EML

E16.2

Description
Diagnostic criteria
Medicine treatment
Referral

DESCRIPTION

Infants and small children have relatively limited glycogen stores with larger brain/body ratios than adults and are therefore at greater risk of hypoglycaemia during starvation.
The causes of hypoglycaemia (outside the neonatal period) include:

hypopituitarism,
adrenal insufficiency,
growth hormone deficiency,
hypothyroidism,
hyperinsulinaemia,
inborn errors of metabolism,
malnutrition,
sepsis,
liver dysfunction,
malaria,
severe illness with poor intake,
accelerated starvation (ketotic hypoglycaemia),
medicine, e.g. insulin, alcohol, aspirin, beta-blockers, oral hypoglycaemic agents, quinine.

DIAGNOSTIC CRITERIA

Clinical

Acute autonomic symptoms: hunger, nausea, anxiety, pallor, palpitations, sweating, trembling.
Neuroglycopaenic symptoms: impaired thinking, change of mood, irritability, dizziness, headache, tiredness, confusion, and later convulsions and coma.
Patients are often asymptomatic especially younger children who may be completely asymptomatic or present only with a behaviour change.

Investigations

Serum glucose concentration <2.6mmol/L.
Hypoglycaemia is a clinical emergency requiring prompt therapy. However, if possible draw a blood sample for investigation prior to the administration of glucose. Collect 5 mL of blood in a plain tube at the earliest opportunity and send for separation and storage of plasma at –20°C. Such samples may provide clear biochemical evidence of the cause of the hypoglycaemic episode thus avoiding having to subject the child to further investigations.

MEDICINE TREATMENT

After collection of initial blood samples:

Dextrose 10%, IV, 2–5 mL/kg.
- Dilute dextrose 50% solution before use to 10% strength. (1mL/kg of dextrose 50% plus 4 mL/kg of water for injection, gives 10% dextrose solution).

If hypoglycaemia persists or the serum glucose is difficult to maintain in the normal range, consider adrenal insufficiency:

ADD

Hydrocortisone, IV, 2–3 mg/kg, immediately.

Stabilisation

Sodium chloride 0.9%/dextrose 5%, or a 10% dextrose IV infusion if needed.

If hypoglycaemia persists, consider adrenal insufficiency or hyperinsulinism. Hyperinsulinism is likely if the rate of glucose infusion required to maintain normoglycaemia is above 8mg/kg/min. An inappropriately high insulin or C-peptide level at the time of the confirmed hypoglycaemia is also strongly suggestive of hyperinsulinism.

If hyperinsulinism is suspected, administer:
Diazoxide, orally, 5 mg/kg/day in three divided doses, may increase to 15 mg/kg/day.

LoEII [5]
LoEII [6]
LoEII [7]

Ongoing treatment
Intravenous fluid therapy as needed.
Start oral feeds as soon as possible.

REFERRAL