September 8, 2007
Diagnosis and Symptoms, Hyperglycemia and DKA
Question from Chilton, Wisconsin, USA:
I need guidance on what my next step should be regarding my daughter’s health. She is four and a half years old and has had intermittent hyperglycemia for the past nine months. She is of normal weight. In October 2006, she was showing symptoms of thirst and fatigue. A finger prick in the doctor’s office showed hyperglycemia (249 mg/dl [13.8 mmol/L]) and a urine dip showed sugar and ketones. Her A1c was checked and was 5.4. Her blood sugar did come down to normal on its own that day so we were told to monitor her blood sugar with a home meter. Since then, she has had two antibody tests done (not the insulin antibodies) and both were negative. She had an OGTT, which she passed. Her fasting insulin was a bit low (1.4), but the doctor told us this meant nothing.
In the past nine months, we have seen 20 or more readings of 200 mg/dl [11.1 mmol/L] or more on our home meter. The highest was 285 mg/dl [15.8 mmol/L]. They always come down on their own, usually within two to three hours of eating (the high spikes are almost always one hour postprandial), but sometimes take longer to return to normal. They are sometimes associated with an accompanying illness (cold, virus, ear infection), but not always. Every time she is ill (even when she is eating well), she shows ketones in her urine, sometimes even large ketones. The spikes do not always seem related to what she just ate. Sometimes she has eaten a healthy, low carbohydrate meal and we still see a spike over 200 mg/dl [11.1 mmol/L] at the one hour postprandial mark.
She did see an endocrinologist who was unconcerned about our home meter results and called them unreliable. We have not been able to get a verified venous draw documenting the spike over 200 mg/dl [11.1 mmol/L] because she often comes back to normal during the long in-take process at the Emergency Room or laboratory.
Is it normal for a child to spike over 200 mg/dl [11.1 mmol/L] routinely after a meal? If this is typical, where can I find that in the literature? If this is not okay, what should we do next? Could this be emerging type 1 diabetes or should we be looking for some other cause? Please give us a direction to proceed; I am worried that routine spikes could be damaging long-term.
Answer:
The high sugars have occurred too often. Assuming that your technique is correct and these are true values, the accuracy of home monitoring is such that there are to many episodes of hyperglycemia. With not many symptoms and none that are persistent, even with negative antibodies, I would assume that she has glucose intolerance, intermittently, and that she remains at risk for full-blown diabetes developing. I would usually continue home monitoring and also follow a meal plan designed to avoid obesity and to reduce fast-acting carbohydrates, i.e., a diabetes meal plan. And, I would monitor antibodies, A1c levels, lipids, thyroid functions, etc.
I’d also suggest that this be done by a pediatric diabetes specialist, not a primary care physician. Time will help figure out what is going on and whether or not there will be a decrease in insulin availability with higher blood sugars. Especially with a growth spurt or illness, I would check blood sugars more frequently since these are the times when most likely things could change quickly, cause dehydration, DKA, etc.
SB
