Hypoglycemia in Children 2

8/6/2019 Hypoglycemia in Children 2

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Jose Batubara

Pediatric EndocrinologyPediatric Dept, University of Indonesia, Jakarta

Hypoglycemia in childrenHypoglycemia in children


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Definition

The precise definition is still controversial

y presence of acute symptoms

y threshold of maintaining the blood levely presence of counter-regulatory hormone

responses

y statistically

y presence of brain damage

y etc


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Definition

For diagnostic purpose

Deficiency of glucose in the blood

40 mg% (< 2.2 mmol) regardless of age.

Hypoglycemia is a biochemical sign, not adiagnostic


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Glucose Homeostasis

Glucose principal energysource in the body

All body cells require glucose toproduce energy

Glucose is broken down toproduce energy by glycolysis


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Normal glucose homeostasis

y Most infants and children maintain blood glucose

levels between 60 120 mg/dl

y Glucose supplied fromy diet

y breakdown of amino acids

y Glycogen in the liver

y Glucose deliver to the cells via blood stream, sothe levels should be strictly controlled to ensure

that the cells have a constant supply


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Control of blood glucose in fed state


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Fasted state of glucose homeostasis


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Endocrine control of glucose homeostasis

y Excess glucose in blood is stored in the form of

y Glycogen in the liver and muscle cells

y

Fat in adipose celly Hormones have an effect on blood glucose

y Insulin

y Glucagon

yAdrenaliney Cortisol

y Growthhormone


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Hormone that regulate glucose homeostasis

y Insulin : Removes glucose from the blood bystimulating its uptake into cells and itsstorage in the liver, muscle and adiposetissue

y Glucagon : Stimulates the release of glucose from theliver

y Adrenalin : Secreted in response to stress and raiseblood glucose levels and inhibit insulinsecretion

y Cortisol and GH :Stimulate the conversion of amino acidsinto glucose in the liver and induce insulinresistance


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Summary of opposing effects of

hormones on glucose metabolism

Insulin

Glucose uptake

Lipolysis

Ketogenesis

Gluconeogenesis

Glycogenolysis

GH, cortisol,glucagon, and

adrenalin

Blood glucose


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Clinical symptoms of Hypoglycemia

Hunger and weakness

Sweating, shakiness and trembling

Pallor, nausea and vomiting

Palpitation

Tachycardia and tremor Nervousness

Adrenergicsymptoms

Headache

Leth

argy, lassitude Visual and Speech disturbances

Mental confusion

Convulsions

Apnea, Coma

Neuroglycopenicsymptoms


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Glucose level and clinical symptoms

4

3

2

1

Blood glucose (mmol/l)

Start of brain dysfunction

Adrenalin release

Sweating, tremor Confusion/loss of

concentration

Permanent brain damage

Coma/seizure


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Hypoglycemia in infancy

y Most common metabolic problem in newborn

y The most common cause is transitional

hypoglycemia normal adaptation to the extrauterine life

y If more than 24 hours usually pathologic


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Clinical signs

y Tremor, jitteriness, hypotonia, irritability

y Seizures

y

Abnormal cry (high

pitch)

y Letargy, poor feeding/sucking

yApnea, tachypnea

y Diaphoresis, pallor

y

Temperature instabilityy Unexplained cyanosis

y Cardiac arrest


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Etiology of neonatal hypoglycemiaEtiology of neonatal hypoglycemia

Etiology Duration of

hypoglycemia

Prematurity, IUGR Transient *Transient *

Asphyxia, hypothermia TransientTransient

Sepsis TransientTransient

Infant of diabetic mother TransientTransient

Erythroblastosis fetalis TransientTransient

Exposure to B agonist tocolysis TransientTransient

Familial hyperinsulinemia ProlongedProlonged

Inborn error of metabolism ProlongedProlonged

*G

enerally < 7 days


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Transitional hypoglycemia

y Hypoglycemia that occur in the first 12 hours of life

y Transition period from intrauterine to extrauterine

glucose homeostasisy Lubchenko : 30 % infants have glucose levels < 50

mg/dl

y Early breast feeding will resolve

y If after 12 hours of life, glucose levels > 60 mg/dl no further investigations are necessary


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Transient hypoglycemia of newborn

y Transient neonatal hyperinsulinemia

y Hypoglycemia in infant SGA


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Infant of diabetic mother

y Specific group at risk of early hypoglycemia

y Its due to increased secretion of insulin persistingafter delivery and often asymptomatic

y Other findingsy Macrosomia

y Birth trauma

y Congenital anomalies

y Respiratory distress

y Polycytemia

y Hyperbilirubinemia

y Myocardial dysfunction


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Hypoglycemia in children


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Hormone deficiency

y Growthhormone deficiency

y Cortisol insufficiency

y Hypothyroidism


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Persistent Hyperinsulinemic Hypoglycemia ofInfancy

y Most common cause of recurrent hypoglycemia in

infancy

y Insulin release increase due to defective K-AT

Pchannel function

y Incidence : 1 : 50.000 live birth in North Europe

y Therapy :y prevent neurologic symptoms and sequelae

y Diazoxide 5 20 mg/day first choice drug

y Surgical treatment is indicated if pharmacologic treatment fail


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Enzyme deficiency

y Glycogen storage desease

y Disorder ofhepatic gluconeogenesis

y Pyruvate carboxylase deficiencyy Galactosemia

y Hereditary fructose intolerance

y Defect in fatty acid metabolism


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Drug induced hypoglycemia

y Insulin

y Sulfonylurea

y Ethyl alcoholy Salicylate and related compounds


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Other causes of hypoglycemia

y Cyanotic congenital heart desease

y Ketotic hypoglycemia

y Hypoglycemia associated with surgery


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Diagnostic evaluation

y Critical blood sample

y History, Physical Examination and Elective fast

y Tolerance testing


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History

y Diabetic mother

y Obesity hyperinsulinism

y Mikropenis & cholestasis hypopituitarismy Hepatomegaly glycogen storage disease

y Drugs

y Diet component inborn error of metabolism


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Treatment

yAim restore blood glucose levels to normal

y Oral glucose

y IV 25% glucose bolus 1 2 ml/kg/hr,then 10% glucose 3 - 5 ml/kg/hr

y If glucose need is > 10 mg/kg/m insulinoma

give Glucagon 5 10 ug/kg/hr

Surgery if not responded to treatment


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Adjunct therapy for hypoglycemiaAdjunct therapy for hypoglycemia

TherapyTherapy EffectEffect DosageDosage

Corticosteroid Decrease peripheral glucoseutilization

HC 5 15 mg/kg /dayPrednisone 2 mg/kg/day

Glucagon Stimulate glycogenolysis 30 mcg/kg/day for N insulin300 mcg/kg/day for insulin

Diazoxide Inhibit insulin secretion 15 mg/kg/day

Somatostatin Inhibit insulin and GH release 5 10 mcg/kg/day every 6 8 h

Pancreatectomy Decrease insulin secretion


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Conclusion

y Hypoglycemia is a biochemical sign, not a

diagnostic

y

For diagnostic purpose hypoglycemia is a bloodglucose levels less than 40 mg/dl

y Early diagnostic and treatment is important

y Diagnostic based on clinical symptoms and lab

result


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Hypoglycemia in Children 2

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