From Philadelphia, Pennsylvania, USA:
My 6 year old son had his annual physical at which time he gave a urine specimen. His appointment was in the late afternoon and throughout the day he was drinking sodas, eating candy and one hour prior to going to the doctor, had a bowl of [sugar-frosted corn flakes] cereal. The next day we got a call from the doctor, who told us that a dipstick test of the urine registered +3 [for sugar]. After a 9 hour fast, the urine was +4, but a blood sugar was only 165. We continued to test his urine at home and occasionally (my wife's a pediatric RN) a finger stick at the hospital. For 3 days his urine measured +4 but his blood glucose was only 126. The last 2 days his urine test registered only a trace amount both fasting and after meals. Does this sound like a diabetic child? He is totally asymptomatic; we have been monitoring him very closely. One more item, at his physical he received a MMR booster and a chickenpox vaccine. Can these vaccinations lead to the elevated levels of glucose we were observing in the urine? It has been almost a week since the shots and thank God his urine seems to be returning to only trace levels of glucose.
From what you describe, I would be concerned that your son might be in the early stages of developing diabetes. We know that the pancreas may slowly be failing and making less insulin for weeks, months, or even years before the blood sugar becomes abnormal. In any child, any stress such as a virus increases the need for insulin. If the child's pancreas is already making all the insulin it can (but less than it should be able to make) and can't make any more, the blood sugar may go up temporarily with an infection and sugar may appear in the urine. Usually in insulin dependent diabetes, you also see ketones in the urine as a sign that the child isn't making enough insulin. However, in this early stage, when the pancreas is just starting to fail, there may be enough insulin to prevent the production of ketones, but not enough to keep the blood sugar completely normal if the child has a mild illness or virus (which may even be asymptomatic.)
On the other hand, occasionally a virus can cause temporary mild increase in blood sugar, and the child is not in the early stages of developing diabetes. Without symptoms of high blood sugar (excess drinking, urination, weight loss), and without a blood sugar over 200 with ketones in the urine, you can not be sure whether or not your child is in the early stages of diabetes.
One way to try and sort this out is to have antibody testing done against the islet cells and insulin. These are usually abnormal in the early asymptomatic stages of diabetes.
In the meantime, it is important to keep a close eye on your child, especially if he develops a cold or virus. It would be a good idea to at least check his urine if he gets an infection as his blood sugar could go up very rapidly and he may spill ketones and become sick if he is developing diabetes and doesn't receive insulin.
If you have not already done so, I would suggest you consult with a pediatric endocrinologist to help you plan further evaluation. Of course, if your child develops symptoms or has sugar in the urine again, you should call your pediatrician or endocrinologist right away.
Additional Comment by Dr. O'Brien:From the information you have supplied, I think that your son probably does have autoimmune or Type 1 Diabetes. The process has almost certainly been going on for some years and for a long time it has been recognised that in the last stages of the destruction of the insulin producing cells in the pancreas any stress such as a subclinical infection can lead to a transient excess of glucose in the urine and high blood sugars. The way to make sure of the diagnosis is to get an antibody test done, something a pediatric endocrinologist can arrange and which you can learn more about by calling 1-800-425-8361.
The actual amount of sugar in the urine depends on the length of time that the blood sugar and thus the amount of sugar filtered through the glomerulus of the kidney exceeds what is called the threshold for reabsorption - somewhere around 180 mg/dl. The concentration of glucose in the urine on the other hand also depends on the amount of water in the urine. This discordance between urine concentration and blood concentration used to be a problem in controlling diabetes in the days when only urine testing was available in the home.
The immunisation had nothing to do with the onset of diabetes. Whatever precipitated the process in a genetically susceptible child happened a long time ago. Just the same there has been some very interesting work recently in Switzerland showing that a specific 'retrovirus' may have a critical role in triggering the autoimmune process.
Please try not to be "distraught;" Type 1 Diabetes is no longer a barrier to a normal life and tremendous advances have recently been made in facilitating and improving treatment. But it will require some patience and determination on behalf of all the family to get it right. A good diabetes care team that includes beside a physician a nurse educator, a nutritionist and an experienced medical social worker can be the greatest help. Not to mention children with DIABETES!
[Editor's comment: The question arises, if this child has positive antibodies, should therapy with low-dose Ultralente insulin (in the fashion being used in the DPT research study) be started? Although this might become standard therapy in the future, it's not advisable (in my opinion) to utilize unproven therapies until the results of the research study becomes known: there may be unexpected consequences of using insulin in this fashion, and it's the part of the design of these research studies to look for adverse effects, as well as for good effects. WWQ]
Original posting 21 Aug 97
Additional comment added 30 Aug 97
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