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August 2, 2009

Diagnosis and Symptoms, Hypoglycemia

Question from Allentown, Pennsylvania, USA:

After doing research on ketotic hypoglycemia, which you suggested recently my daughter might have, I felt it was very likely the cause of my daughter's morning episodes (shaky, thirsty, vomiting). I had also noticed, after going to a weekend event that didn't serve lunch until noon, that she was struggling to make it that long. She was getting weak and fatigued and whimpering that she was hungry. So, I gave her a piece of candy, but it did not seem to perk her up too much until she actually got her meal. In light of this, I felt she was likely suffering from hypoglycemia. To check, I gave her a high protein dinner around 7:00 p.m. then let her go to sleep at her normal bedtime. I checked her sugars frequently thereafter. At 7 p.m., her glucose was 87 mg/dl [4.8 mmol/L] and at midnight, her glucose was 80 mg/dl [4.4 mmol/L]. I let her sleep in my bed so I could watch her carefully and woke at 5:30 a.m. to find she wet the bed (she rarely does this), so I checked her again. This time her sugar was 78 mg/dl [4.3 mmol/L]. I let her continue sleeping, but noticed she began twitching and grinding her teeth after about an hour. At 8 a.m., I checked her again and she was 66 mg/dl [3.7 mmol/L]. I was getting a little worried and didn't want her to get sick, so I woke her around 8:30. I had her pee on a ketone strip and she tested positive (80 mg) for ketones. I gave her a bowl of cereal and a glass of water and checked her again at 10 a.m. and she was 187 mg/dl [10.4 mmol/L] and her ketones were 160 mg. She was still hungry, so I made her a breakfast sandwich (sausage and egg on a roll). At 10:40 a.m., her sugar was down to 111 mg/dl [6.2 mmol/L] and there were only trace levels of ketones in her urine. I feel that this confirms that her morning episodes are attributable to ketotic hypoglycemia. But I still have some nagging questions. Does this rule out diabetes for a certainty? With a blood sugar of 66 mg/dl [3.7 mmol/L], does this qualify as hypoglycemia? Does it make sense that she should be having high quantities of ketones at that level? At home, she has a healthy appetite and eats large portions of food frequently throughout the day. Over the weekend though, she had to wait until noon to eat, without snacks in between breakfast and lunch and was definitely starting to display symptoms of weakness and fatigue. Why did it take almost 12 overnight for her sugars to start dropping, but only four during the day to drop low enough to cause her discomfort? Should I call the doctor about this? I have an appointment with a pediatric endocrinologist in October, but based on the research I've done, it seems I should be able to control her symptoms with diet. I also don't know if the doctor will think I am crazy for not letting them know about this sooner. My final question is regarding her weight. I know that this typically occurs in thin children, which she is, but does it actually "cause" weight loss? I'm hoping your answers will help me figure out exactly what to discuss with the endocrinologist when she finally does have her appointment in October.


I think that you have likely excluded diabetes mellitus for the time being. Having said that, there are experiences of children who initially had HYPOglycemia before being diagnosed with HYPERglycemia (and diabetes mellitus) some time later.

By strictest of definitions, a blood glucose of 66 mg/dl [3.7 mmol/L] is not “hypoglycemia,” but given the clinical and follow up testing you provide, a diagnosis of “ketotic hypoglycemia” seems appropriate and reasonable.

It is typical in ketotic hypoglycemia that the “spells” occur after a prolonged time between meals, such as 12 hours, but glucose levels depend on the types of food consumed, the efficiency of digestion and intestinal absorption, and the body’s overall metabolic rate. And, although there is not enough written about this, sometimes it is the rate of the fall in glucose that elicits symptoms rather than the absolute low level of glucose.

By all means, share the information with your doctor. While ketotic hypoglycemia explains much, it doesn’t explain the recurrent yeast infections, etc. I’d keep the appointment with the pediatric endocrinologist down the line for confirmation and/or consideration of other concerns if the symptoms do not nearly completely abate with dietary changes. Unfortunately, I can certainly think of some conditions that can be associated with a tendency for lower glucose, poor weight gain, recurrent/persistent yeast infections, and some of the other things you describe.

No. Ketotic hypoglycemia seems to be a consequence of, but not a cause, of poor weight gain. Once the muscle and fat mass become great enough, ketotic hypoglycemia seems to fall by the wayside. It is less common in children reaching about kindergarten and 1st grade.

A diet with increased complex carbohydrates (starches) and some increased protein (but must be a bit cautious) given frequently, and with decreased “simple sugars” should help. I think of simple sugars as things that are obviously sweet-tasting with sugar: table sugar, frosted cereals, fruit juices, soda, regular Kool-Aid. Milk would be good. A good bedtime snack might be a peanut butter sandwich washed down with some milk. No sugar added Carnation Instant Breakfast might be good. Again, talk with your doctor, ask for a referral to a general pediatrician and maybe a dietitian. During illnesses, (colds, flu), start screening the urine with those ketone strips and, when positive, treat the child then with some simple sugars. Avoid prolonged fasts. Avoid exposure to alcohol (sips from adults’ drinks, in medications).