January 10, 2017
Diagnosis and Symptoms, Hyperglycemia and DKA
Question from New South Wales, Australia:
Apart from being born six weeks early, my three-year-old daughter has been quite a healthy little girl. She generally has a good appetite and eats well but is very thin. She has been thin since she was a baby and although it worried me at first, it just seemed like she was built this way and destined to be slender. I haven’t noticed her to be losing weight. Lethargy is not a problem; she is bright and energetic. I do not think she is polyuric or polydipsic.
Last week, after being at the beach all day, we put her to bed after dinner as she was exhausted. She probably didn’t drink as much water as she normally would throughout the day and it was very hot weather. The following morning when she woke up she had a dry nappy and didn’t need to urinate. She also complained of being tired and having a headache. I became alarmed when she was falling asleep in her high chair during breakfast. She also appeared clammy and very sweaty, with a deep ‘sighing’ respiration. Her heart was also beating quite fast. I thought she was dehydrated so I gave her lots of water to drink and she ate her breakfast. My husband also gave her a small chocolate. Finally, two hours after waking, (so she had probably gone 14 hours without needing to urinate) she used the toilet and I decided to test her urine and was very alarmed when it came up strongly positive for ketones (4+) and positive for glucose (2+). Concerned she had DKA (on account of the ketonuria, glucosuria, lethargy and abnormal respiratory pattern), I took her to the local hospital.
The nurse there tested her glucose; it was 11 mmol/L [200 mg/dl] and her ketones were 0.5. The nurse was not concerned about diabetes and said the glucose was likely due to the chocolate and ketonuria was common in dehydrated children. She said the ketone reading was normal since it was below 0.6 and although the glucose was a bit up, that was explained by the chocolate she ate approximately one hour prior to the test. By this stage, she was much improved, bright and energetic, so I took her home again. She was normal for the rest of the day.
I have tested her urine three times since over the past week and there is no evidence of ketones or glucose but I remain very concerned about the blood glucose reading of 11 mmol/L [200 mg/dl]. I have done a fair bit of reading and it sounds like a random glucose reading of 11.1 mmol/L [200mg/dl] is considered strongly predictive of a diabetes diagnosis. So, I am planning to take her to our local general practitioner (GP) but I am unable to get an appointment until next week.
Can dehydration alone elevate blood glucose in children as well as causing ketonuria? How common would it be for a diabetic child to have no glucose or ketones in their urine on three separate occasions?
You are correct to be concerned. The nurses information provided to you is incorrect. Blood glucose levels this high do not occur after eating chocolate or any other sugar continuing products, juice, soda etc under normal circumstances. If she were ill with a virus or severely dehydrated, rarely this can be associated with a random high blood sugar reading. Ketones, on the other hand, only signify that the body is burning fat and under conditions of dehydration, inadequate caloric intake for any reason, this may occur. The combination of hyperglycemia and ketonuria, however, is worrisome. Please call back your GP if you have not already seen the GP, and ask for an urgent consultation so that further testing, an A1c test and perhaps also pancreatic antibody testing can be done. It may also be reasonable to consult with a pediatric diabetologist as well. Please continue monitoring either blood glucose levels at home several times a day and/or urine glucose and ketone levels so that you will be aware if these remain abnormal or worsen. This would mean that this “early diabetes” condition has progressed to more overt diabetes and insulin is needed. The main symptoms that imply increasing risks involve ongoing weight loss, excess urination, night time urination, unexplained lethargy.