Ketones in urine

[hamblin9]

Hi,
We found out about 7 weeks ago that our 4 year old has type 1 diabetes. About 3 weeks ago she got sick and started having ketones in her urine, even though her blood sugar levels were within her target range. She had ketones off and on for about a week, and finally ended up in the emergency room with an IV to flush them out. Now she has started having ketones in her urine again even thought she is still within target. They are just in trace amounts, but it still concerns me that she is having them at all. I think she may be getting sick again, but is it normal for her to get ketones every time she gets sick? We are completely new to all of this so I'm pretty clueless.

[mtn_momma05]

my son was diagnosed a year ago next week... he is on a pump and checks for ketones daily... when he starts with a trace this is when we know that he is fighting some kind of bug, which being in school is frequently... encourage LOTS and LOTS of water... good luck

[basketballnut]

I got a great response from Lisa Bolduc-Bissell about this question.

Ketones happen when the body has to "burn" fat for energy. 
 
Under normal circumstances, insulin allows glucose to enter into the cells, and simply put, it is used as energy: the energy we need to do the things we mean to do (walk, talk, etc) but also the energy our bodies need to do live (lungs breathing, heart beating, etc). 
In the case of type 1 diabetes, if there is not enough insulin to allow the glucose to enter into the cells, energy cannot be used in the normal way.  So, the body finds another way to get energy, and it does this by metabolizing, or burning, fat.  What is leftover once this metabolism of fat is complete are ketones.  Ketones are made in the bloodstream, and are eliminated via the kidneys into the urine.  Most people with type 1 diabetes measure urine ketones as: negative, trace, small, moderate, large.  Ketones in the trace to small category are usually not cause for concern, but do need to be monitored to make sure that they don't progress to something more.  Ketones in the moderate to large category are indeed cause for concern, and your diabetes team should be informed immediately.   Ketones can happen quickly (within a matter of a few hours of the body being insulin deficient) and if untreated, can lead to DKA (diabetic ketoacidosis).  Ketones are dangerous because they are an acid, and therefore change the pH of the body, which makes it difficult, and if untreated, impossible, for the body to operate the way it should.
 
Illness can cause ketones.  When the body is under any kind of stress (physical, emotional, etc) it responds by releasing more glucose into the bloodstream to supply itself with more energy in order to heal itself.  In the case of somebody without diabetes, this is a non-issue because the pancreas can in turn make more insulin to compensate.  But, for someone with diabetes, this can lead to high blood glucose levels and ketones because, again, there is that insulin deficiency:  the body cannot make the insulin, and yet, the body needs more insulin due to the circumstances.   Some families have reported high blood glucose levels with ketones before they see any signs of an illness, and this can often be a pre-cursor to that illness.
 
Ketones can happen with "normal" blood glucose levels.  In this case, it is often due to lack of food as opposed to lack of insulin.  For example, it is not uncommon for very young children with diabetes to wake up every morning with ketones, despite having a "normal" blood glucose level.  Perhaps that child ate dinner at 6pm, and then went to bed, and awoke at 6am, 12 hours later.  Young children have very speedy metabolisms, and during that 12 hour period, that child may have started to burn fat for energy (and therefore produced ketones) since no food was eaten to supply the body with energy that can be used more efficiently.  In this case, with a bit of food (and insulin, of course) the ketones will be taken care of.  Again, trace to small ketones are generally not of concern, but should be monitored to ensure that they do  not progress to something of more significance. 
 
Ketones can also happen to people who do not have diabetes.  When someone is losing weight, their body is burning fat for energy, but in this case it is not due to insufficient insulin, but rather to insufficient calories and carbohydrates.  Although these ketones are technically the same ketones, they aren't nearly as dangerous because it is not an issue of insulin deficiency.
 
There is much more information not mentioned here about ketones.  One of the resources we use in our clinic is Understanding Diabetes, by H. Peter Chase of the Barber Davis Center for Childhood Diabetes.