November 10, 1999
Diagnosis and Symptoms
Question from Michigan, USA:
I have a son who is a diabetic and has been since he was 2; it’s been 8 years now. My problem is regarding my second son who is 4 — he, about a year ago, started having problems with wetting at night, etc. I checked his blood on occasion from then and his sugars fluctuate wildly. We took him to an endocrinologist based on recommendations from our pediatrician. His A1c’s are normal. They did a IVGTT — they said that he is on the low end of normal for his C-peptide, but still with in normal levels. At this time, he was not considered to be a diabetic, but they said could be possibly just beginning.
Here’s our problem. This morning, he woke up and was very whiny and cranky, so I checked his blood and he was 44 — he had some juice and then breakfast, later we checked his urine and his blood again and his urine had extremely large ketones present and his blood sugar was 190. After several hours his sugar was 97 and his ketones were normal.
What is going on? The endo is baffled, because at present, he is not a diabetic, but is indicating that he could be and that it is not normal to have sugars and ketones doing these things as often as this happens. His A1c’s are all in the 4.3- 5.0 range. Could this possibly be a form of MODY? Our endo does not have much experience with this. But I ask this because my father who is diabetic for 25 years on and off has been suggested to have MODY. Twenty-five years ago, he was put on an oral agent at the age of 28 — it caused his sugar to go too low, so they took him off, then after several years, he was back on it, he did this for 15 years on and off. Then 5 years ago, he was placed on insulin, now he is going to less and less doses because he is low much of the time even despite eating, etc. He has not lost weight, so this would not be making his sugar “normal again”.
Please help us here, we do not know where to turn, and our endo feels that he should have an IVGTT every 6 months — but in cases of MODY — would this really reveal much?
Answer:
I think the first step should be to ask your younger son’s pediatrician to arrange for an antibody test. A number to call that can help is 1-800-425-8361. From your description, it sounds like there is about a 95% chance that the test will be negative and this will tell you that he does not have Type 1A (autoimmune) diabetes, which is by far the commonest form in North American Caucasian children. In the unlikely event that the test is positive you might want to consider participating in the national DPT-1 research study which is designed to avert actual clinical diabetes. If the test is negative and especially as the A1c’s are normal you can ignore the IVGTT and the one high blood sugar and give some thought to other explanations for the enuresis and urine ketones. The former might well be due to anxiety that he might be getting diabetes like his brother or resentment that his brother may be perceived as getting a lot of extra attention. A combination of patience, simple counselling and sometimes medication can nearly always put this right.
As to the ketones, since you make no mention of glucosuria, I think this reflects a long overnight fast and is really very common in this age group where it simply reflects a temporary reliance on fat rather than carbohydrate for energy. One of the ‘energy’ bars taken as a snack just at bedtime could well put this right and the low morning blood sugar too.
Since your oldest son is apparently insulin dependant and therefore Type 1A, presumably it is very unlikely indeed that your second son would have one of the many variants of MODY. A specific diagnosis can be made; but it is difficult to organise and expensive and in any case the treatment would not be different from the more conventional forms of diabetes.
DOB
