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TAS Endocrinology > Hypoglycaemia ✅ > Flashcards

Hypoglycaemia ✅ Flashcards

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1
Q

What history features should you pay attention to when evaluating a child with hypoglycaemia?

A
  • Autonomic symptoms
  • Neuroglycopenic symptoms
  • Pregnancy details (in neonate)
  • Relationship of symptoms to feeding
  • Access to oral hypoglycaemic medication
  • Family history of sudden infant death or consanguinity
  • Development of symptoms in response to certain foods
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2
Q

What are the autonomic symptoms of hypoglycaemia in a neonate?

A
  • Pallor
  • Sweating
  • Tachypnoea
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3
Q

What are the autonomic symptoms of hypoglycaemia in an older child?

A
  • Palpitations

- Tremor

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4
Q

What are the neuroglycopenic symptoms of hypoglycaemia in a neonate?

A
  • Jitteriness
  • Apnoea
  • Hypotonia
  • Feeding problems
  • Irritability
  • Abnormal cry
  • Convulsions
  • Coma
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5
Q

What are the neuroglycopenic symptoms of hypoglycaemia in older children?

A
  • Hunger
  • Abdominal pain
  • Nausea and vomiting
  • Pins and needles
  • Headache
  • Weakness
  • Dizziness
  • Blurred vision
  • Irritability
  • Mental confusion
  • Odd behaviour
  • Fainting
  • Convulsions
  • Coma
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6
Q

What pregnancy details should be considered when evaluating a neonate with hypoglycaemia?

A
  • Maternal symptoms of diabetes
  • Breech?
  • Birth weight
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7
Q

Why is it important to know if a neonate was breech in hypoglycaemia?

A

Breech said to be more common in hypopituitarism

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8
Q

Why is it important to know the birth weight of a neonate with hypoglycaemia?

A

Hypoglycaemia more common in IUGR or large for gestational age due to maternal diabetes

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9
Q

Why is it important to know the relationship of symptoms to hypoglycaemia?

A

Can help determine if due to inadequate fuel supply or excess fuel requirements, e.g. hyperinsulinism

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10
Q

Why is it important to know about access to oral hypoglycaemic medications?

A

May have been accidentally ingested

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11
Q

Why is it important to know about family history of SIDS or consanguinity?

A

Might suggest an inborn error of metabolism

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12
Q

What foods should you ask about symptom development in response to?

A

Foods containing lactose, fructose, or sucrose

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13
Q

What might symptom development in response to lactose, fructose, or sucrose suggest in hypoglycaemia?

A

Inborn errors in metabolism

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14
Q

What is usually found on examination in hypoglycaemia?

A

Most children with a history of hypoglycaemia will not have any abnormal clinical signs unless hypoglycaemic at the time

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15
Q

Why is it important to look for clinical signs on examination in hypoglycaemia?

A

May indicate associated diagnosis

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16
Q

What might suggest septo-optic dysplasia?

A

Optic atrophy

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17
Q

What is septo-optic dysplasia?

A

A rare congenital malformation syndrome featuring;

  • Underdevelopment of the optic nerve
  • Pituitary gland dysfunction
  • Absence of the septum pellucidum (a midline part of the brain)
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18
Q

What might suggest hypopituitarism?

A
  • Cranial midline defects
  • Short stature
  • Microgenitalia
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19
Q

What might suggest Addison’s disease?

A
  • Increased skin or buccal pigmentation

- Hypotension

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20
Q

What might suggest accelerated starvation?

A

Underweight or signs of malnutrition

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21
Q

What might suggest hyperinsulinism?

A
  • Tall stature

- Excess weight

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22
Q

What might suggest Beckwith-Wiedemann syndrome?

A
  • Abnormal ear lobe creases
  • Macroglossia
  • Umbilical hernia
  • Hemihypertrophy
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23
Q

What might suggest a glycogen storage disorder?

A

Hepatosplenomegaly

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24
Q

What is the aim of investigations in hypoglycaemia?

A
  • Establish severity

- Evaluate counter-regulatory responses and intermediary metabolite pathways

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25
How is hypoglycaemia investigated?
Obtaining blood sample prior to treatment
26
What might be looked for on blood tests in hypoglycaemia?
- Glucose - U&Es - Bicarb and pH - LFTs - Ammonia - Insulin and c-peptide - Cortical, ACTH, and growth hormone - Free fatty acids and beta-hydroxybutyrate - Acylcarnitine - Lactate - Alanine
27
Why is glucose checked in hypoglycaemia?
Confirm severity
28
Why are U&Es done in hypoglycaemia?
Look for evidence of adrenal insufficiency
29
Why are bicarb and pH checked in hypoglycaemia?
Acidosis might imply adrenal failure or inborn error of metabolism
30
Why should LFTs be done in hypoglycaemia?
May be abnormal in; - Primary liver disease - Sepsis - Glycogen storage disease - Galactosaemia - Fatty acid oxidation defects - Hereditary fructose intolerance
31
What can ammonia show in hypoglycaemia?
Can be raised in a number of inborn errors of metabolism and some forms of hyperinsulinism
32
What should happen to insulin and c-peptide in hypoglycaemia?
Should be suppressed
33
What should happen to cortisol, ACTH, and GH in hypoglycaemia?
Should normally be elevated (implying appropriate stress response)
34
What can free fatty acids and beta-hydroxybutyrate show in hypoglycaemia?
If elevated in proportion, imply lipolysis
35
What can acylcarnitine show in hypoglycaemia?
Abnormal in some fatty acid oxidation defects
36
What can lactate show in hypoglycaemia?
Elevated in; - Metabolic liver disease - Glycogen storage disorder - Sepsis
37
What can alanine show in hypoglycaemia?
If low, suggests accelerated starvation
38
What investigation should be done after glucose has been administered to correct the hypoglycaemia?
The next urine sample should be collected
39
What testing is done on the urine sample in hypoglycaemia?
- Screen for inborn errors of metabolism | - Toxicology screen
40
What is looked for on a urine screen for inborn errors of metabolism?
- Ketones - Reducing sugars - Dicarboxylic acids - Glycine conjugates - Carnitine derivatives - Amino acids - Organic acids
41
What does the treatment of hypoglycaemia depend on?
Aetiology
42
What can the causes of hypoglycaemia be broadly subdivided into?
- Causes associated with reduced glucose availability due to detects in counter-regulatory responses (including limited supplies of glucose precursors) - Increased glucose consumption
43
What causes of hypoglycaemia are due to reduced glucose availability?
- IUGR - Prematurity - Hypopituitarism - Adrenal insufficiency - GH deficiency - Hypothyroidism - Accelerated starvation - Glucagon deficiency - Inborn errors of metabolism - Drugs - Liver dysfunction - Congenital heart disease
44
What drugs can cause hypoglycaemia due to reduced glucose availability?
- Alcohol - Aspirin - Beta blockers
45
What does investigation of hypoglycaemia often find when the cause is reduced glucose availability?
Frequently fails to demonstrate any underlying abnormality
46
When can accelerated starvation be diagnosed?
Only once other endocrine and metabolic causes are excluded
47
What is accelerated starvation characterised by?
Normal endocrine counter-regulatory response with raised fatty acid and ketone responses
48
What are the risk factors for accelerated starvation?
- Boys | - Small for gestational age or thin physique
49
What normally happens to accelerated starvation with time?
Usually resolves by puberty
50
What does treatment of acceleration starvation involve?
- Avoidance of prolonged fasting, particularly during illness - Administration of complex carbohydrates prior to bed - IV dextrose as required to reverse acute hypoglycaemia
51
What are the causes of hypoglycaemia caused by increased glucose consumption?
- Congenital hyperinsulinism - Transient neonatal hyperinsulinism - Infant to diabetic mother - Insulinoma - Beckwith-Wiedemann syndrome - Rhesus haemolytic disease - Perinatal asphyxia - Malaria
52
What suggests hyperinsulinism?
Markedly excessive glucose requirements e.g. 12mg/kg/hour + to avoid hypoglycaemia
53
What might congenital hyperinsulinism occur in relation to?
Several genetic defects affecting the regulation of insulin release
54
What are the most commonly identified genetic defects in congenital hyperinsulinism?
- ABCC8 | - KCNJ11
55
What does ABCC8 encode?
The sulphonylurea receptor
56
What does KCNJ11 encode?
Potassium inward rectifying channel
57
What are children affected by congenital hyperinsulinism at increased risk of?
Hypoglycaemia-induced brain damage
58
Why are children with congenital hyperinsulinism at increased risk of hypoglycaemia-induced brain damage?
Hyperinsulinism suppresses not only glucose, but also ketone body production, which is an alternative cerebral fuel source
59
What is the first line management for congenital hyperinsulinism?
Diazoxide and chlorothiazide treatment
60
How does diazoxide evert its effects in congenital hyperinsulinism?
Through actions on the potassium channel, by; - Inducing hyperpolarisation - Decreasing calcium influx - Reducing insulin secretion
61
What is second line management for congenital hyperinsulinism?
Somatostatin analogues
62
How do somatostatin analogues work in congenital hyperinsulinism?
They exert a direct receptor-mediated inhibition of insulin release
63
What are the surgical options for persistent cases of congenital hyperinsulinism?
Surgical excision of part of pancreas
64
What has allowed for the technique of surgical excision of part of the pancreas in congenital hyperinsulinism?
Advances in understanding of genetics and new imaging techniques such as [18F]DOPA-PET scanning, which allows distinction between focal and diffuse pancreatic disease, with the former being curable by surgical excision with minimal morbidity

TAS Endocrinology (6 decks)

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