Starvation Ketosis in the Pediatric Emergency Department

Abstract

Objectives: Starvation ketosis may occur in children during intercurrent illnesses due to metabolic adaptation to fasting, resulting in significant ketonemia and sometimes ketoacidosis. Also known as accelerated starvation, common symptoms are vomiting, lethargy, and seizures. Previous studies found the prevalence of ketotic hypoglycemia to be 4 per 100,000 presentations to the emergency department (ED). We hypothesized that the prevalence had been underestimated due to the retrospective nature and restricted definitions of previous studies. Our aim was to determine if a prospective study would confirm a higher prevalence of starvation ketosis in pediatric patients presenting to the ED.Methods: A prospective observational study of consecutive patients was performed in an urban pediatric ED utilizing point-of-care testing of capillary blood glucose and ketones in symptomatic children.Results: This study found the prevalence of clinically significant ketosis (defined as beta-hydroxybutyrate 2.5 mmol/L or more) to be approximately 1800 per 100,000 ED presentations, with more than 170 per 100,000 also being hypoglycemic. Affected patients were 3 months to 9 years of age. Fifty-five percent of the presentations were boys, and 56% were under the 50th centile for weight.Conclusions: This prospective observational study using a targeted testing regimen found the prevalence of both starvation ketosis and hypoglycemia to be much greater than previous studies which used retrospective analyses. A simple capillary test for ketones should be considered in unwell children younger than 10 years who present with vomiting or lethargy, as this may identify the need for specific therapy to resolve ketosis.

Alterations and diagnostic performance of capillary ketonemia in pediatric acute appendicitis: a pilot study

“…The etiopathogenic and pathophysiologic mechanisms underlying the elevation of CK in patients with PAA responds to multiple phenomena including an increased catabolism, emesis and fasting, all of them being independently associated with dehydration [ 8 – 10 , 16 ]. On fasting, after the consumption of the glycogen reserves, lipolysis occurs, with the release of glycerol, which is transformed into glucose and free fatty acids, which are oxidized to ketone bodies.…”

“…Most of the studies aimed at optimizing the management of patients with PAA focused on surgical aspects, and the evidence on the potential impact of more conservative measures applied during the preoperative period is scarce. It is known that intravenous rehydration significantly reduces the levels of ketone bodies, which are responsible of the perpetuation of nausea and vomiting [ 8 – 10 ]. Ketone bodies can be determined in capillary blood and in urine.…”

Special Anaesthetic Considerations for Brain Tumour Surgery in Children

“…Adding 1% glucose to an isotonic electrolyte solution has been shown to maintain electrolytes such as potassium and sodium within normal ranges and contributes to keeping the acid-base status within the normal physiological limits [ 14 ]. A lack of glucose supply increases the rate of lipolysis and may result in ketoacidosis, especially after prolonged preoperative starvation [ 15 ]. Hyperglycaemia, however, worsens reperfusion injuries.…”

The Computational Acid–Base Chemistry of Hepatic Ketoacidosis

“…While the mortality rates and treatment of ketoacidosis have significantly improved since the late 19th century, the negatively associated stigma remains for the interpretation that ketone bodies are produced as acids that dissociate at physiological pH, resulting in systemic metabolic acidosis. Occurrences of ketoacidosis are still common in hospital critical care wards, with prevalence in undiagnosed or poorly controlled type I and II diabetes mellitus (diabetic ketoacidosis) [ 23 ], alcoholic ketoacidosis [ 24 ], and starvation ketoacidosis associated with eating disorders [ 25 ]. It is logical and rational to have the view that the source of the underlying acidosis should be known for the most effective preventative treatment methods to be developed.…”