From Cheltenham, Gloscestershire, England:
I have eight year old identical twins, one of whom has had diabetes for just over three years, and both were diagnosed with celiac disease seven months ago. I am aware that the twin who doesn't have diabetes has about a 53% risk of the developing it in the future. However, during the last six months or more, she has complained of feeling tired all the time and often doesn't want to go out and play after school. She just wants to lie down and go to sleep, and is tired and grumpy a lot of the time.
I have mentioned it at the celiac and the asthma clinic where she is followed, and they did tests for anemia, thyroid and A1c which are normal. However, there are times when, after exercise, that she complains of feeling shaky and trembling. Its not just after taking Ventolin either (which I thought might cause these symptoms).
I decided to do a couple of blood tests with her sister's meter and they were both about 81 mg/dl [4.5 mmol/L] which doesn't seem excessively low to me. I have mentioned several times when we have seen the paediatrician at the clinics that she seems tired and sleepy, but they just say all the tests were normal. I am puzzled that a child should feel shaky and tremble for no obvious reason.
In the past, the doctor said he didn't think it was worth testing for antibodies as there is no proven prevention treatment for diabetes, and I think he feels that if she gets diabetes, we will pick it up quickly. I don't think he wants us to keep worrying about if she gets diabetes when there is still a possibility that she may not get it.
Could low blood sugar cause these symptoms? Could she have pre-diabetes? Is it possible to have low blood sugars before going on to develop diabetes?
Your question raises some important issues. The first relates to the twin who has both diabetes and celiac disease. This means that she has what is now called the Autoimmune Polyglandular Syndrome Type II, a condition in which a number of autoimmune syndromes occur together. Hypothyroidism is the one most commonly associated with diabetes, although about 8% of people with type 1A (autoimmune) diabetes have celiac disease. Because the second twin has celiac disease, she almost certainly has the same syndrome,even though diabetes has not yet developed.
Your daughter's pediatrician is of course quite right to say that there is, as yet, no way of deferring diabetes, but my own feeling is that it would be important to ask again about antibody testing for ICA 512/IA2, GAD 65, and anti-insulin autoantibodies. This way you might get an insight into the hypoglycemia and also be forewarned about the possibility of some of the other components of the syndrome especially 21-hydroxylase deficiency, an adrenocortical enzyme that can also be tested for.
Hypoglycemia can occur as an early presentation of type 1A diabetes. What happens is that the damaged islet cells, at a point before they cease to respond to a rise in blood sugar, may delay the secretion of insulin. This means that the insulin reaches the blood stream and the cells after the glucose peak and inappropriately leads to hypoglycemia.