Difference between revisions of "Non-neonatal hypoglycemia (peds)"

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==Differential Diagnosis==
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''This page is for <u>non-neonatal pediatric</u> hypoglycemia. See [[hypoglycemia]] for adult patients or [[neonatal hypoglycemia]].''
# Ingestions (e.g. ETOH)
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==Background==
# Metabolic disease^
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===Etiology===
# [[Sepsis (peds)|Sepsis]]
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*Inadequate oral intake
 +
*Excess insulin
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**Newborns of [[DM|diabetic mothers]]
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*Deficient hyperglycemic hormones (growth or [[CAH|adrenal hormone deficiency]])
 +
*[[Inborn errors of metabolism]]: fatty acid oxidation or carbohydrate metabolism disorders
 +
*Prematurity (inadequate glycogen stores)
 +
*[[Sepsis (peds)|Sepsis]]
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*[[ETOH]] exposure (children have low glycogen stores)
  
^Save blood tubes before treatment
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==Clinical Features==
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*Most common features:
 +
**[[nausea and vomiting (peds)|Vomiting]]
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**[[altered mental status (peds)|Altered mental status]]
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**[[failure to thrive (peds)|Poor feeding]]
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**May also see lethargy, apnea, [[seizure (peds)|seizure]]
  
==Treatment==
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==Differential Diagnosis==
''See [[critical care quick reference]] for doses by weight
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====Systemic Illness====
*Glucose
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*Critical Illness
**Bolus [[D10W]] 2mL/kg; then infuse D10W @ 0.06-0.08mL/kg/min
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**[[Sepsis (peds)|Sepsis]]
*[[Glucagon]]
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*Organ Failure
**Used for persistent hypoglycemia despite glucose administration
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**[[Hepatic failure]]
**0.03 mg/kg subq/IV
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**[[Renal failure]]
 
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*Endocrinopathy
{{Pediatric hypoglycemia chart}}
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**[[Adrenal insufficiency]], [[congenital adrenal hyperplasia]]
 
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*[[Seizure (peds)|Seizure]]
==See Also==
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*[[Inborn errors of metabolism]]
[[Hypoglycemia (Neonatal)]]
 
 
 
[[Hypoglycemia]]
 
  
[[Category:Peds]]
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====Drugs====
[[Category:Endo]]
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*Anti-hyperglycemic
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**[[Insulin]]
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**Oral secretagogue
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***[[Sulfonylurea toxicity]]
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*Other
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**[[EtOH]]
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**[[B-blocker]]
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**[[ACE inhibitor|ACEI]]
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**[[Acetaminophen Overdose|Acetaminophen (OD)]]
  
=== Diagnosis ===
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====Malignancy====
*Glucose <45 in symptomatic neonate
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*Insulinoma
*Glucose <35 in asymptomatic neonate
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*Non-islet cell
*Most common features: vomiting, AMS, poor feeding
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*Insulin/receptor autoantibodies
**May also see lethargy, apnea, sz
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*High tumor burden
 
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====Other====
===Etiology===
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*Artifactual
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**Specimen collection
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**Consumption
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***[[Leukemia (peds)|Leukemia]]
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***Erythrocytosis
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***[[hemolytic anemia|Hemolytic disease]]
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*Starvation
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**[[Anorexia nervosa]]
  
#Inadequate oral intake
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====Precipitants of anti-hyperglycemic induced hypoglycemia====
#Excess insulin
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*Decreased glucose
##Newborns of diabetic mothers
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**Missed meal
#Deficient hyperglycemic hormones (GH or adrenal hormone deficiency)
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**Consumption (exercise, illness)
#Fatty acid oxidation or carbohydrate metabolism disorders
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*Increased drug
#Prematurity (inadequate glycogen stores)
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**Error (patient, provider)
#Sepsis
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**Intentional overdose
 +
**Increased availability
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***[[Hepatic failure]]
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***[[Renal failure]]
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***Drug interaction
  
 +
==Evaluation==
 
===Work-Up===
 
===Work-Up===
 
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*Blood glucose level
*Rapid glucose
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*[[Urinalysis]]
*UA
 
 
**If ketones: adrenal or GH deficiency, inborn errors of metabolism
 
**If ketones: adrenal or GH deficiency, inborn errors of metabolism
 
**If no ketones: Hyperinsulinemia, fatty acid oxidation defects
 
**If no ketones: Hyperinsulinemia, fatty acid oxidation defects
*Glucagon 0.3 mg/kg IM or IV
 
**If BS corrects then likely due to hormonal deficiency (e.g. adrenal insufficiency)
 
  
=== Treatment  ===
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===Diagnosis===
 +
*Blood glucose <45 in symptomatic neonate
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*Blood glucose <35 in asymptomatic neonate
  
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="width: 621px; height: 444px;"
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==Management==
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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''See [[critical care quick reference]] for doses by weight
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Patient Age
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*Glucose
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dextrose Bolus Dose
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**Bolus [[D10W]] 2mL/kg; then infuse D10W at 0.06-0.08mL/kg/min
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dextrose Maintenance Dosage
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*[[Glucagon]]
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Other Treatments to Consider
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**Used for persistent hypoglycemia despite glucose administration
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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**Will not work with etoh exposure as glycogen stores are already low
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Neonate
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**0.03mg/kg IM/IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | D10 5 mL/kg PO/NG/IV/IO
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | 6 mL/kg/h D10
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg IM
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Hydrocortisone, 25 grams PO/IM/IV/IO
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="4" class="font12" | Infant
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | D10 5 mL/kg PO/NG/IV/IO
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="4" class="font12" | 6 mL/kg/h D10
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg IM
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | ''or''&nbsp;
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="3" class="font12" | Hydrocortisone, 25 grams PO/IM/IV/IO
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | D25 2 mL/kg
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &nbsp;
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Child
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | D25 2 mL/kg PO/NG/IV/IO
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" |
 
6 mL/kg/h D10 for the first 10 kg
 
  
+ 3 mL/kg/h for 11–20 kg
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{{Pediatric hypoglycemia chart}}
  
+ 1.5 mL/kg/h for each additional kg &gt;20 kg
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==Disposition==
 +
*
  
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg/IM
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==See Also==
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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*[[Hypoglycemia]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Hydrocortisone, 50 grams PO/IM/IV/IO
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*[[Neonatal hypoglycemia]]
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Adolescent
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | —
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" |
 
6 mL/kg/h D10 for the first 10 kg
 
 
 
+ 3 mL/kg/h for 11–20 kg
 
  
+ 1.5 mL/kg/h for each additional kg &gt;20 kg
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==References==
 +
<References/>
  
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg IM
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[[Category:Pediatrics]]
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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[[Category:Endocrinology]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Hydrocortisone, 100 grams PO/IM/IV/IO
+
[[Category:FEN]]
|}
 

Latest revision as of 19:08, 6 October 2019

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

Background

Etiology

Clinical Features

Differential Diagnosis

Systemic Illness

Drugs

Malignancy

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

Other

Precipitants of anti-hyperglycemic induced hypoglycemia

  • Decreased glucose
    • Missed meal
    • Consumption (exercise, illness)
  • Increased drug

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 D25 or D50 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

Disposition

See Also

References