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April 23, 2004

Hypoglycemia, Other

Question from Philadephia, Pennsylvania, USA:

My six year old daughter had a severe seizure five days ago. She had a blood sugar of 63 mg/dl [3.5 mmol/L] at 2 a.m. which was treated with three glucose tabs (usually enough to treat at this level). At 6:30 a.m., she came to my room confused and shaking, unable to speak clearly. We quickly started to give cake frosting rubbed in her gums and, as she started to stop shaking, she drank 1/2 can of Coke. We then checked her glucose which was now 290 mg/dl [16.1 mmol/L]. She did not respond to us even though her blood glucoses were higher. She looked glazed and could not speak so we took her to the emergency room. Since her blood glucoses were now high and she was still unresponsive, they thought this seizure was not related to the diabetes, but rather a seizure disorder. Also, they had to put a tube down her throat to give oxygen since some blood gas level was way too high. The endocrine team at Children's Hospital of Philadelphia (CHOP) thinks this was diabetic low, but the emergency room doctors think it was seizure disorder. Is there anyway to know for sure? What could have caused the blood problems? She had one other seizure 11 months ago, but it was not this severe although it did require a visit to the emergency room. Does this mean she will have seizure problems a lot? Is two seizures in one year considered a lot? I know some kids who have never had a seizure. Her A1c's have ranged between 7.4 to 7.9 this year. If I let her numbers run a little higher to try avoid this, am I compromising her health later in life? I know I have a lot of questions but I am lost. If I go for tight control, she has seizures. If I loosen up a bit, it's heart failure and kidney disease.


I agree that this was probably an impressive episode of hypoglycemia. Sorry, but I don’t understand your description of the “seizure” part. She was shaking but was conscious? That is not typical of a seizure–i.e. convulsion.”Seizures” are usually not associated with being conscious and often, but not always, can be associated with rhythmic, repetitive, rather forceful “jerkings” of the arms, legs, or other more subtle repetitive movements such as lip-smacking or eye blinking. Sometimes, seizures are associated with “staring off spells” but these little seizures are typically brief in their duration. Being awake but unresponsive just sounds like a severe low to me without a true “seizure.” Sometimes there is a lag between the blood glucose and the glucose level in the spinal fluid bathing the brain.

To address your questions, having true hypoglycemic seizures does not seem to predispose someone to epilepsy. But the type of hypoglycemic reaction a diabetic gets often is repeated in that individual. For instance, if one tends to get jittery and shaky with hypoglycemia, that’s typical for you, so I would not expect routine loss of consciousness. If headaches are typical for you, then I would not expect other manifestations. This is not to say that one could never have other symptoms of hypoglycemia, rather it just emphasizes that you tend to get the same symptoms that you tend to get.

If one does have an underlying seizure disorder/epilepsy, then hypoglycemia could lower your threshold to trigger a convulsion. How can you tell? Sometimes a bit of trial and error: seizure symptoms with completely normal glucoses on a recurring basis suggests a real seizure disorder to me. Epileptic seizures tend to be recurrent and stereotypical. Hypoglycemic reactions should not be so frequent. The Diabetes Control and Complications Trial (DCCT) showed a three-fold increase in significant hypoglycemia with good control. Nevertheless, if you get so gun shy about seizures and allow the glucose levels to rise, you may well be sacrificing future health. You have a world-class endocrine team at CHOP. I’d continue to have you confer with them. The DCCT also demonstrated that you don’t need super-tight control in order less the risk of eye, kidney, or nerve damage.

You may want to ask your team about your child trying the Continuous Glucose Monitoring System to try to elucidate subtle glucose patterns that might then allow you to alter her insulin-meal-activity plans a bit. It is a sensor one wears for three days to see a pattern in one’s blood sugars.