Hypoglycemia

Dear Lisa,

My 11 year old daughter has been having bouts of vomiting once a month for the past 4 months. Her episodes always start with a feeling of extreme hunger and body shakes and immediately she feels a loss of appetite when she is about to eat. She will then have diarrhea and will vomit about 1/2 hour later. She will usually vomit a few times before feeling better. Her diarrhea will continue for the majority of the day. She has never had a fever with these bouts but once complained of a bad headache and fatigue. I have a doctor’s appointment for the end of the month but I am growing very concerned. She has started puberty but is not menstruating yet. I did not know if this was hormone related or not. Please let me know what your thoughts may be.

Thanks so much!

“Mom to 11 year old with frequent vomiting”

Dear ”Mom to 11 year old with frequent vomiting”,

Your daughter’s symptoms aren’t consistent with the typical causes of vomiting and diarrhea in an adolescent child. Being that her symptoms have been occurring on a regular basis for the past four months an investigation into the cause is warranted. An evaluation and consultation with your Physician is a very good idea. Your Doctor will be able to answer your questions after performing a complete history and physical examination on your daughter.

In the meantime it is only natural to be concerned and wonder about the possible causes of your daughter’s problems. Without performing a complete medical examination and having knowledge of her past medical history and family history is not possible to tell you the cause of her problems. I can only tell you potential causes based on the symptoms that you described.

The interesting thing about your daughter’s symptoms is that they begin with a feeling of extreme hunger and body shakes. This would lead one to suspect that her gastrointestinal symptoms are related to an electrolyte imbalance such as low levels of blood glucose also known as Hypoglycemia. Some children are sensitive to sugar levels in their blood that are at the lower levels of normal and others may have a condition that causes their blood glucose levels to be low.

Hypoglycemia is a rare finding in late childhood, after the newborn period. Metabolic disorders, hormone deficiencies and problems with glucose metabolism that lead to hypoglycemia are usually detected in the newborn period. The development of hypoglycemia in an older child usually signifies a milder form of metabolic disease or hormone deficiency. Other causes of Hypoglycemia include acute alcohol intoxication, drug poisoning, liver disease, malnutrition and Malabsorption.

Signs of Hypoglycemia include perspiration, palpitations, pale color, trembling, anxiety, hunger, weakness, nausea, vomiting, headache, mental confusion, inability to concentrate, staring, personality changes and convulsions. (1) The inability to maintain a normal glucose level during fasting is a common finding.

The symptoms of hypoglycemia are non-specific and may represent other disorders. Therefore the only way to determine that Hypoglycemia is the reason for a child’s presenting symptoms is to have testing done during an episode.

In regards to your daughter’s situation it would be important to know if she is presently taking any medication that could be causing her symptoms. Excess amounts of Aspirin, alcohol, Propranolol, Pentamidine, Quinine or oral hypoglycemic agents can cause Hypoglycemia. (1) It would also be important to know about your daughter’s dietary habits. Is she overly concerned about her weight or a picky eater or dieting? Does she have a history of diarrhea, fatty stools or problems digesting certain types of food that would be suggestive of malabsorption? Do these episodes occur after a period of fasting or skipping a meal? This is the type of information that you need to bring with you to the evaluation at your Physician’s office.

In addition, it would be helpful to your doctor if you keep a diary of the episodes. You should record each event, the time of day, duration, activity before the episode, what she ate that day, associated symptoms, medications taken and social surroundings. A record of your daughter’s height and weight over the last couple of years will also aid your Doctor in making a diagnosis.

The last issue to consider is a psychosocial cause for your daughter’s symptoms. Psychogenic vomiting can occur in some children in a response to stress, fear, depression or anticipation of unpleasant events. (2) It would be important to discuss with your doctor if there are any social changes in your daughter’s life that may be precipitating her symptoms. Is there a monthly event in your household or at school that may be upsetting your daughter? Some children may become upset after visiting a sick grandparent in a nursing home or sleeping over their father’s house during a marital separation. Many times these negative feeling are manifested in somatic complaints such as headaches or bellyaches. It might be a good idea to sit down and talk with your daughter about her social life, school or possible stressors in her life before your Doctor's visit. This way you can collect and present information to the doctor that will be needed in order to make a diagnosis.

I wish you and your daughter a speedy resolution to her problems and a healthy future.

References:
(1)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:616-618.
(2) Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 355-356.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents