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![Management Questions
in Acute Hypoglycemia
• [2 am phone call]: “Doctor, I just checked a
blood sugar on your patient, and it’s 45.
What do you want me to do?”](https://image.slidesharecdn.com/pediatrichypoglycemia-140425205801-phpapp02/85/Pediatric-hypoglycemia-4-320.jpg)
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Pediatric hypoglycemia
This document discusses the diagnosis and management of pediatric hypoglycemia. It defines hypoglycemia as blood glucose levels less than 40-45 mg/dl accompanied by symptoms. It outlines the causes, symptoms, definitions, and treatment approaches for both transient neonatal hypoglycemia and persistent neonatal hypoglycemia. It also discusses childhood hypoglycemia, including common etiologies like hormone deficiencies, insulin excess, and metabolic diseases. The document provides guidance on diagnosing and managing acute hypoglycemic episodes in infants and children.
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Pediatric hypoglycemia
- 1. Diagnosis and Management ofPediatric Hypoglycemia J. Paul Frindik, MD CDE
- 2. Hypoglycemia • Two ormore sequential blood glucose values less than 40-45 mg/dl • “Hypoglycemia” refers to symptoms or “low blood sugar” and is not a diagnosis.
- 3. Hypoglycemia – Learning Objectives •Symptoms and Definitions • Causes of Hypoglycemia – Neonatal • Transient vs. Persistent • Treatment Options – Childhood • Management
- 4. Management Questions in AcuteHypoglycemia • [2 am phone call]: “Doctor, I just checked a blood sugar on your patient, and it’s 45. What do you want me to do?”
- 5. Management Questions in AcuteHypoglycemia • “Is the patient having a hypoglycemic episode?” • “What are the symptoms of hypoglycemia?”
- 6. Symptoms of Hypoglycemia •Neonatal • Cyanosis, apnea • Respiratory distress • Poor feeding • Hypothermia • Seizures • Children • Inattention, “spells” • Lethargy • Hunger • Behavioral problems • Seizures
- 7. Symptoms of Hypoglycemia •Non-specific and non-diagnostic • Correlation between an individual blood sugar value and – Acute clinical symptoms: YES – Long term clinical outcome: NO Pediatrics 105(5):1141-1145; 2000
- 8. Definitions of Hypoglycemia Whipple’sTriad Diagnosis of acute hypoglycemia requires 1. Clinical symptoms of hypoglycemia plus 2. Simultaneous low plasma glucose plus 3. Clinical signs must resolve when normoglycemia is established Ann Surg 101:1299-1310; 1935
- 9. Management Questions in AcuteHypoglycemia • “Is the patient having a hypoglycemic episode?” • “What are the symptoms of hypoglycemia?” • “Do I need to treat ? How? When ?”
- 10. Definitions of Hypoglycemia SuggestedTreatment Thresholds • Controversies Regarding Definition of Neonatal Hypoglycemia: Suggested Operational Thresholds M. Cornblath et. al., Pediatrics 105(5): 1141- 1145; 2000. • “Blood glucose levels at which clinical interventions should be considered”
- 11. Definitions of Hypoglycemia SuggestedTreatment Thresholds • Any symptomatic infant with plasma glucose less than 45 mg/dl • Asymptomatic at risk infants with – Plasma glucose < 36 mg/dl (feed if possible) – Plasma glucose < 20-25 mg/dl (IV glucose) • Therapeutic objective is plasma glucose over 45-60 mg/dl Pediatrics 105(5):1141-1145; 2000
- 12. Management Questions in Hypoglycemia •“Is the patient having a hypoglycemic episode?” • “What are the symptoms of hypoglycemia?” • “Do I need to treat ? How? When ?” • “Does this patient have an underlying medical condition causing low blood sugars?”
- 13. Hypoglycemia – Learning Objectives •Symptoms and Definitions • Causes of Hypoglycemia – Neonatal • Transient vs. Persistent • Treatment Options – Childhood
- 14. Classification of Neonatal Hypoglycemia Tr a n s ie n t H y p o g ly c e m ia P e r s is t e n t H y p o g ly c e m ia N e o n a t a l H y p o g ly c e m ia
- 15. Neonatal Hypoglycemia Transient • Postnatalinstability, inadequate fuel • 2 – 3 per 1000 live births • Occurs within first 12 hours after birth • Resolves within 3 – 5 days
- 16. Transient Neonatal Hypoglycemia HighRisk Groups • Premature, SGA, smaller of twins • Respiratory distress, sepsis, other stress • Large birth weight infants – Infant of diabetic mother hyperinsulinemia from islet cell hyperplasia
- 17. Transient Neonatal Hypoglycemia Treatment 1.Anticipate hypoglycemia in infants at risk 2. Early feeding, if possible 3. Supplemental IV glucose as needed 4. Medication (e.g. steroids) rarely needed
- 18. Neonatal Hypoglycemia Persistent • 5%of infants with hypoglycemia • Persistent (recurrent) hypoglycemia – Does not resolve within 5-7 days • Hormone deficiencies and excess • Metabolic diseases
- 19. Persistent Neonatal Hypoglycemia Etiologies1 • Hormone Deficiencies (15 %) • GH Deficiency • Cortisol Insufficiency – Primary adrenal – Secondary pituitary • ACTH • Physical findings • Midline congenital anomalies – Ambiguous genitalia – Micropenis – Facial anomalies • Cleft palate • Central incisor • Nystagmus
- 20. Persistent Neonatal Hypoglycemia Treatmentof Hormone Deficiencies Diagnosis primary problem • Cortisol / ACTH deficiency Hydrocortisone: ~ 15 mg / M2 / day • Divided t.i.d. or q.i.d. P.O. or I.V. • GH deficiency Growth hormone 0.5 mg / day SQ
- 21. Persistent Neonatal Hypoglycemia Etiologies2 • Hormone excess (hyperinsulinemia) – B cell hyperplasia (neisidioblastosis) – B cell adenoma – Beckwith-Weideman syndrome • Macrosomia, Macroglossia, Microcephaly, ear-lobe fissures • Metabolic diseases (inborn errors of metabolism)
- 22. Persistent Neonatal Hypoglycemia SuspectHyperinsulinemia if: 1. Persistent IV glucose requirement of 10- 12 mg/kg/min plus 2. Absence of serum / urine ketones plus 3. Insulin level over 5-10 mcgU/ml with a simultaneous plasma glucose of less than 40 mg/dl
- 23. Persistent Neonatal Hypoglycemia Treatmentof Hyperinsulinemia 1. Diazoxide 10 – 25 mg / kg / day divided t.i.d. 1. Octreotide (Sandostatin) 1 – 20 mcg / kg / day SQ divided t.i.d. or continuous infusion via insulin pump 1. Glucagon 1 mg / 24 hrs continuous infusion 1. Pancreatectomy
- 24. Hypoglycemia – Learning Objectives •Symptoms and Definitions • Causes of Hypoglycemia – Neonatal • Transient vs. Persistent • Treatment Options – Childhood Hypoglycemia
- 25. Childhood Hypoglycemia: Etiologies •Hormone Deficiencies – GH Deficiency – Cortisol Insufficiency • Primary adrenal • Secondary pituitary – ACTH • Insulin Excess – Adenoma – Exogenous • Metabolic Diseases • Ingestions – Alcohol, Oral hypoglycemics
- 26. Childhood Hypoglycemia Diagnostic Clues Ageless than 12 – 18 months: • Congenital pituitary / adrenal defects • Hyperinsulinemia • Metabolic diseases
- 27. Childhood Hypoglycemia Diagnostic Clues Ageover 12 – 18 months: • Acquired pituitary / adrenal defects • Islet cell adenoma (rare) • Metabolic diseases (usually present earlier) • “ketotic hypoglycemia”
- 28. Childhood Hypoglycemia Diagnostic Cluesfrom Physical Exam • Short stature – GH deficiency • Poor weight gain – Cortisol deficiency • Pigmentation – Adrenal defects • Midline defects – Pituitary defects • Ambiguous genitalia – Adrenal defects • Micropenis – Pituitary
- 29. Laboratory Diagnosis • Studiesmust be obtained when the patient actually is hypoglycemic • Endocrine Evaluation: – Urine / serum ketones – Insulin / C-peptide – Cortisol – Growth Hormone