My two and a half year old has been waking up with blood sugars as high as 234 mg/dl [13 mmol/L]. She is pre-clinical without the autoantibodies and is being monitored at home due to occasional high readings. She is not overweight and does not take any insulin. Is there any other disease that can affect the blood sugar levels besides diabetes? Is this early detection of diabetes? Do the antibodies always have to be present?

Assuming that this single high fasting blood sugar was neither an isolated event nor due to some technical aberration, I think that your daughter must have some form of diabetes, it is important to pursue the situation further. You should not just await events because what seems a rather benign pattern at the moment might become DKA [diabetic ketoacidosis] with the stimulus of an intercurrent infection.

The likelihood of type�1A (autoimmune) diabetes still has to be considered despite the negative antibody test. I think that you should ask the diabetes doctor whether this was just the conventional immunofluorescent islet cell antibody screening test which can give rise to false negatives. If this was the case, I think you should discuss getting the more conventional battery of anti-GAD, anti-insulin antibodies, and ICA512.

If these too are negative, there are other possibilities to consider. Type�2 diabetes is increasingly common in children, but, as you point out your daughter is not overweight and would also be very young for this diagnosis. Another possibility is type�1B diabetes, which occurs in only 5% of Caucasian families, but which does present in much the same way as the autoimmune form and may, at a later stage, become insulin independent. Some of the other possibilities to consider are the various forms of Maturity Onset Diabetes of the Young (MODY) and even mitochondrial diabetes and other rarities linked to chromosomal changes.

In the meantime, it would help to know if insulin levels were low and it would also be a good idea to develop a profile of blood sugars throughout the 24 hour period including one or two in the very early morning. It is just possible that the high morning blood sugar is a sequel to an unusually low blood sugar during the night which could be an uncommon presentation of type 1A.. The final definitive diagnosis is not of immediate importance because treatment is always linked to keeping blood sugars near to the normal range. There are indeed also some very rare endocrine disorders which can produce glucose intolerance, but which would be expected to have other physical signs.

As to what to do now while additional tests are being done I would discuss with the doctor, depending on the overall blood sugar pattern, whether it might be appropriate to start on very small doses of NPH insulin given in the morning to see if that will achieve hemoglobin A1c levels of less than 1% above the upper limit of normal.

Finally, if you are going to end up doing lots of blood sugars, you might consider one of the new almost painless devices that take only a minute amount of blood from the forearm such as the or FreeStyle meter.

DOB