About eight months ago, my then five year old daughter had one yeast infection after another, her pediatrician found sugar in her urine, and her blood sugar at the time was 220 mg/dl [12.2 mmol/L]. We were told to come in the next day for a fasting sugar, which was within normal range. Two weeks later she had strep throat and again sugar in her urine.

I pushed to see an endocrinologist who decided to do an oral glucose tolerance test. Her two hour reading was 186 mg/dl [10.3 mmol/L], and she was diagnosed with impaired glucose tolerance. All of her antibodies were negative and her A1c was normal, but her insulin levels were low. Six months later, the endocrinologist gave us a meter and had me test her for two weeks. The fasting sugar levels were from 60 to 130 mg/dl [3.3-7.2 mmol/L] (the majority were normal), and her bedtime sugars were 80-265 mg/dl [4.4-14.7 mmol/L]. After analyzing the numbers, the endocrinologist decided to see us again in six months, and we are call if symptoms arose. Does this seem like a safe tactic? Can blood sugars really shoot out of the target ranges in a person who does not have diabetes? Why would my daughter be going high once in a while? Can this happen?

Although an infection can cause temporary high blood sugars that resolve in 24 hours and never recur, if your daughter’s blood sugar is going above 200 mg/dl [11.1 mmol/L] repeatedly, it sounds like she is slowly developing diabetes and may need insulin. Your pancreas has to fail 50-90% before blood sugars are consistently elevated. If your child’s pancreas is in the process of failing, she may be able to make enough insulin when she isn’t sick and has a small meal, but may not be able to make enough insulin when she is sick and eats a big meal (when she needs to make more insulin).

You shouldn’t restrict her calories to keep her blood sugar normal. if she can’t keep her blood sugar normal on a normal amount of calories for age, it might be worth starting a very low dose of insulin sooner rather that later. Sometimes kids like this do very well with a very low dose of either Ultralente twice a day or Lantus (insulin glargine) once a day (“long acting” insulins). This will provide some insulin for her basal requirements” (insulin she needs when she is not eating), and she may still make enough insulin to match what she needs when she eats so she doesn’t have to be so strict on a meal plan for a while. This may delay the onset of complete failure of the pancreas for a while and help make the adjustment period easier.

If you don’t start insulin yet, make sure to check her blood sugar (and urine for ketones) more frequently when she is sick as her blood sugar may go very high, and she might spill ketones in the urine and could get even sicker with DKA [diabetic ketoacidosis] if she didn’t get insulin right away.

In the meantime, I think it would be a better idea to see her at least every three months and check her hemoglobin A1c and a blood sugar taken after a big meal. I’d want to make sure she is growing normally and gaining weight normally. If she hasn’t had her thyroid tested, I would make sure to do that as an overactive thyroid can raise the blood sugar and cause weight gain — and if she had any thyroid problem (overactive or underactive), you’d be suspicious she was at high risk for developing diabetes as kids with diabetes often have thyroid problems too.

TGL
Additional comments from Dr. Donough O’Brien:

With intermittent glucosuria and repeated yeast infections together with a number abnormal blood glucose readings, it is difficult to believe that your little daughter does not have some form of diabetes. From what you say she had the full range of anti-GAD, anti insulin and ICA512 tests which would exclude the most common form of diabetes — type 1A or autoimmune diabetes. This leaves a number of possibilities such as type 1B diabetes and all the insulin resistance syndromes.

However, I am sure the issue that concerns you is whether or not she should be starting on some more formal treatment though not necessarily insulin or even metformin. On this issue, I would agree with the endocrinologist that nothing further is indicated as long as the hemoglobin A1c test is normal. There could be a number of reasons for the erratic blood sugars including, dietary, exercise related and stress. To elaborate the latter point, small children can show abrupt rises in blood sugar in situations where they might be stressed by needles, white coats, strange faces and a worried mother.

In the meantime and until the answer becomes clear, it would be important to monitor blood sugars closely during any intercurrent infection and to keep reviewing the problem every few months.

DOB
Additional comments from Dr. Larry Deeb:

I see a number of cases a year like this and no diabetes emerges from it. I can’t explain; I just use urine glucose and tell them to call if it gets positive.

LD