Special Issues Affecting Diagnosis

1. Mentally challenged children can be especially difficult to evaluate. Often they have dysautonomia as well as feeding difficulties. A low threshold for blood glucose evaluation is appropriate in these patients, especially if the caretakers note a change in baseline behavior or mental status.

2. Most children who present with self-harming thoughts, suicidal threats, or true suicide attempts should have their glucose checked as part of their medical clearance. This is especially true of diabetic children and those with access to a relative's oral hypoglycemic agents. Inpatient monitoring of glucose may be necessary if overdose of an oral hypoglycemic agent is suspected. Most cases, however, will demonstrate hypoglycemia within 6 to 8 h. Management of such overdoses is often complex and is beyond the scope of this chapter.

3. In patients thought to have a factitiously depressed glucose associated with an elevated insulin level, the C-peptide level should be determined. 78 Typically the insulin level in these cases will be very high. If exogenous insulin is the cause, the C-peptide level will be inappropriately suppressed. 7 Normally C-peptide is produced in equimolar quantities during the processing of proinsulin to insulin; therefore, its levels should follow those of insulin itself. In cases of insulinoma, for example, both the insulin and C-peptide levels will be high.

4. Patients found to have hypoglycemia and non-glucose-reducing substances in their urine should have galactosemia ruled out. The dipstick urine test will be negative for glucose, but the laboratory evaluation for reducing substances will be positive in this case. This disease usually presents during infancy with failure to thrive, vomiting, hepatomegaly, and jaundice.

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