My five year old sons found ketones in a five year old seem to show possible diabetes. What do you think?

Patient

Q: My five year old sons saw a doctor for what we suspected to be allergies (lactose intolerance). He is having frequent loose stools and complaining of stomach pain after eating meals for several months. Although the bowel movements have improved since removing dairy or buying on lactose intolerant versions, the stomach pain and him holding his upper belly continues after almost every time he eats. He then started asking for water a lot and even asked for extra drinks in his lunch. Given both my grandmothers died of diabetes, one at 50 and the other at early 60's, I asked for labs to look into possible diabetes too. Upon physical examination, the doctor mentioned his pancreas felt swollen. Besides that comment no other mention of this has been made including in the medical notes. Calls about further explanation of this have gone unanswered by the doctor although it has been a week since the appointment. My son's labs came back overall normal. Although the following was abnormal:

SPECIFIC GRAVITY result 1.036 ref. range 1.005-1.030 (Above High Normal)

PROTEIN result 1+ ref. range NEGATIVE/TRACE (Abnormal)

KETONES result 3+ ref. range NEGATIVE (Abnormal)

These numbers concern me considering the diet I provide him due to the strong diabetes in family history on both sides. He was unable to eat for fasting required by the test but drank a ton of water prior. I only buy organic food with labeled sugar ranges of 5mg or less. I will occasionally allow him to have 8-9 mg on treats. With the mention of a swollen pancreas, his strict low sugar diet, and these above mentioned results, should I have him further evaluated. The doctor simply left a message saying all labs were normal and I saw that they were not ALL normal when I reviewed them through the online portal.

To me this seems like kidneys are releasing protein and found ketones in a five year old seem to show possible diabetes. What do you think?

Symptoms:  Frequent loose stools after meals, Stomach pain upon eating, thirsty, allergy appointment doctor said physical examination showed a swollen pancreas.
Doctor

A:   Hi.
Thanks for your query and an elucidate history.
You have really put it so nicely.
The most important points noted are:
Age of the patient 5 years: Type I diabetes can be suspected only if the Blood sugars are high, HbA1c is high

Main complaints: He is having frequent loose stools and complaining of stomach pain after eating meals for several months- Although the bowel movements have improved since removing dairy or buying on lactose intolerant versions, the stomach pain and him holding his upper belly continues after almost every time he eats - thirsty - allergy appointment doctor said physical examination showed a swollen pancreas.

Noted the reports you have posted.

I would like to know a few details for me to assist you more:
- Any MRI or MRCP or at least ultrasonography done?
- Stool tests reports?

My thoughts and advise:
The commonest reasons for such a history in a child of 5 years may be:
- Appendicitis
- Chronic entero-colitis
- Enlarged lymph nodes in the abdomen with the causes to be found.
- Any other inflammatory process like Meckel's Diverticulitis
- Sub-acute intestinal obstructions
- Worms ( can cause pancreatitis in children)

I would advise him the following: Please discuss this with your Doctor so that missing tests can be done:
Tests of blood: Review tests along with the routines- Blood Sugar- Fasting, post-meal and random too.Urea, creatinine, liver function tests, Thyroid function tests, Amylase and lipase (for pancreas)
Tests of urine and to compare with the previous one to see any changes
Tests of stool: for 3 consecutive days, routine, microscopy, culture and sensitivity, tests for lactose intolerance
High-resolution ultrasonography of the abdomen
MRCP of the abdomen (Since pancreatitis is suspected.

Second opinion of a General Surgeon or Pediatric Surgeon/ Gastroenterologist; the clinical evaluation and examination helps to get a proper diagnosis and gives a plan for proper treatment.

I hope this answer helps your son to get an early and proper diagnosis which is very important to give a proper treatment plan,
Please feel free to ask further relevant queries if you need to or if you feel that there is a gap of communication.

Comments / Follow Ups

Patient: I forgot to mention his lab also showed the following results for his BUN/CREATININE RATIO results 36 ref. range is 9-27 (Above High Normal)

These test were done and had all negative or normal ranges:
C DIFF TOXIN A+B, QUAL IA, STOOL (result negative)
O&P (OVA & PARASITES), STOOL (result negative)
GIARDIA LAMBLIA AG, EIA, STOOL (result negative)
SALMONELLA/SHIGELLA SCREEN (result negative)
CAMPYLOBACTER CULTURE (result negative)
E COLI SHIGA TOXIN EIA (result negative)

HEMOGLOBIN A1C result 5.4 ref. range 4.8-5.6 ***IS this high considering I will only allow him to eat foods with an average of 5mg of sugar. He was also fasting and had not eaten for almost 15 hours. ******

CHLORIDE, SERUM result 97 ref. range 97-108 test in MMOL/L units *** although this is in range, I noticed it is barely in range, one unit away from low****

I basically want to know if the combination of these abnormal results, family history, lifestyle, and patient complaints at such a young age, are of concern to you as a medical professional.




RESULT NOTE FASTING YES
NOTE FROM LAB A DUPLICATE REPORT HAS BEEN GENERATED DUE TO DEMOGRAPHIC UPDATES.
Doctor: Your query:
I basically want to know if the combination of these abnormal results, family history, lifestyle, and patient complaints at such a young age, are of concern to you as a medical professional.

Certainly yes.
As all the investigations at the age of 5 are necessarily absolutely within normal limits.
And all these positive tests indicate the further tests as I have mentioned and the second opinions of the Specialist concerned, like Nephrologist and others as I have mentioned.

Get the Specialists' opinions and give me the feedback, mere discussions do not help.

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