January 8, 2004
Other Illnesses
Question from Manchester, New Jersey:
My son has a history of leukemia which required a bone marrow transplant at the age of 2 (he is in remission). Once he was off of all his IV and NG feedings, it was noted that his sugar was low, 40 mg/dl [2.2 mmol/L], after fasting. He had a fasting inpatient test with an endocrinologist and after 16 hours he was diagnosed with Ketotic Hypoglycemia and other illnesses were ruled out. We were sent home with the instruction to avoid a fast greater than 12 hours when well and 8 hours while sick.
He has had a couple of episodes while sick, where his blood sugar was around 60 mg/dl [3.3 mmol/L], but he was difficult to arouse and complained of upper quad pain. Each time he was taken to the ER. The first time they gave him an IV bolus of D50%, 23cc. His sugar 30 minutes later was 600 mg/dl [33.3 mmol/L]! It was then 200 mg/dl [11.1 mmol/L] at the 2 hour mark.
The second time, they did not bolus him with anything other than Normal Saline for hydration. He woke up and ate a few crackers and still his sugar went up to 300 mg/dl [16.7 mmol/L]. Over all his sugar levels range between 80-110 mg/dl [4.4-6.1 mmol/L] with no high fasting results. Occasionally I get a higher than normal random sugar, 150 mg/dl [8.3 mmol/L]. My pediatrician feels he will become a diabetic. Are the two related or is he presenting as a normal child with ketotic hypoglycemia should? My last question is how should he be best managed if he requires an ER visit?
Answer:
These are difficult and important questions that you pose. You should really ask these specific questions to your endocrinologist who should be in close contact with the oncology team as well as the pediatrician so that appropriate management decision and monitoring can take place.
Some hypoglycemia may precede development of diabetes but this is not so clear. This sounds like some pancreatic damage and a system that is not appropriately sensing and managing glucose metabolism needs in a normal fashion. Measuring insulin levels at times of hypoglycemia as well as hyperglycemia may be helpful. Antibody measurements may be helpful as well. Home blood glucose monitoring would be critical if you are not already doing this. But go back to the endocrine team and work out a mutually acceptable plan.
SB
