Non-neonatal hypoglycemia (peds): Difference between revisions

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''This page is for <u>non-neonatal pediatric</u> hypoglycemia. See [[hypoglycemia]] for adult patients or [[neonatal hypoglycemia]].''
==Background==
==Background==
===Etiology===
===Etiology===
*Inadequate oral intake
*Inadequate oral intake
*Excess insulin
*Excess insulin
**Newborns of diabetic mothers
**Newborns of [[DM|diabetic mothers]]
*Deficient hyperglycemic hormones (GH or adrenal hormone deficiency)
*Deficient hyperglycemic hormones (growth or [[CAH|adrenal hormone deficiency]])
*Fatty acid oxidation or carbohydrate metabolism disorders
*[[Inborn errors of metabolism]]: fatty acid oxidation or carbohydrate metabolism disorders
*Prematurity (inadequate glycogen stores)
*Prematurity (inadequate glycogen stores)
*Sepsis
*[[Sepsis (peds)|Sepsis]]
*[[ETOH]] exposure (children have low glycogen stores)


==Clinical Features==
==Clinical Features==
*Most common features: vomiting, AMS, poor feeding
*Most common features:  
**May also see lethargy, apnea, sz
**[[nausea and vomiting (peds)|Vomiting]]
**[[altered mental status (peds)|Altered mental status]]
**[[failure to thrive (peds)|Poor feeding]]
**May also see lethargy, apnea, [[seizure (peds)|seizure]]


==Differential Diagnosis==
==Differential Diagnosis==
*Ingestions (e.g. ETOH)
====Systemic Illness====
*Metabolic disease^
*Critical Illness
*[[Sepsis (peds)|Sepsis]]
**[[Sepsis (peds)|Sepsis]]
*Organ Failure
**[[Hepatic failure]]
**[[Renal failure]]
*Endocrinopathy
**[[Adrenal insufficiency]], [[congenital adrenal hyperplasia]]
*[[Seizure (peds)|Seizure]]
*[[Inborn errors of metabolism]]
 
====Drugs====
*Anti-hyperglycemic
**[[Insulin]]
**Oral secretagogue
***[[Sulfonylurea toxicity]]
*Other
**[[EtOH]]
**[[B-blocker]]
**[[ACE inhibitor|ACEI]]
**[[Acetaminophen Overdose|Acetaminophen (OD)]]
 
====Malignancy====
*Insulinoma
*Non-islet cell
*Insulin/receptor autoantibodies
*High tumor burden
====Other====
*Artifactual
**Specimen collection
**Consumption
***[[Leukemia (peds)|Leukemia]]
***Erythrocytosis
***[[hemolytic anemia|Hemolytic disease]]
*Starvation
**[[Anorexia nervosa]]


==Diagnosis==
====Precipitants of anti-hyperglycemic induced hypoglycemia====
*Blood glucose <45 in symptomatic neonate
*Decreased glucose
*Blood glucose <35 in asymptomatic neonate
**Missed meal
**Consumption (exercise, illness)
*Increased drug
**Error (patient, provider)
**Intentional overdose
**Increased availability
***[[Hepatic failure]]
***[[Renal failure]]
***Drug interaction


==Evaluation==
===Work-Up===
===Work-Up===
*Blood glucose level
*Blood glucose level
*UA
*[[Urinalysis]]
**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
===Diagnosis===
*Blood glucose <45 in symptomatic neonate
*Blood glucose <35 in asymptomatic neonate


==Management==
==Management==
''See [[critical care quick reference]] for doses by weight
''See [[critical care quick reference]] for doses by weight
*Glucose
*Glucose
**Bolus [[D10W]] 2mL/kg; then infuse D10W @ 0.06-0.08mL/kg/min
**Bolus [[D10W]] 2mL/kg; then infuse D10W at 0.06-0.08mL/kg/min
*[[Glucagon]]
*[[Glucagon]]
**Used for persistent hypoglycemia despite glucose administration
**Used for persistent hypoglycemia despite glucose administration
**0.03 mg/kg IM/IV
**Will not work with etoh exposure as glycogen stores are already low
**0.03mg/kg IM/IV


{{Pediatric hypoglycemia chart}}
{{Pediatric hypoglycemia chart}}
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="width: 621px; height: 444px;"
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Patient Age
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dextrose Bolus Dose
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dextrose Maintenance Dosage
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Other Treatments to Consider
|- 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" | Neonate
| 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
+ 1.5 mL/kg/h for each additional kg &gt;20 kg
| 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, 50 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="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
| 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, 100 grams PO/IM/IV/IO
|}


==Disposition==
==Disposition==
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<References/>
<References/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
[[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 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

Disposition

See Also

References