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November 22, 2006

Hyperglycemia and DKA

Question from Huntsville, Alabama, USA:

About a month ago, my three year old asked if she could go potty on a stick (ketone test strip) like her sister. I figured it was no big deal and allowed her to do so. I was shocked to see that she had large ketones. I thought maybe the strip was bad, so I thought I'd test her the next day. Again, she had large ketones. I called her pediatrician and he wanted to see her that day. He confirmed that she had large ketones. He ran blood work (A1c, thyroid, and all other pertinent diabetes tests). These all came back normal. I have continued to check her urine occasionally and have had at least four occasions where she had large ketones. I again asked her pediatrician and he is baffled by this. What could cause this? I will tell you that my child is a very good eater and drinks a lot. She is very thin, in the 10th percentile for weight and 80th for height. I know that starvation and dehydration can cause ketones, but this certainly could not be the case. What else could cause a child of this age to have large ketones often?


The urine ketone tests acetone and acetoacetate, both indications of fat metabolism. Hypoglycemia will sometimes show up also with ketonuria. To decide if hypoglycemia is a possible explanation, one would need to check frequent pre-breakfast and sequential blood sugar levels, especially if this is an intermittent finding. For different reasons, it could be insulin deficiency and hyperglycemia as well, but this seems to have been excluded from consideration. None of this is specific but suggests that she is getting inadequate calorie intake from what you have described (thin child) despite her being described as an otherwise good/healthy eater. If all of the other tests are negative and physical exam and specific detailed history is also negative, then there are some very rare metabolic possibilities such as amino acid abnormalities that should be entertained. Your pediatrician should be able to call the local specialty laboratory and/or medical school and figure out the sample of blood and urine required to do such metabolic evaluations and determine the source of the ketonuria.