Difference between revisions of "Non-neonatal hypoglycemia (peds)"

 
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''This page is for <u>non-neonatal pediatric</u> hypoglycemia. See [[hypoglycemia]] for adult patients or [[neonatal hypoglycemia]].''
 
==Background==
 
==Background==
 
===Etiology===
 
===Etiology===
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*Prematurity (inadequate glycogen stores)
 
*Prematurity (inadequate glycogen stores)
 
*Sepsis
 
*Sepsis
 +
*Etoh exposure (children have low glycogen stores)
  
 
==Clinical Features==
 
==Clinical Features==
*Most common features: vomiting, AMS, poor feeding
+
*Most common features: vomiting, altered mental status, poor feeding
**May also see lethargy, apnea, sz
+
**May also see lethargy, apnea, seizure
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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*[[Sepsis (peds)|Sepsis]]
 
*[[Sepsis (peds)|Sepsis]]
  
==Diagnosis==
+
==Evaluation==
*Blood glucose <45 in symptomatic neonate
 
*Blood glucose <35 in asymptomatic neonate
 
 
 
 
===Work-Up===
 
===Work-Up===
 
*Blood glucose level
 
*Blood glucose level
*UA
+
*[[Urinalysis]]
 
**If ketones: adrenal or GH deficiency, inborn errors of metabolism
 
**If ketones: adrenal or GH deficiency, inborn errors of metabolism
 
**If no ketones: Hyperinsulinemia, fatty acid oxidation defects
 
**If no ketones: Hyperinsulinemia, fatty acid oxidation defects
 +
 +
===Diagnosis===
 +
*Blood glucose <45 in symptomatic neonate
 +
*Blood glucose <35 in asymptomatic neonate
  
 
==Management==
 
==Management==
 
''See [[critical care quick reference]] for doses by weight
 
''See [[critical care quick reference]] for doses by weight
 
*Glucose
 
*Glucose
**Bolus [[D10W]] 2mL/kg; then infuse D10W @ 0.06-0.08mL/kg/min
+
**Bolus [[D10W]] 2mL/kg; then infuse D10W at 0.06-0.08mL/kg/min
 
*[[Glucagon]]
 
*[[Glucagon]]
 
**Used for persistent hypoglycemia despite glucose administration
 
**Used for persistent hypoglycemia despite glucose administration
**0.03 mg/kg IM/IV
+
**Will not work with etoh exposure as glycogen stores are already low
 +
**0.03mg/kg IM/IV
  
 
{{Pediatric hypoglycemia chart}}
 
{{Pediatric hypoglycemia chart}}
 
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="width: 621px; height: 444px;"
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Patient Age
 
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dextrose Bolus Dose
 
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dextrose Maintenance Dosage
 
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Other Treatments to Consider
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Neonate
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | D10 5 mL/kg PO/NG/IV/IO
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | 6 mL/kg/h D10
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg IM
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Hydrocortisone, 25 grams PO/IM/IV/IO
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="4" class="font12" | Infant
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | D10 5 mL/kg PO/NG/IV/IO
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="4" class="font12" | 6 mL/kg/h D10
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg IM
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | ''or''&nbsp;
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="3" class="font12" | Hydrocortisone, 25 grams PO/IM/IV/IO
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | D25 2 mL/kg
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &nbsp;
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Child
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | D25 2 mL/kg PO/NG/IV/IO
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" |
 
6 mL/kg/h D10 for the first 10 kg
 
 
+ 3 mL/kg/h for 11–20 kg
 
 
+ 1.5 mL/kg/h for each additional kg &gt;20 kg
 
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg/IM
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Hydrocortisone, 50 grams PO/IM/IV/IO
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Adolescent
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | —
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" |
 
6 mL/kg/h D10 for the first 10 kg
 
 
+ 3 mL/kg/h for 11–20 kg
 
 
+ 1.5 mL/kg/h for each additional kg &gt;20 kg
 
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Glucagon, 0.3 milligram/kg IM
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Hydrocortisone, 100 grams PO/IM/IV/IO
 
|}
 
  
 
==Disposition==
 
==Disposition==
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<References/>
 
<References/>
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
[[Category:Endo]]
+
[[Category:Endocrinology]]

Latest revision as of 16:17, 15 March 2019

This page is for non-neonatal pediatric hypoglycemia. See hypoglycemia for adult patients or neonatal hypoglycemia.

Background

Etiology

  • Inadequate oral intake
  • Excess insulin
    • Newborns of diabetic mothers
  • Deficient hyperglycemic hormones (GH or adrenal hormone deficiency)
  • Fatty acid oxidation or carbohydrate metabolism disorders
  • Prematurity (inadequate glycogen stores)
  • Sepsis
  • Etoh exposure (children have low glycogen stores)

Clinical Features

  • Most common features: vomiting, altered mental status, poor feeding
    • May also see lethargy, apnea, seizure

Differential Diagnosis

  • Ingestions (e.g. ETOH)
  • Metabolic disease^
  • Sepsis

Evaluation

Work-Up

  • Blood glucose level
  • Urinalysis
    • If ketones: adrenal or GH deficiency, inborn errors of metabolism
    • If no ketones: Hyperinsulinemia, fatty acid oxidation defects

Diagnosis

  • Blood glucose <45 in symptomatic neonate
  • Blood glucose <35 in asymptomatic neonate

Management

See critical care quick reference for doses by weight

  • Glucose
    • Bolus D10W 2mL/kg; then infuse D10W at 0.06-0.08mL/kg/min
  • Glucagon
    • Used for persistent hypoglycemia despite glucose administration
    • Will not work with etoh exposure as glycogen stores are already low
    • 0.03mg/kg IM/IV

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
Pediatric 2mo-8yrs <60 D25W 2 mL/kg

D10W:

  • 6 mL/kg/h for first 10 kg
  • + 3 mL/kg/h for 11–20 kg
  • + 1.5 mL/kg/h for each additional kg >20 kg
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

Disposition

See Also

References