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March 17, 2002

Diagnosis and Symptoms

Question from Oklahoma, USA:

My a nine and a half year old son was diagnosed with hypoglycemia a couple of years ago which was maintained well with a regular snack schedule and glucose monitoring, but a few months ago, he developed impaired glucose tolerance. This is extremely hard to control because my son also is underweight, has ADHD, and takes Adderall and Remeron to improve appetite and sleep patterns. I have found very little information on this condition in children. We are still in a wait and see stage, what else would you suggest?

Answer:

I am not certain that I can help. If I am reading your letter correctly, your son, with ADHD is on Adderall (which often inhibits appetite and can lead to poor weight gain) and Remeron (which is a type of anti-depressant, but which also sometimes increases appetite), and I gather he may be on the Remeron to offset the appetite suppressing effects of the Adderall. However, He also has a history of low blood glucoses, and now he is in an impaired glucose tolerance stage — I’m really not sure what you mean. It would be helpful to know how this last diagnosis was established.

To my knowledge, the only way to formally establish a diagnosis of “impaired glucose tolerance” is with a formal, specially conducted, oral glucose tolerance test (OGTT). The patient must eat at least 60% of their calories as carbohydrates for the three days before the test, must come in after an eight hour fast, and must get a very specific glucose load (1.75 grams of glucose per kilogram of body weight to a maximum of 75 grams), and then must have serum (not fingerstick) glucose levels measured during the specified times. Using these criteria, “impaired glucose tolerance” is then defined as a two-hour glucose value that is greater or equal to 140 mg/dl [7.8mmol/L], but less than 200 mg/dl [11.1 mmol/L].

Periodic elevated random glucose by fingerstick can be suspicious for glucose intolerance, but fingerstick sugars (whether blood or plasma determinations; check your meter) remain a screening device. If you have been seeing some higher readings this way, I would first suggest you review your fingerstick technique, being certain to clean the skin well before poking and then assuring that the cleansing agent (do you use alcohol?) is very dry before the poke. While a nine year old can very much help in his own fingersticks (or arm sticks or wherever depending on your meter), if the values are confounding, you should supervise his technique.

DS