Hypoglycemia in children–evaluating and managing

Question 1

What happens when the brain is exposed to prolonged hypoglycemic episodes or state?

Answer 1

+Seizures and brain damage with resulting developmental delays and disabilities.

Question 2

Through what regulatory systems to maintain euglycemia does the body used to protect the brain?

Answer 2

Multiple body systems were to maintain blood sugar level.

Question 3

What are 4 metabolic systems that if any one of them should fail can trigger hypoglycemia?

Answer 3

1. Disorders of excess insulin
2. Ketotic hypoglycemia
3. Fatty acid oxidation disorders
4. Disorders of gluconeogenesis

Question 4

What are the physiologic pathways the body uses to maintain blood sugar levels in response to a fasting state?

Answer 4

First insulin suppression
Second counter regulatory hormones rise
Third glycogenolysis
Fourth gluconeogenesis
Fifth ketogenesis

Question 5

Describe the first response for hypoglycemia

Answer 5

Insulin is suppressed and the counter regulatory hormones of growth hormone, cortisol, glucagon and epinephrine increase

Question 6

What occurs with the second phase of the fasting response to maintain glucose?

Answer 6

The liver starts to breakdown its glycogen stores known as glycogenolysis

Question 7

What are the main building blocks needed for gluconeogenesis?

Answer 7

Glucose is produced from amino acids, glycerol, and lactate.

Question 8

What source of energy store is finally utilized with prolonged states of fasting?

Answer 8

Adipose tissue then becomes the source of fuel. Fatty acid is broken down to free fatty acids, lipolysis, and ketones such as beta hydroxybutyrate known as ketogenesis.

Question 9

What does the brain use as its source of energy once the glucose is no longer available?

Answer 9

The brain switches to ketones out of necessity

Question 10

When should a work-up of hypoglycemia include laboratory evaluation?

Answer 10

After 48 hours of hypoglycemia.

Question 11

Below what blood glucose level after 48 hours should laboratory evaluation be done in a patient with persistent hypoglycemia?

Answer 11

Less than 60 mg/dL measured in a lab work confirmed in the lab not point-of-care testing

Question 12

What is the “critical sample” level of glucose for an adequate laboratory evaluation to occur in a patient with hypoglycemia?

Answer 12

The critical sample must be obtained with the plasma glucose is less than 50 mg/dL+

Question 13

Neonate’s and infants with hypoglycemia states are more likely to have what for disorders?

Answer 13

1. Hyperinsulinemia
2. Panhypopituitarism
3. Inborn errors of metabolism
4. Disorders of gluconeogenesis

Question 14

Toddlers with hypoglycemia states are more likely to have what disorders?

Answer 14

1. Glycogen-storage disorders
2. Ingestions
3. Idiopathic ketotic hypoglycemia
4. Growth hormone
5. Or cortisol deficiencies

Question 15

Older children and adolescents with hypoglycemic states are more likely to have one of what 3 disorders?

Answer 15

1. Fictitious hypoglycemia
2. Toxic ingestions
3. Insulinoma

Question 16

How does timing and frequency of hypoglycemic episodes help in the differential of the etiologies?

Answer 16

Hypoglycemia after only a few hours or more likely to be due to hyperinsulinism or one of the more severe glycogen-storage diseases (type I or type III)

Question 17

How can certain foods triggering hypoglycemia help in the differential of the etiologies?

Answer 17

Symptoms after consumption of fructose raise concerns for hereditary fructose intolerance
Or after milk products raising concerns for galactosemia

Question 18

What medications can be ingested leading towards hypoglycemia in children?

Answer 18

Diabetes medications including sulfonylureas, or beta-blockers and and also must think about ethanol ingestion

Question 19

How can physical exam findings help narrow the differential etiologies in someone with hypoglycemia?

Answer 19

1. Short stature and slow growth velocity hint of growth hormone deficiency
2. Hepatomegaly: Consider glycogen storage disorders
3. Poor weight gain: Consider adrenal insufficiency glycogen-storage disease and idiopathic ketotic hypoglycemia
4. Midline defects, micropenis, or undescended testes: Consider hypopituitarism
5. Tall stature, macroglossia, abdominal wall defects: Consider Beckwith Weidman syndrome
6. Hyperpigmentation: This may indicate primary adrenal insufficiency

Question 20

What are the critical sample labs that should be obtained when someone has serum glucose less than 50 mg/dL?

Answer 20

1. Serum glucose
2. Insulin
3. C-peptide
4. Beta hydroxybutyrate
5. CMP
6. Free fatty acids
7. Lactate
8. Ammonia
9. Cortisol
10. Growth hormone
11. Acyl-carnitine profile
12. Free and total carnitine’s
13. Urine for ketones if beta hydroxybutyrate testing is not available
    If hypoglycemia is suspected always try to obtain a critical sample after bedside testing and if possible before treatment and then obtain a first urine after the episode.

Question 21

What other tests must be considered for given circumstances.

Answer 21

If suspicious for ingestion then test for specific drugs, also consider genetic testing.

Question 22

Management of hypoglycemia is generally initiated at a blood sugar level of less <____, and if the patient is symptomatic?

Answer 22

70 g/dL

Question 23

What treatment should be given to a patient who is symptomatic and has a low blood sugar level?

Answer 23

Give 10 to 20 g of fast acting carbohydrate ASAP this may include corn syrup, crackers, juice, sugar, soda if the patient is awake and able to swallow

Question 24

List some of the concentrations of glucose in some treatment options for hypoglycemia?

Answer 24

Glucose tablet 4 to 5 g/tab.
Glucose gel 15 g per tube
Juice 12 g per 4 ounces
Soda, not diet soda, 18 g per 6 ounces
Honey 17 g per 1 tablespoon
Table sugar 12.5g/tbsp.
Fruit approximately 15 g per 4 ounces

Question 25

In an altered mental state what should be given?

Answer 25

Glucagon 0.5 mg in a patient less than 25 kg or 1 mg in a patient greater than 25 kg IM or SQ
Or IV bolus of D10, 2 mL per kilo gram infused over a few minutes

Question 26

How often should the blood sugar be tested after treatment initiated for hypoglycemia?

Answer 26

Blood sugar should be checked every 10 to 15 minutes until it is greater than 70 mg/dL, then every 30 to 60 minutes until stable.

Question 27

What should be done if the repeat blood sugar levels are low?

Answer 27

Repeat the carbohydrate bolus if this is needed then an IV infusion of dextrose will be needed.

Question 28

Discussed the treatment protocol and more of an emergent or persistent hypoglycemic patient?

Answer 28

For infants and young children give 2 mL per kilo of D10, with a max dose of 500 mL or 50 g of dextrose. For adolescents give 1/2 to 1 ampoule of D50,
Then establish IV access if not already done and start IV fluids containing D10. Titrate rate to maintain glucose in safe range, typically 70 to 120 mg/dL

Question 29

Discussed the concept of percent solutions?

Answer 29

This refers to grams per 100 mL for example D50 refers to 50 g of dextrose per 100 mL of water, so 50 mL ampule would equal 25 g of dextrose