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Question:

From Amarillo, Texas, USA:

My nine year old son has had all the classic symptoms of diabetes so we did two finger sticks, found them to be elevated (as high as 222 mg/dl [12.3mmol/L]), and I called his pediatrician. I talked to the nurse who gave an order for a three-hour OGTT (not including insulin levels) and a urinalysis were normal, but the test failed to show that just 30 minutes after the test, he was was back up to 245 mg/dl [13.6 mmol/L]. I asked the nurse what we do now, and she basically said that if he's drinking more, he's going to pee more. I wasn't comfortable with that answer so I called a doctor here who deals more with children who have diabetes for a second opinion.

I brought him a detailed history, and a very detailed blood sugar graph with diet and activity correlations. This second doctor ordered an A1c which was 5.5% so we just ran a five-hour OGTT with insulin levels, and he had fingersticks of: start -- 97 mg/dl [5.4 mmol/L]; one-hour -- 103 mg/dl [5.7 mmol/L]; two-hour -- 43 mg/dl [2.4 mmol/L]; three-hour -- 80 mg/dl [4.4 mmol/L]; four-hour -- 81 mg/dl [4.5 mmol/L]; and five-hour -- 23 mg/dl [1.3 mmol/L]! He was still walking and talking but seemed flighty, so I checked him two more times to be sure it was really that low, and it was.

We have been keeping him on the ADA diet with three meals an three snacks, proteins, and complex carbs, etc., but he has always eaten that way before. We are unsure if he has diabetes, hypoglycemia or something else for that matter, and I think my second opinion may be as confused as we are. What would be causing my son to run high for two weeks, then suddenly low? When do I ask for a referral to an endocrinologist?

Answer:

Well, I certainly appreciate your apprehension and confusion. On the presumption that the two oral glucose tolerance tests were done appropriately, then I must conclude that your son does not have diabetes. A glucose level at the two-hour mark of greater than 200 mg/dl [11.1 mmol/L] defines diabetes in a proper OGTT. The GTT has specific requirements, that far too often are not performed by many clinics. The patient should have consumed at least 60% of his calories as carbohydrates for the three days before the test, he should have been fasting at the time of the OGTT, a specific amount of glucose (1.75 grams for every kilogram of her weight, to a maximum of 75 grams) should have been administered, and insulin levels should have been measured concurrently with the glucose. Without this information/instructions, the results should be interpreted with caution. What were all the values from the three-hour OGTT? Did they properly measure insulin during the OGTT?

Because of the concerns with technique, quality control, etc. with fingersticking, I think you can only use fingersticks as a screen for glucose and cannot make a definitive diagnosis of diabetes. The hemoglobin A1c also cannot be used to confirm a diagnosis of diabetes. Nevertheless, an A1c value of 5.5% is normal (in most assays).

The lower values measured in the OGTT due suggest so-called reactive hypoglycemia which is often treated in a way similar to that which you are already doing: frequent small meals using complex carbs and avoidance of "simple" sugars as found in juice, fruit, candy, frosted cereals, etc.

A referral to a pediatric endocrinologist may be very appropriate if your other health care providers feel stumped.

DS

DTQ-20020506143040
Original posting 29 May 2002
Posted to Diagnosis and Symptoms

  
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Last Updated: Tuesday April 06, 2010 15:09:34
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