Paeds · investigations-procedures-and-technology

Point-of-care glucose, ketone and urinalysis testing

Also known as Bedside blood glucose meter · Capillary glucose testing · Beta-hydroxybutyrate testing · Blood ketone monitoring · Urine dipstick · Urinalysis · Reagent strip testing · Point-of-care testing

Fellowship guide to the three core paediatric point-of-care tests. Covers the capillary blood glucose meter and its known inaccuracy in the neonate from the high haematocrit and the galactose or maltose interference with the glucose dehydrogenase strips, the rule to confirm any critical value with a laboratory plasma glucose, the blood beta-hydroxybutyrate ketone meter as the preferred measure over the urine acetoacetate in diabetic ketoacidosis with the ISPAD thresholds of greater than three millimoles per litre for the diagnosis and the fall that tracks the resolution, and the urine dipstick with the leukocyte esterase and the nitrite performance, the lower sensitivity of the nitrite in the young infant, and the rule that the dipstick screens while the culture confirms the urinary tract infection.

high11 referencesUpdated 17 July 202625 min readVerification in progress

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Acting on a single capillary glucose meter reading in a neonate because the high haematocrit, the low oxygen, and the galactose or maltose interference with the glucose dehydrogenase strips can give a falsely low or falsely high value; confirm any critical or unexpected value with a laboratory plasma glucoseReassuring a family that the urine ketones are improving when the acetoacetate pad stays high or even rises during the recovery from the diabetic ketoacidosis, because the beta-hydroxybutyrate converts to the acetoacetate as the ketosis resolves and the urine test lags behind the true metabolic stateExcluding a urinary tract infection from a negative nitrite in a young infant, because the frequent voiding gives no bladder dwell time for the nitrate conversion and the nitrite sensitivity falls to approximately fifty percent even though the specificity stays highDiagnosing a urinary tract infection from a dipstick alone, because the leukocyte esterase and the nitrite are a screen and the febrile non-toilet-trained child needs the culture from a low-contamination specimen before any antibioticMissing the euglycaemic diabetic ketoacidosis because the glucose is under eleven millimoles per litre, which occurs in the young or partially treated child; the ketone and the blood gas make the diagnosis, not the glucose alone

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Care settings

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States that the capillary blood glucose meter measures the whole-blood glucose by the glucose oxidase or the glucose dehydrogenase reaction and that a critical or unexpected reading in a neonate must be confirmed by a laboratory plasma glucose because the high haematocrit and the galactose or maltose interference can bias the resultRecognises that the blood beta-hydroxybutyrate ketone meter is the preferred measure over the urine acetoacetate in the diabetic ketoacidosis because the beta-hydroxybutyrate is the predominant ketone and tracks the resolution, while the urine ketones can lag or paradoxically rise during the recoveryDescribes the urine dipstick pads of the leukocyte esterase and the nitrite as a screen for the urinary tract infection that does not replace the culture, and the lower sensitivity of the nitrite in the young infant from the frequent voidingApplies the ISPAD 2022 diabetic ketoacidosis definition of the blood beta-hydroxybutyrate greater than three millimoles per litre with the venous pH under 7.3 and the bicarbonate under fifteen, and the glucose greater than eleven millimoles per litreInterprets the combined leukocyte esterase and nitrite result with the high negative predictive value of the both-negative dipstick and the need for the culture from the catheterisation or the suprapubic aspiration in the febrile non-toilet-trained childAnticipates the point-of-care glucose meter errors in the neonate from the haematocrit, the oxygen, and the galactose or maltose interference and selects a meter with the interference correctionThe blood beta-hydroxybutyrate thresholds of the less than 0.6 millimoles per litre as the normal, the 0.6 to 1.5 as the mild ketosis, and the greater than 3.0 as the level associated with the diabetic ketoacidosisThe dipstick performance with the leukocyte esterase sensitivity of approximately 67 to 94 percent, the nitrite sensitivity of approximately 50 percent and the specificity of approximately 98 percent, and the lower nitrite reliability in the young infantThe glucose meter interference in the neonate and the rule to confirm the critical value with the laboratory plasma glucosePerforms and interprets the capillary blood glucose, the blood beta-hydroxybutyrate ketone, and the urine dipstick at the bedside with the correct specimen handling and the quality controlCommunicates the result, the limitations, and the next step to the family in the language they understand, and frames the dipstick as a screen pending the cultureRecognises and manages the falsely reassuring results including the lagging urine ketones, the negative nitrite in the infant, and the meter error in the neonateLevel 1: Performs the capillary blood glucose, the blood ketone, and the urine dipstick with the correct technique and the safety checksLevel 2: Interprets the three point-of-care tests in the clinical context, recognises the meter and the dipstick limitations, and confirms the critical glucose with the laboratory plasma glucoseLevel 3: Leads the point-of-care testing quality programme, the staff training, and the protocol for the confirmation of the critical valuesThe three point-of-care tests, the specimen, the chemistry, and the clinical use of eachThe blood beta-hydroxybutyrate thresholds and the reason it is preferred over the urine acetoacetate in the diabetic ketoacidosisThe leukocyte esterase and the nitrite performance and the lower nitrite sensitivity in the young infantDemonstration of the bedside capillary glucose and the blood ketone measurement with the correct technique and the safety checks in a structured oral or the objective structured clinical examinationInterpretation of the urine dipstick in the febrile child and the communication of the screen-versus-culture principle to the examinerDiscussion of the falsely reassuring results and the confirmation of the critical valuesThe American Academy of Pediatrics urinary tract infection guideline principle that the dipstick is a screen and the culture from the catheterisation or the suprapubic aspiration confirms the infection in the febrile non-toilet-trained childThe beta-hydroxybutyrate over the urine ketone in the diabetic ketoacidosis and the ISPAD diagnostic thresholdsThe glucose meter interference in the neonate and the confirmation of the critical value with the laboratory plasma glucosePerforms and interprets the capillary glucose, the blood ketone, and the urine dipstick at the bedside as a core procedural competencyRecognises and counsels on the meter and the dipstick limitations and the falsely reassuring resultsLeads the point-of-care testing quality programme and the confirmation of the critical valuesThe Canadian approach to the bedside glucose, ketone, and urinalysis with the confirmation of the critical glucose and the culture-based diagnosis of the urinary tract infectionThe blood beta-hydroxybutyrate over the urine ketone in the diabetic ketoacidosis and the ISPAD thresholdsThe glucose meter interference and the quality programme for the point-of-care testing in the paediatric intensive care unit

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Red flags

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescent

Care settings

ed-acutewardnicupicuoutpatientrural-remotetelehealth

Clinical exam formats

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Overview & Definition

The three point-of-care tests in this topic give a rapid bedside answer to three different clinical questions. The capillary blood glucose meter answers whether the child is hypo- or hyperglycaemic at this moment. The blood beta-hydroxybutyrate ketone meter answers whether the child has accumulated ketones and how severe the ketosis is. The urine dipstick answers whether the urine contains the cells, the chemicals, and the metabolites that point to the infection, the glycosuria, or the dehydration. Each test takes seconds to minutes, runs on a small device or a reagent strip at the bedside, and changes the immediate management. [1]

The unifying principle is that these are screening and monitoring tools, not definitive laboratory measurements. The glucose meter, the ketone meter, and the dipstick guide the first decision, but the laboratory plasma glucose, the formal blood gas, and the urine culture carry the definitive answer. The clinician who trusts a single bedside value over the clinical picture, or who forgets the known interference and the timing errors, makes the error that this topic is built to prevent. The ISPAD 2022 diabetic ketoacidosis guideline is the central reference for the glucose and the ketone thresholds, and the American Academy of Pediatrics urinary tract infection guideline is the central reference for the urinalysis. [1]

The clinical settings span the emergency department, ward, neonatal and the paediatric intensive care, the diabetes outpatient clinic, and the rural and the remote service. The febrile infant, the vomiting child, the breathless and acidotic child, the neonate with the poor feeding, and the child with the known diabetes all trigger one or more of these tests. The same three devices sit in every paediatric resuscitation bay, and the skill of performing and interpreting them correctly is a core competency for the general paediatric trainee and the fellow. [2]

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References11Show ledger

[1]Glaser N, Fritsch M, Priyambada L, et al. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state Pediatric Diabetes, 2022.PMID 36250645
[2]Roberts KB Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months Pediatrics, 2011.PMID 21873693
[3]Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in childhood: a meta-analysis Pediatric Infectious Disease Journal, 2008.PMID 18316994
[4]Gorelick MH, Shaw KN Screening tests for urinary tract infection in children: a meta-analysis Pediatrics, 1999.PMID 10545580
[5]St John A, Boyd JC, Lowes AJ, Price CP The use of urinary dipstick tests to exclude urinary tract infection: a systematic review of the literature American Journal of Clinical Pathology, 2006.PMID 16880133
[6]Raizman JE, Shea J, Daly CH, et al. Clinical impact of improved point-of-care glucose monitoring in neonatal intensive care using Nova StatStrip: evidence for improved accuracy, better sensitivity, and reduced test utilization Clinical Biochemistry, 2016.PMID 27157715
[7]Wada Y, Nakamura T, Kaneshige M, et al. Evaluation of two glucose meters and interference corrections for screening neonatal hypoglycemia Pediatrics International, 2015.PMID 25441549
[8]Pulungan AB, Juwita E, Pudjiadi AH, et al. Diabetic ketoacidosis in adolescents and children: a prospective study of blood versus urine ketones in monitoring therapeutic response Acta Medica Indonesiana, 2018.PMID 29686175
[9]Vanelli M, Mastrorilli C, Fainardi V, et al. Clinical utility of beta-hydroxybutyrate measurement in the management of physiological ketosis at home in children under 5 Acta Bio-Medica, 2019.PMID 31124998
[10]Diviney J, Jaswon MS Urine collection methods and dipstick testing in non-toilet-trained children Pediatric Nephrology, 2021.PMID 32918601
[11]Futatani T, Shimao A, Ina S, et al. Capillary blood ketone levels as an indicator of inadequate breast milk intake in the early neonatal period Journal of Pediatrics, 2017.PMID 29173326

Point-of-care glucose, ketone and urinalysis testing

high11 referencesUpdated 17 July 202625 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References11Show ledger

[1]Glaser N, Fritsch M, Priyambada L, et al. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state Pediatric Diabetes, 2022.PMID 36250645
[2]Roberts KB Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months Pediatrics, 2011.PMID 21873693
[3]Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in childhood: a meta-analysis Pediatric Infectious Disease Journal, 2008.PMID 18316994
[4]Gorelick MH, Shaw KN Screening tests for urinary tract infection in children: a meta-analysis Pediatrics, 1999.PMID 10545580
[5]St John A, Boyd JC, Lowes AJ, Price CP The use of urinary dipstick tests to exclude urinary tract infection: a systematic review of the literature American Journal of Clinical Pathology, 2006.PMID 16880133
[6]Raizman JE, Shea J, Daly CH, et al. Clinical impact of improved point-of-care glucose monitoring in neonatal intensive care using Nova StatStrip: evidence for improved accuracy, better sensitivity, and reduced test utilization Clinical Biochemistry, 2016.PMID 27157715
[7]Wada Y, Nakamura T, Kaneshige M, et al. Evaluation of two glucose meters and interference corrections for screening neonatal hypoglycemia Pediatrics International, 2015.PMID 25441549
[8]Pulungan AB, Juwita E, Pudjiadi AH, et al. Diabetic ketoacidosis in adolescents and children: a prospective study of blood versus urine ketones in monitoring therapeutic response Acta Medica Indonesiana, 2018.PMID 29686175
[9]Vanelli M, Mastrorilli C, Fainardi V, et al. Clinical utility of beta-hydroxybutyrate measurement in the management of physiological ketosis at home in children under 5 Acta Bio-Medica, 2019.PMID 31124998
[10]Diviney J, Jaswon MS Urine collection methods and dipstick testing in non-toilet-trained children Pediatric Nephrology, 2021.PMID 32918601
[11]Futatani T, Shimao A, Ina S, et al. Capillary blood ketone levels as an indicator of inadequate breast milk intake in the early neonatal period Journal of Pediatrics, 2017.PMID 29173326