Non-neonatal hypoglycemia (peds)

This page is for non-neonatal pediatric hypoglycemia. See hypoglycemia for adult patients or neonatal hypoglycemia.

Background

Etiology

• Inadequate oral intake
• Excess insulin
  • Newborns of diabetic mothers
• Deficient hyperglycemic hormones (growth or adrenal hormone deficiency)
• Inborn errors of metabolism: fatty acid oxidation or carbohydrate metabolism disorders
• Prematurity (inadequate glycogen stores)
• Sepsis
• ETOH exposure (children have low glycogen stores)

Clinical Features

• Most common features:
  • Vomiting
  • Altered mental status
  • Poor feeding
  • May also see lethargy, apnea, seizure

Differential Diagnosis

Systemic Illness

• Critical Illness
  • Sepsis
• Organ Failure
  • Hepatic failure
  • Renal failure
• Endocrinopathy
  • Adrenal insufficiency, congenital adrenal hyperplasia
• Seizure
• Inborn errors of metabolism

Drugs

• Anti-hyperglycemic
  • Insulin
  • Oral secretagogue
    • Sulfonylurea toxicity
• Other
  • EtOH
  • B-blocker
  • ACEI
  • Acetaminophen (OD)

Malignancy

• Insulinoma
• Non-islet cell
• Insulin/receptor autoantibodies
• High tumor burden

Other

• Artifactual
  • Specimen collection
  • Consumption
    • Leukemia
    • Erythrocytosis
    • Hemolytic disease
• Starvation
  • Anorexia nervosa

Precipitants of anti-hyperglycemic induced hypoglycemia

• Decreased glucose
  • Missed meal
  • Consumption (exercise, illness)
• Increased drug
  • Error (patient, provider)
  • Intentional overdose
  • Increased availability
    • Hepatic failure
    • Renal failure
    • Drug interaction

Evaluation

Work-Up

• Blood glucose level
• Urinalysis
  • If ketones: adrenal or GH deficiency, inborn errors of metabolism
  • If no ketones: Hyperinsulinemia, fatty acid oxidation defects

Diagnosis

• Blood glucose <45 in symptomatic neonate
• Blood glucose <35 in asymptomatic neonate

Management

See critical care quick reference for doses by weight

• Glucose
  • Bolus D10W 2mL/kg; then infuse D10W at 0.06-0.08mL/kg/min
• Glucagon
  • Used for persistent hypoglycemia despite glucose administration
  • Will not work with etoh exposure as glycogen stores are already low
  • 0.03mg/kg IM/IV

Pediatric Hypoglycemia Dextrose Chart

Category	Age	Glucose	Treatment	Initial IV Bolus	Maintenance Dose
Neonatal	<2mo	<40	D10W	2.5-5 mL/kg	6 mL/kg/h
Pediatric	2mo-8yrs	<60	D25W	2 mL/kg	D10W: 6 mL/kg/h for first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg
Adult	>8yrs	<70	D50W	50mL (1 amp) OR 1 mL/kg

• Consider diluting the D25W or D50W bolus, with NS 1-to-1, as those concentrations may be sclerosing to veins
• Recheck 5 minutes after dose and repeat dose if low.
• Consider glucagon IM/SQ if IV access is not readily available

See Also

• Hypoglycemia
• Neonatal hypoglycemia