Pediatric hypoglycemia

Diagnosis and Managementof Pediatric Hypoglycemia

J. Paul Frindik, MD CDE

Hypoglycemia

• Two or more sequential blood glucose values less than 40-45 mg/dl

• “Hypoglycemia” refers to symptoms or “low blood sugar” and is not a diagnosis.

Hypoglycemia – Learning Objectives

• Symptoms and Definitions

• Causes of Hypoglycemia– Neonatal

• Transient vs. Persistent

• Treatment Options

– Childhood

• Management

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?”


• “Is the patient having a hypoglycemic episode?”

• “What are the symptoms of hypoglycemia?”

Symptoms of Hypoglycemia

• Neonatal• Cyanosis, apnea• Respiratory distress• Poor feeding• Hypothermia• Seizures

• Children• Inattention, “spells”• Lethargy• Hunger• Behavioral problems• Seizures

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

Definitions of Hypoglycemia

Whipple’s Triad

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


• “Is the patient having a hypoglycemic episode?”• “What are the symptoms of hypoglycemia?”

• “Do I need to treat ? How? When ?”


Suggested Treatment 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”


Suggested Treatment 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

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?”


• Symptoms and Definitions

• Causes of Hypoglycemia– Neonatal

• Transient vs. Persistent


– Childhood

Classification of Neonatal Hypoglycemia

TransientHypoglycem ia

PersistentHypoglycem ia

NeonatalHypoglycem ia

Neonatal Hypoglycemia

Transient

• Postnatal instability, inadequate fuel

• 2 – 3 per 1000 live births

• Occurs within first 12 hours after birth

• Resolves within 3 – 5 days

Transient Neonatal Hypoglycemia

High Risk Groups

• Premature, SGA, smaller of twins

• Respiratory distress, sepsis, other stress

• Large birth weight infants– Infant of diabetic mother

hyperinsulinemia from islet cell hyperplasia

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

Neonatal Hypoglycemia

Persistent

• 5% of infants with hypoglycemia

• Persistent (recurrent) hypoglycemia– Does not resolve within 5-7 days

• Hormone deficiencies and excess

• Metabolic diseases

Persistent Neonatal Hypoglycemia

Etiologies 1• 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


Treatment of Hormone Deficiencies

Diagnosis primary problem

• Cortisol / ACTH deficiencyHydrocortisone: ~ 15 mg / M2 / day

• Divided t.i.d. or q.i.d. P.O. or I.V.

• GH deficiencyGrowth hormone 0.5 mg / day SQ


Etiologies 2

• 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)


Suspect Hyperinsulinemia 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


Treatment of Hyperinsulinemia1. Diazoxide

10 – 25 mg / kg / day divided t.i.d.

2. Octreotide (Sandostatin)1 – 20 mcg / kg / day SQ divided t.i.d. or continuous infusion via insulin pump

3. Glucagon1 mg / 24 hrs continuous infusion

4. Pancreatectomy


• Symptoms and Definitions• Causes of Hypoglycemia

– Neonatal• Transient vs. Persistent


– Childhood Hypoglycemia

Childhood Hypoglycemia: Etiologies

• Hormone Deficiencies– GH Deficiency

– Cortisol Insufficiency• Primary adrenal

• Secondary pituitary– ACTH

• Insulin Excess– Adenoma

– Exogenous

• Metabolic Diseases• Ingestions

– Alcohol, Oral hypoglycemics

Childhood Hypoglycemia

Diagnostic Clues

Age less than 12 – 18 months:• Congenital pituitary / adrenal defects

• Hyperinsulinemia

• Metabolic diseases


Diagnostic Clues

Age over 12 – 18 months:• Acquired pituitary / adrenal defects

• Islet cell adenoma (rare)

• Metabolic diseases (usually present earlier)

• “ketotic hypoglycemia”


Diagnostic Clues from Physical Exam

• Short stature– GH deficiency

• Poor weight gain– Cortisol deficiency

• Pigmentation– Adrenal defects

• Midline defects– Pituitary defects

• Ambiguous genitalia– Adrenal defects

• Micropenis– Pituitary

Laboratory Diagnosis

• Studies must be obtained when the patient actually is hypoglycemic

• Endocrine Evaluation:– Urine / serum ketones– Insulin / C-peptide– Cortisol– Growth Hormone

Pediatric hypoglycemia

Education

Transcript of Pediatric hypoglycemia