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November 26, 2019

Diagnosis and Symptoms

Question from Spanish Fork, Utah, USA:

My daughter is two years old. I’m concerned about her because, for the last week, she has suddenly developed an acetone smell on her breath; I’m worried it could be an indicator of type 1 diabetes/DKA.

Just a quick snapshot of her recent health: She was sick with what I suspect was a GI bug/virus for the first two days of the last week, I noticed the acetone smell on day 1 of her sickness but because she was vomiting multiple times/day and also had diarrhea I attributed the smell to be a result of inadequate nutrition and fat breakdown for energy. I wasn’t too concerned about this and decided I’d worry if she wasn’t able to eat/hold her food down for more than a few days. She had a good appetite despite the illness and was holding down fluids, only looked nauseous/vomited when she had solids. She didn’t appear to be dehydrated at all. She did have two diapers where I could visibly see red blood in the diaper/on the outside of a formed stool… (This has now resolved unless I cannot visualize the blood now). Two days later, her diarrhea and vomiting symptoms resolved and right away my son who is one-year-old had the same illness (vomiting/diarrhea) except his breath did not smell of acetone like my daughters and I didn’t see any blood in any of his stools. He was irritable while sick, but this ended when he got better while my daughter has continued to be extremely irritable. She has been much harder to console when upset. She just isn’t acting like herself and the sudden behavior change is very concerning to me and out of her character.

After her GI illness resolved, in addition to becoming increasingly irritable, she has also been crying upon urination as if she is in pain (she is diapered and I notice she looks uncomfortable and she says “ow” just as the blue line appears on her diaper.) I took my child in to the pediatrician’s office and asked for a urine specimen container that I would later return to check for/rule out a UTI. At this time, I had overlooked the acetone breath and wrongfully left out that symptom by mistake during the office visit. I focused too strongly on the suspected UTI and forgot all about it! A day or so after the visit, I noticed the smell again so strongly when my daughter was crying, and that’s when I realized the painful urination could be due to a yeast infection (common in type 1 diabetics). I don’t see any white patches/diaper rashes/inflammation in her diaper, though.

We have yet to be successful in collecting a urine specimen because my daughter is diapered. We can’t plan her voiding prior to bladder emptying but, because I am now so concerned about possible DKA with this acetone breath, I picked up some urine ketone strips tonight and pressed them into a urine-saturated part of her diaper to check for ketones (strips indicated negative ketones).

Tomorrow, I am going to make absolutely sure I am able to get that urine specimen so I can see if there is glucose, ketones, or any WBC’s/UTI detected in her urine, but I am worried I am putting my daughter at risk by waiting to see what the results are. Should I take her in to the office tomorrow and ask for a blood glucose reading to help rule out DKA/diabetes or should I just be patient and wait for the urine culture/lab results and go from there? I am wondering if I should buy a glucose monitor and just check her fasting and post-meal glucose to see it her blood glucose is elevated? I’m not sure what to do.

I can definitely smell acetone on her breath, but the negative ketones in her urine has me feeling conflicted about seeking prompt care and forcing my little one to get those fingersticks. I wonder if I should just wait to see if there is glucose in her urine when I send in the specimen, but I feel like that will only show up if her blood glucose is extremely elevated and glucose is spilling from the blood to the urine I do not want to delay diagnosing possible diabetes and preventing DKA/possible death in my little daughter by relying only on a urine glucose test.


From: Dr. Stuart Brink

It is best to get her checked. With new diabetes and ketoacidosis (DKA), usually there is excess urination, excess thirst, weight loss as well as the ketones. If you actually checked a multistrip urinalysis, there would have been glucose checked as well as ketones so, if negative for glucose and negative for ketones, it is unlikely DKA.  While she may scream with a fingerstick blood glucose test, either positive or negative, provides more information than you currently have.  Odd that you were smelling the fruity odor of ketones but the urine ketones without adequate food were negative. Your doctor should recheck a urinalysis again to be sure there was no problem with the strips you used or technique. Also, there are other conditions that should be considered such as a yeast infection, other type of bowel problems (colitis, celiac disease) not just a presumed virus.  Sometimes probiotic treatment will also be helpful after such a (presumed) viral abdominal illness to hep rebalance the microbiome. Either way, go back to your doctor and ask some more questions, and get your daughter checked out.