October 7, 2003
Diagnosis and Symptoms
Question from Round Lake, Illinois, USA:
I recently wrote in a question about my two and half year old son, and one of the doctors wrote back to me and said that it sounded like he had ketotic hypoglycemia. I did some looking in this, and a lot of it sounds like what my son is going through. I even found some people somewhat linking it with pyloric stenosis which my son had at the age of two weeks. However, I brought this up to his pediatrician who said that it was not likely because the levels of alanine in his blood was normal. Is this true? I’m curious to know why alanine is so important in diagnosing ketotic hypoglycemia.
I know that when he shakes he is low because I’ve tested him, and he was 70 mg/dl [3.9 mmol/L], and he also an A1c of 4.1%. I know these numbers are still considered normal but low enough to cause symptoms. I’ve also noticed that his tremors are strongly related to exercise. Here is the weird part. I know ketotic hypoglycemia can become dangerous if the child gets sick. Well, one night my son and daughter started running a fever of 101 to 102F. My daughter couldn’t stay awake, and my son was running around playing like there was nothing wrong. In fact, I kept checking him because I didn’t believe the thermometer. Anyway, I didn’t give him any medicine because he didn’t seem sick and sure enough his fever broke during the night. However, I tested him the next morning after he hadn’t eaten for about 12 1/2 hours, and it said 163 mg/dl [9.1 mmol/L]. I’ve also gotten other high non fasting numbers (309 mg/dl [17.2 mmol/L], and he was very thirsty, flushed and could not stay still.
I also brought this up to his pediatrician who said that it was normal for a growing two and half year old boy to have variations in his metabolism, it is normal to have a high fasting blood sugar after running a fever. Is this true? Everyone seems to have conflicting opinions, and I’d like to hear the answer from an endocrinologist who deals with this kind of stuff on a day-to-day basis. I just feel that with our family history of autoimmune problems, I need to know if these readings are normal for a very happy, healthy two and half year old boy.
Answer:
Ketotic hypoglycemia is a common issue in small children who have been deprived of carbohydrate for any reason. The shaking, the relationship to exercise and the low A1c would certainly support a diagnosis of some form of hypoglycemia. However, the normal serum alanine, a reflection of the boy’s attempt to sustain blood glucose from protein, would be against ketotic hypoglycemia.
The occasional high blood sugars could be a response to stress of some kind including the stress of a low blood sugar. The data are conflicting nonetheless, and my response to the story would be to spare a ‘very happy, healthy two and a half year old boy’ a lot of further investigation. Obviously, you yourself are anxious that all this might be linked to an autoimmune condition, especially perhaps type 1A diabetes. Whilst it is true that a full and properly conducted series of antibody tests could go a long way to eliminating this possibility, I would be inclined to wait and see if any stronger evidence of a clinical problem develops.
DOB
