My four year old grandson is very shaky in the mornings, wakes up to urinate at night and is thirsty most of the time. This past weekend, he woke up vomiting and extremely shaky. My son-in-law is a diabetic so we tested my grandson with his meter. His blood sugar was 46 mg/dl [2.6 mmol/L]. We got apple juice in him and he ate breakfast (NO sugar). We tested him an hour later and his sugar was 177 mg/dl [9.8 mmol/L]. The vomiting stopped and there were no further incidents.

I took him to a pediatrician and they ran blood tests on him. She told me he is fine because his sugar was 89 mg/dl [4.9 mmol/L] when they tested him, his liver profile was fine and there were only trace ketones in his urine. She said there is no reason to run additional tests or send him to a specialist.

Should they have done a fasting sugar on him to see how his body is processing the sugar? Should I take him somewhere else or just take her word that everything is fine? I don’t know what to do.

I think that, most probably, this four year old experienced what, in the past, was called “ketotic hypoglycemia.” This usually occurs in preschool-aged, rather thin children, who have gone for a more prolonged time than usual between dinner the night before and breakfast the next morning. Sometimes, the child also has a mild intercurrent illness (mild cold, for example).

When the body does not have access to available sugar and/or has used up the “stored” sugar in the liver and muscles (and for a thin child this can happen rather quickly after about eight to 12 hours or so), the body starts to make ketones, a breakdown product of fat. The ketones maintain energy for the brain but tend to make the tummy upset so people with ketones often feel sick to the stomach and may vomit. The key is giving something that can quickly raise the blood glucose, such as juice and then follow with some real food — just like you all did.

The good news is that this is commonly a transient phenomenon that will fade after the child gets a bit more “meat-on-his-bones” and has more independent access to eat. During times of illness or unexpectedly lengthy times between meals, it is advisable to have some rapid-acting glucose around. You can also purchase inexpensive urine testing strips for ketones. The combination of LOW glucose plus the PRESENCE of ketones almost assures this diagnosis. Diabetes would be more likely if there were HIGH glucose and the presence of ketones.

The bad news is that if this is something worse, it will continue and other symptoms will evolve.

The increased thirst is a little odd for “ketotic hypoglycemia.” I am not too impressed with the glucose of 177 mg/dl [9.8 mmol/L] after the feeding.

Your pediatrician can guide you more.

DS