I've had a 4 year old with T1D at school this year, and he's been very interesting. Sometimes he comes in with a blood glucose that's rollercoastering, sometimes stubbornly low, at other times it's up in the rafters.
The other day was a stubbornly low day. Lots of supplemental carbs, I even reset the pump to it's lower basal setting. I kept mom in the loop. She wondered if he was getting sick and asked me to check for ketones.
I've never heard of high ketones with a low sugar. An (admittedly) quick search for info online was a dead end. (Just articles about hyperglycemia and ketosis.)
Does anyone have any experience with this seeming paradox? If you do, any idea why it might happen?
I think the over riding issue would be to treat the patient according to the presentation. Ketones would not be relevant in acute hypoglycemia treatment. I've never checked for ketones in a hypoglycemic patient. I'm wondering if the parent doesn't quite comprehend the ins and outs of diabetes yet.
These parents are pretty well trained. I guess there's a precedent of him having ketones when coming down with something even though his sugars were low.
These parents are pretty well trained. I guess there's a precedent of him having ketones when coming down with something even though his sugars were low.
Go figure...
Gotta be...kinda like the parent of a chronically ill kid who tells you where "they usually" put the IV. If you try otherwise you're doomed! They know their child and you don't.
If I saw low ketones and low sugar, I'd suspect they need to eat a LOT more carbs AND insulin. They aren't getting insulin because their sugar is low so they aren't able to use glucose for energy. They need to break down proteins causing ketosis. That's not on you to treat though. So long term, the endo needs to look at it. Was there a growth spurt recently or other change in metabolic need? Have they missed an appointment and the kids outgrown their orders. I'm sure there are many variables. Acutely, it's not a concern. Ketosis is not ketoacidosis. Where I get fuzzy on the patho is, where are all the carbs you are giving going? Why wasn't sugar rising? The only time I really understand that is in fulminate liver failure. Those ICU patients that we kept pushing D50 amps into with no real gain. Or, in theory, CF kids if we didn't give amylase. One of my diabetics does have times that simple carbs don't seem to raise her as quickly as they should so we need to take care to avoid major spikes 6 hours after all the carbs even though we see no change in 15 minutes.
Are you looking at his hydration? How is his fluid intake. Might be getting high ketones related to being dry.
Questions I would ask are...is he bottoming out with all activity? Is he taking a break to eat? What is going on with his long term intake of complex carbs, fats and proteins. Does he eat before activity? Is his insulin dose too high at exercise times. Might need a diet journal for a week or two to see if can find any trends/patterns.
Last thing to consider, is he hypersensitive to certain carbs. Had a hypoglycemic pt who couldn't eat most carbs or would bottom out. Pretty rare but maybe the type of carb might be an influence.
I'm sharing my "2-4-6-8" Quick Diet Choices Tool. A serving size is a palm full. Have had good response from patient's with this. If questions, let me know.
Weird note- learned at camp, when the sugar won't get over 75 despite a lot of glucose tabs or juice, we added string cheese or a T of peanut butter. This was a brittle kid who was also a high metabolizer of everything. I suspect but cannot prove we provided his body an energy source other than sugar...and it worked.
We prefer proteins in acute care, especially for night times. Longer sustain in keeping sugars up, very important when pulling from glycogen stores
Weird note- learned at camp, when the sugar won't get over 75 despite a lot of glucose tabs or juice, we added string cheese or a T of peanut butter. This was a brittle kid who was also a high metabolizer of everything. I suspect but cannot prove we provided his body an energy source other than sugar...and it worked.
We had good results with greek yogurt at camp for a camper who was bottoming out at night before we got her basal rates adjusted to be conducive to the activity level at camp. It took some trial and error but we finally got her to a place where we weren't up 3-5 times adjusting her rates and giving her snacks because she was a roller coaster. I just heard that she is returning to camp this year so I'm hoping we have an easier time getting her body adjusted!
Specializes in ICU/community health/school nursing.
On 4/12/2019 at 8:38 AM, kidzcare said:
We had good results with greek yogurt at camp for a camper who was bottoming out at night before we got her basal rates adjusted to be conducive to the activity level at camp. It took some trial and error but we finally got her to a place where we weren't up 3-5 times adjusting her rates and giving her snacks because she was a roller coaster. I just heard that she is returning to camp this year so I'm hoping we have an easier time getting her body adjusted!
Greek yogurt for the win!! It's weird. Dairy has lactose (which is a sugar), protein and fat. Maybe it's that magic combo for those who go up and down at hyperspeed.
Jedrnurse, BSN, RN
2,776 Posts
These parents are pretty well trained. I guess there's a precedent of him having ketones when coming down with something even though his sugars were low.
Go figure...