- 1 Background
- 2 Clinical Features
- 3 Differential Diagnosis
- 4 Evaluation
- 5 Management
- 6 Disposition
- 7 See Also
- 8 References
- 3 births per 1000 with hypoglycemia
- Maternal DM (hyperinsulin)
- Premies (cannot store glycogen)
- Sick kids (depleted glycogen)
- Growth restricted babies (depleted glycogen)
- Macrosomic kids
- Decreased substrate availability
- Intra-uterine growth retardation
- Glycogen storage disease
- Inborn errors of metabolism (e.g., fructose intolerance)
- Prolonged fasting without IV glucose
- Other endocrine abnormalities:
- Increased glucose utilization:
- Miscellaneous conditions:
Persistent neonatal hypoglycemia
- Too much insulin:
- Idiopathic, asphyxia, rhesus diagnoses, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
- Not enough anti-insulin:
- Hypopituitarism, adrenal hyperplasia
- Inborn errors of metabolism
- Glycogen storage disease, fatty oxidation errors
- Blood glucose level
- blood glucose <40mg/dL (preterm infants repeated levels below <50)
There is a normal fall in glucose @ 2-4hr of life
- If no obvious precipitant, consider workup for inborn errors of metabolism
Pediatric Hypoglycemia Dextrose Chart
|Category||Age||Glucose||Treatment||Initial IV Bolus||Maintenance Dose|
|Neonatal||<2mo||<40||D10W||2.5-5 mL/kg||6 mL/kg/h|
|Adult||>8yrs||<70||D50W||50mL (1 amp) OR 1 mL/kg|
- Consider diluting the D25 or D50 bolus, with NS 1-to-1, as those concentrations may be sclerosing to veins
- Recheck 5 minutes after dose and repeat dose if low.
- Consider glucagon IM/SQ if IV access is not readily available
- Glucometer reading 20-40mg/dL, infant is term and is able to feed:
- Draw blood for stat blood glucose.
- Feed 5 mL/kg of D5W.
- Repeat blood glucose or Glucometer 20 min after feeding.
- Glucometer reading:
- <20mg/dL or
- <40mg/dL and NPO or preterm or
- <40mg/dL after feeding or
- <40mg/dL and symptomatic
- Draw blood for stat glucose measurement.
- Give IV bolus of 2-3 mL/kg of D10W.
- Begin continuous infusion of D10W at 4-6mg/kg/min.
- If infant of diabetic mother, begin D10W at 8-10mg/kg/min (100-125 cc/kg/d).
- Repeat blood glucose in 20 min and pursue treatment until blood sugar >40mg/dL.
- For persistent hypoglycemia despite above measures:
- Increase rate of glucose infusion stepwise in 2mg/kg/min*increments up to 12-15mg/kg/min glucose. Use increased volume with caution in infants where volume overload is a concern. Maximal concentration of glucose in peripheral IV is D12.5.
- If infant requires IV dextrose concentrations >12.5%, insert central venous catheter.
- Do not use D25W or D50W IV or large IV volume boluses as this creates rebound hypoglycemia in infants who are hyperinsulinemic. In addition, administration of D25W or D50W can cause dangerous increase in plasma osmolarity.
- If hypoglycemia is not controlled with above measures:
- Obtain Endocrine Consult to guide further diagnostic evaluation and management.
- While awaiting consult, send blood (while blood sugar is low) for glucose, plasma cortisol, growth hormone and insulin concentrations
- Further management may include glucocorticoids, diazoxide, somatostatin or pancreatectomy.
Calculate rate of glucose administration
Use either of the following formulas:
- (% glucose x mL/kg/d)/144 = glucose infusion rate (mg/kg/min)
- (% glucose x mL/h)/(6 x body weight in kg) = glucose infusion rate (mg/kg/min)
- Check insulin, c-peptide, GH, cortisol, beta hydroxybutyrate, UA
- Increase volume by 30cc/kg/d
- Increase glucose to 12.5%
If continues for >3 d: consult endocrinology, or sooner
- Weaning IV dextrose infusion: When blood glucose has been stable for 12-24 h, begin decreasing IV infusion by 1-2 mL/hr q3-4 hours if blood glucose remains >60mg/dL.