Hypoglycemia
Hypoglycemia is defined by venous plasma glucose below 60 mg/dL. Normally, the body has several mechanisms that prevent hypoglycemia during fasting. Recurrent hypoglycemia suggests a defect in one of these fasting systems. The brain relies on glucose as an energy source; in infancy and childhood, hypoglycemia can injure the developing brain and result in permanent neurodevelopmental sequelae.
Differential Diagnosis
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Normal neonates (in first 24 hours of life)
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Ketotic hypoglycemia
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Insulin excess
–Exogenous insulin
–Sulfonylurea ingestion
–Infant of a diabetic mother
–Perinatal stress-induced hyperinsulinism
–Congenital hyperinsulinism
–Beckwith-Wiedemann syndrome
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Hormone deficiency
–Panhypopituitarism
–Growth hormone deficiency
–ACTH or cortisol deficiency
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Defects of glycogenolysis
–Glycogen storage diseases
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Defects of gluconeogenesis
–Glycogen storage disease type 1
–Fructose-1,6-diphosphatase deficiency
–Pyruvate carboxylase deficiency
–PEPCK deficiency
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Fatty oxidation and ketogenesis defects
–Medium-chain acyl-CoA dehydrogenase deficiency (most commonly)
–Carnitine transport and metabolism
–Electron transfer
–HMG CoA synthase deficiency
–HMG CoA lyase deficiency
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Liver disease
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Galactosemia
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Hereditary fructose intolerance
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Disorders of amino acid metabolism
–Maple syrup urine disease
–Methylmalonic acidemia
–Tyrosinemia
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Dumping syndrome
–Associated with Nissen fundoplication
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Reye syndrome
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Ethanol intoxication
–Impaired gluconeogensis
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Salicylate intoxication
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Diarrhea and malnutrition
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Malaria
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Jamaican vomiting sickness
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Measurement error
–Glucometer measurements are inaccurate in low range
–Plasma glucose levels gradually fall if samples are not immediately tested
Workup and Diagnosis
- History
–Classic symptoms associated with hypoglycemia that resolve with glucose ingestion
–Symptoms of hypoglycemia: Anxiety, irritability, hunger, diaphoresis, tachycardia, shakiness, nausea/vomiting, weakness, headache, visual changes, poor speech, poor concentration, confusion, lethargy, somnolence, loss of consciousness, coma, hypothermia, seizure, personality changes
–Fasting duration or frequency of feeding
–Intercurrent illness, medications in the home
–Birth history: Gestational diabetes, birth weight, stress
–Developmental history: Delayed milestones
- Physical exam
–Weight and height
–Dysmorphism consistent with known genetic syndrome
–Hyperpigmentation (in primary adrenal insufficiency)
–Funduscopic exam (e.g., cataracts in galactosemia)
–Midline defects (cleft palate, central incisor,
microphallus) in hypopituitarism
–Hepatomegaly (in glycogen storage and liver disease)
–Neurologic exam for signs of CNS disease
- Critical labs during hypoglycemia: Electrolytes, HCO3, insulin, C-peptide, cortisol, GH, free fatty acids, lactate, ammonia, β
-hydroxybutyrate, acetoacetate, total and free carnitine, acyl carnitine profile, urine organic acids
–Glycemic response to glucagon during hypoglycemia suggests hyperinsulinism or hypopituitarism
Treatment
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If awake and alert, give glucose/feed orally
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If impaired consciousness, D10 or D25 2-4 cc/kg IV/NG
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For hyperinsulinism:
–Glucagon injection acutely
–Supranormal glucose intake chronically
–Dietary manipulation (increased feeding frequency, some are protein sensitive)
–Medical options: Diazoxide, octreotide
–Surgical option: Subtotal pancreatectomy
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For defects in fasting adaptation (including defects in glycogenolysis, gluconeogenesis, fatty acid oxidation, and ketogenesis): Frequent or continuous feeding, night-time cornstarch helpful for some
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For hormone deficiencies: Hormone replacement (i.e., growth hormone and/or hydrocortisone)
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Goals of therapy: Prevent recurrent hypoglycemia, prevent catabolic state, promote growth and development
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hypoglycemia
Read excerpts from these other book chapters related to Hypoglycemia:
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Hypoglycemia
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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» Next page: HYPOGLYCEMIA (Differential Diagnosis in Primary Care)
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