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September 29, 2007

Diagnosis and Symptoms

Question from St. Louis, Missouri, USA:

Our three-year-old will sometimes wake up and shake so much at breakfast that he spills his juice. He is not a great eater. One day this summer, we took him in for a check up since he had large ketones, which I tested since I have an older son with diabetes. The doctor confirmed the ketones and small traces of sugar in the urine. His blood sugar was 175 mg/dl [9.7 mmol/L]. We were sent immediately to my older son's endocrinologist who wasn't convinced it was diabetes. She said anyone could have ketones if their bodies are starving and my younger son had not eaten dinner the night before. His blood sugar then was 189 mg/dl [10.5 mmol/L]. She ran a number of tests, including antibody tests, and they all came back fine. Since then, on another day his blood sugars were in the 200 mg/dl [11.1 mmol/L] to 300 mg/dl [16.7 mmol/L] range. Is there any explanation for a random blood sugar to be that high? He does not have high blood sugars all the time and we are only checking him when he is symptomatic. Secondly, if it were early diabetes, what is your best guess until we notice it more regularly?


Your questions are not unreasonable.

With respect to your first question, there are lots of explanations for a random high blood sugar, ranging from impaired glucose tolerance to an improperly coded meter to an unclean finger since his jelly sandwich earlier in the day. You know the expression: “Not all that glitters is gold?” Well, not all that is hyperglycemia is diabetes. (But, it too often is!)

You did not specifically indicate which pancreatic antibodies were measured, but such assays are not perfect. The diagnosis of diabetes is not made by the antibody test. The diagnosis is made by the glucose pattern. Recall what you learned when your other child was diagnosed (or refer to other questions on this site about the Diagnosis and Symptoms of diabetes). For diagnosis,

fasting serum (not “fingerstick”) glucose confirmed over 125 mg/dl [6.9 mmol/L]; OR

random serum glucose (not “fingerstick”) greater or equal to 200 mg/dl <11.1 mmol/L], but in the presence of diabetes symptoms; OR elevated two hour serum (not "fingerstick") glucose greater or equal to 200 mg/dl [11.1 mmol/L] in a properly formed glucose tolerance test. Your younger child may indeed be manifesting some glucose dysregulation. You may wish to discuss with your pediatric endocrinologist about considering an oral glucose tolerance test (OGTT) (which I think is rarely needed, but this might be one such time.) Regarding your second question, if you have the OGTT tolerance test, you might find out THEN that there really is diabetes going on. Barring that, it is hard to know when someone will develop type 1 diabetes. If all the antibodies (GAD-65, IA-2, insulin autoantibodies) are truly negative, then the answer might be never. Heck, it might be never even in the presence of antibodies. But, in general, after the pancreas becomes "inflamed" with the an autoimmune process, it might be six to 36 months or so. There is a process of "super-antibody" inflammation that can lead to diabetes in weeks. And, of course, other causes of diabetes, such as trauma, pancreatitis, etc., can lead to diabetes in hours. So, I think either you worry all the time about this or get it checked out now. DS