April 19, 2006
Diagnosis and Symptoms, Hypoglycemia
Question from Ontario, Canada:
My three year old daughter seems to have severe reactions to illnesses that cause her to eat poorly. Recently, she had gastroenteritis and stopped eating. A day or so after this, she seemed confused, so we took her to the Emergency Room. They did blood work. Her electrolytes were slightly off; her blood glucose was 3.3 mmol/L [59 mg/dl], and urine ketones were 2+. She then went on to have eight seizures within the next 18 hours. Her glucose level after the first seizure was 4.9 mmol/L [88 mg/dl]. She was given normal saline, but not glucose.
This is the third such episode that she has had. When she was 14 months, she had a viral illness, ate very poorly for several days and then went on to have two seizures. Last March, another viral illness and one seizure. She is not febrile during these episodes and her blood glucose is always between 4 and 5 mmol/L [72 and 90 mg/dl] after the seizures. These have been the only fasting episodes she has ever had and always results in seizures. If she is sick, but I can get her eating, she is fine.
After this third, more serious episode, the doctors suggested ketotic hypoglycemia, but she can fast for 12 hours and be fine. From what I understood about ketotic hypoglycemia, a child would not be able to fast for this period and be okay. Also, one doctor suggested that a glucose of 3.3 mmol/L [59 mg/dl] was not low enough to cause this kind of reaction.
Other than these terrible episodes, she is very healthy. What do you think?
Answer:
It is unclear if this is sufficient hypoglycemia for me to be comfortable making a diagnosis of ketotic hypoglycemia. So, I would suggest going back to your pediatric endocrine team and having a conference to ask these excellent questions and be clear about what needs to be done during upcoming illnesses to ensure adequate nutritional intake or when to take her to the hospital for intravenous glucose/saline to prevent further seizures. Also, you might want to discuss home blood glucose monitoring needs. Other complex metabolic abnormalities are also associated with hypoglycemia.
Lastly, do you know if growth hormone, insulin, and cortisol levels were checked? Deficiencies of growth hormone and cortisol and excesses of insulin, when compared to simultaneous blood glucose levels, can also be associated with severe hypoglycemia and often precipitated by other (common) illnesses.
SB
