October 28, 2018
Diagnosis and Symptoms, Hyperglycemia and DKA
Question from Adelaide, South Australia, Australia:
My five-year-old daughter has been having erratic blood sugar levels over the past month, however, not every day. Her levels are consistently between 3.8 mmol/L [68 mg/dl] and 13.3 mmol/L [239 mg/dl]. Her first presentation to our general practitioner followed an episode of vomiting during the night. She was very pale, clammy, shaking, and her eyes were rolling back in her head, but she was still alert. That afternoon, she was tested for iron, glucose and ketones, both of which were strongly positive. A finger prick blood sugar level was 13.3 mmol/L [239 mg/dl]. She was hospitalised overnight where her sugar levels were stabilised to the 8 to 9 mmol/L [145 to 162 mg/dl] range, with blood ketones dropping. We were discharged, with advice to monitor levels at home. Her fasting levels are always normal or low, with the lowest being 3.8 mmol/L [68 mg/dl], which rapidly rose to 7.6 mmol/L [137 mg/dl] after 15 minutes of eating something sweet. More often than not she has consistently high post prandial readings, often 8 to 10 mmol/L [145 to 180 mg/dl] after 1 to 2 hours. The hospital suggested ketotic hypoglycaemia, but could this be early type 1 diabetes given the highs and lows? She also had one reading fasting at 4.8 mmol/L [86 mg/dl], but had 0.8 mmol/L blood ketones. We are awaiting autoantibody tests, etc.
Sorry, but it sounds like type 1 diabetes or some other type of diabetes (monogenic maybe). I would suggest you consult with a board certified pediatric diabetologist/endocrinologist to see if she needs insulin, dietary management, education for the family, monitoring advice, etc. This does not appear to fit the diagnosis of ketotic hypoglycemia. Antibody levels (islet cell, insulin, GAD-65, zinc transport 8 antibodies) would be helpful, especially at diagnosis, coupled with insulin or C-peptide levels at the times of hyperglycemia.