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Question:

From Milwaukee, Wisconsin, USA:

My 3 year old granddaughter was diagnosed 12 months ago. She is very difficult to control. Nevertheless, her last HbA1c was 7%. Her endocrinologist expressed concern that this was too low! He said that she might suffer some brain damage. She has never been so hypoglycemic that she lost consciousness or required professional treatment. I can find nothing in Medline to document the concern of HbA1c being too low. Everything I have read says, "the lower the better" unless the patient suffers severe hypoglycemic events. Furthermore, it seems that hypoglycemic events are not related to HbA1c. Could you comment and give me bibliographic references which address this issue, if any exist?

Answer:

Obtaining good blood sugar control in a volatile three year old is never easy; but one point that you might like to discuss with your daughter's endocrinologist is the possibility of getting an antitransglutaminase antibody test done to look for celiac disease. About 10% of Type 1A (autoimmune) diabetics have this other autoimmune disorder of the intestinal mucosa and it has been recently recognised as a cause of erratic carbohydrate absorption and consequently of unstable control even when it is asymptomatic. Treatment involves eliminating wheat protein.

Your second question about the risks and advantages of meticulous control at this age is a difficult one to resolve as it involves finding a balance between two important but conflicting objectives. On the one hand there is evidence that even quite a modest degree of hypoglycemia, whatever the cause, may lead to developmental delay. If you search in PubMed under 'Hypoglycemia and developmental delay' you will find a number of texts and if you then have access to a medical library I would suggest looking at Lucas, A. et al. in the British Medical Journal Volume 297, page 1304, Nov 19th 1988, and in Jacobs, DG in the Journal of Pediatric Surgery Volume 21, page 1184, 1986. At three years old, the risk is beginning to lessen as a toddler can increasingly express the sensations of hypoglycemia.

At the opposite side of the argument is the evidence that meticulous control from the very beginning diminishes the chances of long term complications even in childhood. If you went to the same website and searched under 'Control and long term complications in children' you would find a report by Holl, R.W. in the Journal of Pediatrics Volume 132, page 790, 1998 which reviews this issue.

I would have thought that the risks of hypoglycemia would be small in your daughter and that 7% A1c was fine if she has had no problems, at the same time there are two points that you might discuss with the endocrinologist that you might call prophylactic:

  1. Maintain as comprehensive as possible a profile of blood sugars around the clock with an occasional one in the early hours of the morning and special attention to any effect from extra physical activity. This will tell you if there are periods in the day when hypoglycemia might occur.

  2. If you have not already done so consider a change in the short acting insulin component to Humalog. This has the advantage that it can be given immediately after a meal and the dose adjusted to the pre-meal blood sugar and to appetite.

DOB

Original posting 12 Apr 1999
Posted to Hypoglycemia and A1c, Glycohemoglobin, HgbA1c

  
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Last Updated: Tuesday April 06, 2010 15:09:02
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