Indian Pediatr 2019;56: 332
Diabetic Ketoacidosis due to Faking of Blood Sugar
Measurements by an Adolescent
Devi Dayal and Jaivinder Yadav*
Endocrinology and Diabetes Unit, Department of
Pediatrics, PGIMER, Chandigarh, India.
The current guidelines for care of children and adolescents with Type-1
Diabetes (T1D) recommend a gradual transition of independence in its
self management, appropriate to the level of maturity and understanding
of the child or adolescent with emphasis on continued parental
supervision throughout transition . Lack of parental supervision may
result in poor metabolic control or diabetic ketoacidosis (DKA),
especially during adolescence.
A 12-year-old boy, diagnosed with T1D one year ago
presented with severe DKA (blood pH 6.9, HCO3 6.4 mEq/L and positive
urine ketones), and required insulin infusion for 16 hours. Due to
frequent episodes of ‘hypoglycemia’, the boy had missed several insulin
boluses over last two weeks, and then basal insulin as well for two days
prior to presentation. The self-monitored blood glucose diary showed
multiple records of blood glucose <50 mg/dL. There were no associated
symptoms of hypoglycemia. On suspicion, the glucometer memory was
checked that showed almost all records in the range of 250-400 mg/dL in
the past 2 weeks; the average blood sugar was 290 mg/dL. The HbA1c was
9.8%. On further probing, it was revealed that the child was allowed
independent self-care of his diabetes status by parents, and he recorded
blood sugar readings in hypoglycemic ranges to avoid injections without
realizing the consequences of missing insulin. A decision to allow only
limited self-care autonomy to the child was taken after discussions with
Children develop readiness for diabetes
self-management at different rates and at different chronological ages
. Parental supervision during transition is associated with better
glycemic control, and is instrumental to prevent deterioration in
adherence and mishaps [3,4]. Adolescents, in particular, are at-risk for
poor adherence due to unique biological and behavioral challenges during
this period . The desire to avoid injections altogether may push an
unsupervised adolescent into faking blood sugar records and devising
novel ways to fake measurements . While missing the insulin boluses
is associated with deterioration in HbA1c, missing the insulin
altogether may result in DKA as happened in this patient. Although the
blood sugar values could be easily detected to be fake in our patient by
a careful history and checking the glucometer memory, a cleverer
maneuvering may at times be very difficult to detect . Supervision by
parents or caregiver and assessment of readiness for self-care is thus
of utmost importance during transition of autonomy of diabetes
management in children and adolescents with T1D.
Acknowledgements: Dr Vijai Williams and Dr
Muralidharan Jayashree, Pediatric Critical Care Unit, Department of
Pediatrics, PGIMER, Chandigarh for their inputs and patient care.
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