A 3 year old female is brought into ED with a 3 day history of fever, coryzal symptoms and vomiting.

Causes of ketosis in children include –

DKA

IEM

Accelerated starvation of childhood

Salicylate overdose

Ethanol

Anorexia Nervosa

Ketogenic Diet

The most likely cause in this child is accelerated starvation – this occurs in some children who have a reduced caloric intake for a short period of time, usually complicated by intercurrent illnesses. The excessive ketones leads to gastrointestinal symptoms of abdominal pain and vomiting, and this vicious cycle delays spontaneous resolution.  Ketone levels of more than 3.5 mmol/l in a child not taking orally is abnormally high, and represents a poor adaptation to starvation and risk of hypoglycaemia.

Management of this child

• clearly identify underlying cause for the vomiting/concurrent illness and treat that.

-Exclude other causes of ketosis

• consider ondansetron

• if child requires fluid resuscitation use normal saline 10-20ml/kg

-maitainence fluid should contain dextrose

• if iv fluid is not required and the child is mildly dehydrated as in this case, the child can be started with a trial of ORS. ORS does not contain sufficient sugar to reverse the ketosis, therefore breast milk/cows milk, juice or sandwiches should be  given when the child is tolerating orally.

• once the child is tolerating orally and behaving normally and has a normal BSL, and ketones are decreasing (ideally <2.5mmol/l)  the child can be discharged with dietary advice to parents.  These children my be prone to further episodes when they have a period of starvation up to the age of 7, after which they normally out grow it. Parents need to be aware of how to manage these kids.

-if the child presents with hypoglycaemia as well further investigation is required to exclude IEM