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November 3, 2010

Diagnosis and Symptoms

Question from Rochester, New Hampshire, USA:

Last Tuesday, at my five-year-old son's well-child visit, the doctor noticed sugar and ketones in a routine urine sample. A blood draw revealed a blood sugar of 265 mg/dl [14.7 mmol/L]. We were sent to the hospital for a full metabolic panel, which showed sugars at 239 mg/dl [13.3 mmol/L]. The pediatrician felt sure my son had diabetes and we caught it in the infancy of its process. He sent us to a major teaching hospital in our state for inpatient monitoring, teaching, etc. On the drive up, my husband and I were discussing the preceding day's events to determine if it was possible that my son was just having a "bad day" blood sugar wise. The day before the doctor's visit (Monday) my son had eaten a normal breakfast, only ate about half his lunch and refused to eat dinner at all; he had a normal day playing outside with a neighbor friend. My son woke up at 4 a.m. vomiting mostly clear stomach contents. An hour before our doctor's visit on Tuesday morning, he ate three bowls of cereal with milk (a serving of this particular cereal had 8 g of sugar per serving) and toast with butter. He had also had a slight cold the week before, and (with two older brothers) we had had a busy weekend with fall sports and commitments. At the hospital, my son's blood sugar gradually showed declining values to within normal ranges, with no ketones in his urine. They sent us home with recommendations to monitor his blood sugar before and two hours after one meal/day for two weeks and discuss his results with his pediatrician at that point. We have been monitoring our son for almost six days and all his numbers have been great. Before meals, he is around 85 mg/dl [4.7 mmol/L] and post meal has been 101 mg/dl [5.6 mol/L] or so. Yesterday and today before lunch, however, his readings were 131 mg/dl [7.3 mmol/L] and 130 mg/dl [7.3 mmol/L], but post meal numbers were 96 mg/dl [5.3 mmol/L] and 95 mg/dl [5.3 mmol/L]. It was more than three hours since my son had eaten his last meal when I tested his pre-lunch blood sugar. So, is it possible that a combination of events (getting over cold, weird eating pattern and early morning. emesis) could cause a "blip" in blood sugar that is not indicative of diabetes? I really got the sense from the hopitalists that my son had a "blip" that they were not really worried about, but my son's pediatrician is more concerned that my son is actually in a pre-diabetic stage. This is all so new to me! Lest you wonder, the pediatrician we use for our children's care is really fantastic and come highly recommended within our community.


The blood glucose numbers you reports are very high so it is unlikely this is a “blip.” However, it is somewhat unusual to have the blood glucose values subsequently become so normalized so quickly. Illness occasionally does this but mostly we believe that such illnesses are the “final straw” that allows the high sugars to show up as the pancreas insulin production wanes. Detecting diabetes early sometimes allows the pancreas to do this, however. Key tests would include evaluating autoimmune problems of the beta cells of the pancreas. We usually do islet cell, IA2, GAD-65 antibodies since these are all available from reliable laboratories to most endocrinologists. If these are positive, then more likely the high sugar levels will return and this is just an early phase of type 1 autoimmune diabetes mellitus. If these are negative, then it is more difficult to know for sure. You should find out if the diabetes consultants ran these tests and what results they obtained. Ongoing close monitoring of blood glucose levels will be key and staying in close contact with a knowledgeable pediatric diabetes team will be very important to know when and if insulin will be needed.