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Question:

From Illinois, USA:

My four-year-old daughter has had excessive thirst for years. We never thought anything of it until it became out of control, as did her urinating. She drinks around 100 ounces of fluids a day, which I understand would make anyone urinate more often. After mentioning this to her doctor, they did standard blood work and it came back normal, so we went with that meaning everything was okay.

A few months later, we took her to the doctor because she had fever and we thought she had a UTI, so we tested her urine. The doctor also swabbed her throat. When he came back in the room, the doctor said my daughter had strep and also a high amount of glucose in her urine. He sent us straight to the laboratory for another blood test concerned she might have diabetes. It came back normal.

About three months later, I thought she had another UTI, so I took her to the Urgent Care and the doctor came in my room very concerned and said no UTI, but she had a high amount of glucose in her urine! They did a fingerstick and it was 256 mg/dl [14.2 mmol/L]. I told her that my daughter had been tested for diabetes and the results came back fine. She said that if she doesn't have it now, my daughter will develop it later on; very reassuring. I called my doctor and they set up a fasting glucose test, which came back in the normal range. The doctor suggested that maybe she had illness induced glucose in urine the first time and stress induced the second time. Has anyone experienced this? Also, should I be concerned when she is ill because she is spilling glucose?

This was almost a year ago and my daughter still drinks the same amount. I haven't worried about it too much, but when she runs a fever or gets sick, it really worries me. Should I be concerned about this being type 1 and get a second opinion?

Answer:

You ask several interesting questions and your daughter's story is curious, but you did not give some specific information that might be helpful for complete responses to your questions.

Let me start by addressing your specific questions:

  1. Has anyone experienced this ("stress-induced glucose in urine")? - Yes.

  2. Also, should I be concerned when she is ill because she is spilling glucose? - Not necessarily.

  3. Should I be concerned about this being type 1 and get a second opinion? - Yes.

Now, my questions for you: Is your four-year-old healthy? Is she "sickly?" Is she growing taller and gaining weight? How are her energy levels? Is she active and curious and developmentally on target? Is she on any medications on a routine-type basis? Is there a family history of type 1 or type 2 diabetes? Are there an other important family illnesses? Is there a family history of kidney diseases? What were the specific values and the specific tests that were done that had been relayed as "normal?" When the glucose was 256 mg/dl [14.2 mmol/L], was this fasting? Does she awaken at night to drink or urinate? Does she wet the bed? Does she have a persistent or recurring yeast infection? With her increased thirst, is there a preference for types or characterizations of the liquids she prefers to drink?

In a child, diabetes does not usually percolate for "years" before being diagnosed. Typically, children have symptoms for merely weeks before diagnosis.

The glucose value of 256 mg/dl [14.2 mmol/L] certainly is abnormal, but it is difficult to reconcile that with previous and subsequent normal values. A fingerstick irregularity could be due to poor preparation of the skin site.

For most people, the glucose sugar will not begin to filter in the kidneys from the blood into the urine until the blood glucose is more than 180 mg/dl [10.0 mmol/L]. A FASTING SERUM glucose (from a vein and not simply measured with a glucose meter) of more than 125 mg/dl [7.0 mmol/L] is consistent with diabetes mellitus as is a random serum glucose of more than 200 mg/dl [11.1 mmol/L] in the face of symptoms. But, a fasting value over 100 mg/dl [5.6 mmol/L] is not quite normal either (although not "yet" consistent with diabetes mellitus).

Some people have a "lower threshold" of when glucose can begin to filter through the kidneys into the urine. This is a benign condition and is not associated with diabetes mellitus. Stressful conditions, such as illnesses, certainly can raise the serum glucose,even to values high enough (more than 180 mg/dl [10.0 mmol/L]) to then filter into the urine. Still, an older study suggested that a significant number of children with this type of exaggerated glucose response to stress, may be at risk for impaired glucose tolerance (J Pediatr. 1982 Sep;101(3):340-4. Prognosis of impaired glucose tolerance in children with stress hyperglycemia, symptoms of hypoglycemia, or asymptomatic glucosuria.)

I think your daughter should be seen in consultation by a Board certified pediatric endocrinologist for review of the complete story (with answers to the many questions that I have raised above - and many more), complete review of all the blood testing results, and consideration for more screening (e.g., pancreatic antibody screening) and possibly consideration of a properly performed (correct dosing and sample acquisition) oral glucose tolerance test. If there were a family history of diabetes mellitus, this recommendation would be made even more strongly. The advice you were given that your daughter "will develop diabetes later on" may be correct (but may not be) but shouldn't loom over your head like a stone! Special testing can better formulate her risk or likelihood.

Finally, I should add that not all conditions associated with increased urination and thirst are related to glucose issues and diabetes mellitus. Some conditions have the confusing moniker of having the word "diabetes" in them, but are unrelated to glucose metabolism (e.g."diabetes insipidus"). As you alluded, increased intake of liquids in of itself can lead to increased urination. But, excessive fluid losses in urine can lead to the intake of increased liquids to compensate. In order to discern which came first ("the chicken or the egg") in your daughter's story, your consultation with a pediatric endocrinologist will hopefully be helpful.

DS

DTQ-20110305194251
Original posting 11 Mar 2011
Posted to Diagnosis and Symptoms

  
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Last Updated: Friday March 11, 2011 12:40:50
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