From Waukesha, Wisconsin, USA:
I have a 22 month old. We took her to the ER after collapsing and vomiting. Her blood sugar was at 35. They did further tests and found nothing (this happened 3 months ago). We had a lot of concerns. Her grandfather has hypoglycemia and has a grandmother insulin dependent diabetic.
We had another incident last week. She was running around playing and just collapsed.She seemed to be real out of it and really spacey. We got some quick sugar in her and after about 15 minutes she was once again up and running. My question is what tests if any should her pediatrician do? This had only happened when she first wakes up. Or do I just continue to monitor it and keep an eye on her?
Without a lot more detail it would not be appropriate to suggest the next steps in unraveling your little daughter's problems, particularly using e-mail. I would suggest that you begin by reviewing what has happened so far with her pediatrician.
To my mind the first step would be to establish the validity of using hypoglycemia as a diagnosis. If, for example, the blood sugar of 35 mg/dl in the ER was done only on a portable reflectometer [blood glucose meter], it might not have been reliable. On the other hand if the low blood sugar was confirmed in the clinical laboratory and if you also noted a low blood sugar with the second episode and perhaps too in the morning sometimes, then that would confirm the diagnosis. If the hypoglycemia story does not stand up rigorously then obviously other explanations of these episodes have to be considered.
From your account, I also gather that the history and physical exam were non-contributory and that your daughter is otherwise a normal little girl who has developed normally in every way so far. This is important in making it much less likely that an inborn error of carbohydrate or organic acid or amino acid metabolism would be a cause of the hypoglycemia. The same might be argued for disorders of the hormonal regulation of blood sugar. It also suggests that for the time being there is no great urgency for more elaborate laboratory evaluation in hospital, something that can have important emotional repercussions in a two year old, even if you can spend the night there with her.
However it would still be important to establish a pattern of blood sugar levels throughout the 24 hours and especially over the hours between midnight and breakfast. It is possible although it is very rare at her age, that she has what is called a "delayed first phase insulin release." What this means is that after the stimulus of a glucose load, insulin is not excreted into the blood stream at once; but is delayed some hours until the blood sugar is no longer high and hypoglycemia may result. This is a phenomenon seen occasionally in young adult diabetics; but it is also a possibility in young children who may have islet cell damage for other reasons and who are especially susceptible to the hormone. If there are low blood sugars in the early morning it would be important to get a serum insulin level and even to do a five hour glucose tolerance test with insulin levels.Also, if you have evidence of low blood sugars at any particular time of the day you need to talk to your pediatrician or to a nutritionist with experience in this age group about instituting high protein snacks at bedtime and if indicated and practical in the middle of the night in order to prevent further 'abscences.'
Original posting 6 Jan 98
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