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

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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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[[Category:Pediatrics]]
 
[[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 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