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April 30, 2009

Diagnosis and Symptoms, Hyperglycemia and DKA

Question from United States:

I asked a question here several months ago regarding my two and a half-year-old daughter. In summary, she had frequent episodes of drinking and urinating. My neighbor tested her and she was 315 mg/dl [17.5 mmol/L]. We went to the pediatrician and the Emergency Room, but they could not find anything. I then took my daughter to an endocrinologist. All tests were negative. The pediatrician suggested random blood sugar and urine testing at home and said to watch for symptoms. Today, four months later, my daughter continues to have high numbers after eating, from 130 mg/dl [7.3 mmol/L] to 187 mg/dl [10.4 mmol/L]. These numbers are about one hour after eating. Yesterday, she didn't seem right 45 minutes after a breakfast of cereal and milk; she was 166 mg/dl [9.2 mmol/L]. I took her to the sitter who then took my daughter to school. After school, I picked her up and she was 215 mg/dl [11.9 mmol/L]. I thought I didn't do it right, so I checked her several more times. All readings were in the 199 mg/dl [11.1 mmol/L] to 215 mg/dl [11.9 mmol/L] range. I called the school and they said she had eaten a cupcake for a birthday party. So, she had breakfast, then nothing to eat from 8:45 to 10:30, then the cupcake. My pediatrician is not concerned and said that I really should wait until two hours post meal. That's not what I've heard or read. My understanding is one hour to catch her spike because that's always been when she spikes and then she goes down. I called an endocrinologist for a second opinion and repeat of the A1c. If you can believe it or not, they wouldn't even see her. They had me fax her tests from four months earlier and said that she didn't require a visit. I insisted that my pediatrician repeat the A1c, which he will do next week. I'm not really sure what my question is. I just feel like something is happening and nobody will listen. I know they can't diagnose, nor do I want them to, or treat her for diabetes. However, I just feel that I need to know if she were really truly headed that way, if I should continue blood sugar testing or if I should just relax and watch for worsening symptoms. I don't know if it's going to happen and I can't do anything about it but, each day, I wake up waiting for the other shoe to drop, like yesterday, when she went over 200 mg/dl [11.1 mmol/L], which shocked me and I freaked out. Today, I actually had a panic attack and the doctor gave me Xanax. I feel like my daughter is going to end up with diabetes. I feel like my doctors and my family think I'm losing my mind! Do most children spike over 200 mg/dl [11.1 mmol/L] after a cupcake? On another note, I have a 12 year old son who's been wetting the bed, often. My husband said it's probably puberty and he's experiencing puberty issues at night. The underwear smells clearly of urine. He's a picky eater, eats small meals. One evening he ate a HUGE amount of dinner - pasta and fried chicken. Fifteen to 20 minutes later, he came to me and said he was dizzy. I tested him and he was 47 mg/dl [2.6 mmol/L]. To be sure, I checked him with two meters and he was 45 mg/dl [2.5 mmol/L] to 51 mg/dl [2.8 mmol/L]. When I checked him later, he was 150 mg/dl [8.3 mmol/L]. I am afraid to take him to the pediatrician for fear of being accused of Munchausen by Proxy! My son seems to have an opposite issue than my daughter although I wouldn't know if he has "highs" because I don't test him. Could the two be related? He doesn't drink/urinate a lot, but the wetting the bed concerns me. I just figured as long as he's okay, with no other symptoms I should just wait it out, then I wonder if I just don't pay too much attention to it because I'm afraid of what might be. Does anything I've said ring bells here? Am I worried over nothing? Should I test one hour or stop testing? Do you think it's normal to spike such numbers after eating?


First, with your daughter, you are correct that these are high (hyperglycemic) blood glucose values post-eating. Exactly what time to check is unknown but post-food values should be below 126 mg/dl [7.0 mmol/L], some would say 140 mg/dl [7.8 mmol/L] on a home monitor. So, the values you report are clearly hyperglycemic values and not normal. Since they are not persistent, however, it is difficult to make an exact diagnosis of diabetes. Assuming that the islet cell, GAD-65 and IA2, as well as Zn8 antibodies have been tested several times and remain negative, then we do not know exactly the kind of diabetes. By age, this is a pre-diabetes condition and still most likely autoimmune. Exactly what to do is ever more unclear. My recommendation would be routine monitoring with symptoms, routine monitoring with a growth spurt and routine blood glucose monitoring with any illness since those are the three conditions most likely to be associated with deterioration of glucose control, higher sugars and more dramatic loss of insulin production by the “presumed” damaged beta cells of the pancreas. Whether or not it just stays like this for months or years or progresses, ultimately, to frank need for insulin and clinical diabetes is also unclear. In our practice, we would follow your lead, let you report changes to us between visits and see your child about every four months to track progress, A1c, changes and review blood sugar values with you.

For your son, enuresis is not a normal part of puberty so I would disagree with your husband’s ideas. I would also suggest that you discuss this with your pediatrician and make sure that there is no urinary, kidney or bladder problem causing the enuresis. The low blood sugar values you report are unrelated to the enuresis, although, sometimes with hypoglycemia there is some loss of bladder control. Hypoglycemia can be a forerunner of diabetes, however, but you do not report high values at all. Either way, I would review your concerns with your pediatrician to be safe.