April 14, 2004
Diagnosis and Symptoms
Question from Pasadena, Maryland, USA:
I have a two and a half year old daughter who has recently had a few scattered high blood glucose readings: 296 mg/dl [16.5 mmol/L] two hrs after breakfast, 161 mg/dl [8.9 mmol/L] two hours after lunch, and 175 mg/dl [9.7 mmol/L] two hours after dinner. Each of these high readings was on a different day. Her fasting blood sugars have ranged from 75 to 109 mg/dl [4.2 to 6.1 mmol/L] and other readings, all two hours after a meal, have ranged from 74 to 122 mg/dl [4.1 to 6.7 mmol/L. She has always shown negative for ketones. We have been to the pediatrician, who has us checking ketones in her urine and testing her blood glucose two hours after each meal for one week. At the doctor's office, a urine dip stick was negative for glucose and she read 116 mg/dl [6.4 mmol/L] one and a half hours after lunch. We started checking the glucose at home after a few potty "accidents, " which is highly abnormal for her, and her requests for more fluids. Her father is an insulin dependent diabetic, diagnosed at age 24 and having only a family history of type 2. I had gestational diabetes, insulin dependent, while pregnant with her. My mother, her grandmother, was diagnosed with type 1 at age 12, while her maternal great grandfather was diagnosed with type 1 in his thirties. There are three other insulin dependent grandparents/great grandparents on my side; they would be my daughter's great or great-great relatives. She is 36 inches tall and weighs 28 pounds. There has been no weight loss and it appears as though her "accidents" and higher fluid intake is tapering off. She has always been a poor eater. She eats very little at meal times and throughout the day. Given all this, what do you suppose is the reason for her seemingly random high glucose readings? Whenever she got a high reading, a non-diabetic family member would check theirs to make sure it was not the machine and all persons tested were within normal limits. Does this suggest MODY? Could my husband (her father) have a form of MODY and not type 1? What tests should we request, if any, from our pediatrician? Also, can infections in a non-diabetic person affect blood glucose levels, and, to what extreme? My daughter had one urinary tract infection (UTI) about three months ago. The pediatrician is doing a culture to rule out a UTI that may skew blood glucose levels, which is why I ask. Any insights you have to offer is greatly appreciated.
Certainly, your daughter has an impressive family history that should make people suspicious for the development of diabetes.
MODY (Maturity Onset Diabetes of Youth) is rare. It typically is inherited in such a way that one would expect someone in every generation from that side of the family to develop it. It is not so ketosis prone.
Clearly, infections and other “stresses” can lead to temporary increase in blood glucose. But, the effect should be short-lived for just a couple of days, not three weeks. Very elevated glucose levels can also set up for some infections, as germs love sugar! Yeast infections in the mouth or vaginal yeast infections in females are not at all uncommon in poorly controlled diabetes.
While your daughter has had some higher readings, I am not certain that she fulfills criteria for diabetes at this time. You can search this web site for diabetes definitions at Classification and Diagnosis of Diabetes and other questions pertaining to this. In short, diabetes is diagnosed when:
Fasting SERUM or PLASMA glucose (NOT “Whole Blood”), measured from a venipuncture (NOT a finger stick on a home/bedside glucometer) is confirmed to be > 125 mg/dL (>126) OR
A random SERUM or PLASMA glucose (NOT “Whole Blood”), measured from a venipuncture (NOT a finger stick on a home/bedside glucometer) is confirmed to be > 200 mg/dL WITH THE PRESENCE OF SYMPTOMS (increased urination, increased thirst, weight loss, etc) OR
If during a properly prepped and prepared and dosed oral glucose tolerance test, the SERUM or PLASMA glucose (NOT “Whole Blood”), measured from a venipuncture (NOT a finger stick on a home/bedside glucometer) is > 200 mg/dL.
I do not usually advocate for an oral glucose tolerance test (OGTT) but this may be warranted in your daughter. It is important to know that for a proper OGTT, the patient should consume a diet in the three days prior to the test that is at least 60 percent carbohydrate. The proper glucose load is VERY specific, and often done incorrectly, at 1.75 grams for each kilogram of her body weight to maximum dose of 75 grams. For a 28 pound girl (12.7 kg), we’re talking only a 22 gram dose of glucose.
Another idea to help better assess risk would be to ask her physician to measure specific pancreatic antibodies, typically the GAD64, ICA-512, which is also the IA2 antibody, and even insulin antibodies. This test will not tell that she has diabetes NOW (high glucoses as noted above make the diagnosis), but will assess risk.
All in all, I doubt that she has diabetes at this time, especially with a lack of symptoms, borderline high on a glucometer, and lack of ketones. I’d also suggest that, before the next time you do a finger stick on your daughter, you must be absolutely certain the finger site is completely clean with alcohol or even soap and water, and completely dry before you test.