchewan, Canada:

I took my three and a half year old son to see our family doctor to check for a bladder infection as he has developed secondary nocturnal enuresis. The test for the infection came back negative, although he was found to have ketones in his sample. There was no glucose in his urine. I never would have thought diabetes, but now that I have it in mind I realize that he has many of the symptoms. He often says that he's so starving, or is very tired and lays down in the middle of playing or even eating, or is very thirsty. I've noticed the fruity smelling breath, too. He also complains often that his tummy hurts. I mostly attributed the complaints to being dramatic as he is a very intense child, and he eats and drinks tons. He also has aggressive tendencies, and is very rambunctious, which is amplified when he eats sugary food. Why would there be ketones in his urine without glucose? How accurate is the test preformed in the office (routine bladder infection test) at picking up levels of both ketones and glucose? Why would my doctor say that she wanted to refer us to a nephrologist?

Answer:

Ketones only means that there is body fat being used/metabolized/burned. Often, this happens when there is insufficient energy eaten/provided but sometimes this can happen during illness. If it occurs frequently, then looking for sources of ketosis would be important. If there is also hypoglycemia associated with ketones, then a different list of possibilities comes up. In any case, if the pediatrician is not comfortable looking at some of these possibilities, then consultation with a pediatric endocrinologist would be reasonable.It does not sound like a kidney problem from your limited description. Ketotic hypoglycemia might cause some of the symptoms you describe and then adjustment of food and snacks would usually solve the problem once more serious reasons for such a metabolic situation were ruled out. Occasionally, diabetes presents as hypoglycemia for several weeks or months before the pancreas loses its ability to produce insulin, but this could also be evaluated by a pediatric endocrinologist.

SB