Shortly after my son turned one, I noticed that he would become shaky at various times during the day. He seemed to be worse in the morning and late at night. Some days he’d shake very little. I consulted his pediatrician and family doctors here, and all said he’d grow out of it.

I was back home in the US for a visit last month and consulted a pediatrician there who did a three-hour glucose tolerance test and determined that my son has reactive hypoglycemia. The pediatrician then sent me to a dietitian to obtain general diet guidelines, but I felt the dietitian was a bit too general and vague, and I left feeling like I was already feeding my son quite well. I am back in Hong Kong and I feel lost and confused. My questions are:

I can’t seem to stay on top of his hunger and shakiness. He wants to eat or drink milk about every 90 minutes, and I find that we are constantly feeding him. Is there such things as overfeeding him?
Was the three-hour glucose tolerance test the appropriate test to determine his reactive hypoglycemia?
I have been giving my son a snack of carbohydrate and protein before bed, but he still wakes up very shaky and has been waking in the middle of the night to ask for milk. Should I be giving him a snack during the night?
Must I eliminate refined sugars completely from his diet?
I never know if I am giving him a good balance of complex carbs and protein. Can you recommend a book or web site that could advise about a toddler’s diet?

In order to diagnose reactive hypoglycemia, he should have had a substantial amount of carbohydrate intake for three days prior to the test. Most people would do blood glucose levels every 30 minutes for three hours and some would go to five or six hours with insulin levels. Some would also suggest 15 minute sampling the first hour. Blood glucose would have to be below 60 mg/dl [mmol/L] with concomitant symptoms to be able to definitively diagnosis hypoglycemia during such a test.

If he is symptomatic and blood glucose levels during such symptoms are below 60 mg/dl [mmol/L], even without a glucose tolerance test, then I usually have great success with the following treatment regimen:

Generally avoid simple sugars (milk, juice, fruit, candy)
Always provide protein and fat foods at no more than three hours apart (i.e., breakfast, mid-morning snack, lunch, mid-afternoon snack, suppertime and bedtime snack). The fat content is the most important because this slows down the gastrointestinal emptying time and thus slows down the absorption of food so that it is longer and somewhat smoother.

This usually works for more than 90% of our patients with such symptoms. The rest usually respond when provided with extra food associated with extra activity. Some need simple carbohydrates immediately before or in the midst of added activity and other needs food provision just after activity is done. This depends upon whether or not the hypoglycemia is activity-induced in addition to reactive. The reactivity reflects an insulin overproduction and so less simple carbohydrate allows the body to not “overproduce” insulin as much. The high fat content slows the food absorption and thus makes the food provision more sustained. If there is an additional exercise related component, counterbalancing this effect should work.

SB

[Editor’s comment: Also, see Other causes of hypoglycemia at the Diabetes Monitor.

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