Download Hypoglycaemia in infants and children: Aetiology, investigation and

Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
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Hypoglycaemia in infants and children: Aetiology, investigation and
treatment
Guideline for the management of hypoglycaemia in infants, children and
young people: Aetiology, investigation and treatment
Nov 2007
Explicit definition of patient group
to which it applies:
This guideline is intended for infants outside of the neonatal period (i.e.
>28 days) children and young people up to the age of 19 years who do not
have a diagnosis of diabetes or other established metabolic disorder.
Name of contact author
Dr Becky Smith, Paediatric SpR
Dr Tabitha Randell, Consultant Paediatrician
Ext:
Revision Date
Nov 2010
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and
application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague
or expert. Caution is advised when using guidelines after the review date.
Hypoglycaemia in infants and children: Aetiology,
investigation and treatment
Scope of Guideline
This guideline is intended for infants and children outside of the neonatal period (i.e. >28
days) who do not have a diagnosis of diabetes or other established metabolic disorder. There
is a separate neonatal guideline available from the Neonatal Unit.
Definition
Hypoglycaemia refers to the inadequacy of circulating levels of blood glucose and is defined
as a laboratory blood glucose measurement of < 2.6mmol/l. Hypoglycaemia may be
associated with clinical symptoms and signs or be asymptomatic.
Background
Hypoglycaemia in children beyond the neonatal period is relatively common accounting for 1
in 500 hospital admissions. The majority of these will be in patients with known diabetes. In
children with no previously identified cause for hypoglycaemia up to 30% of cases are due to
defects in fatty acid oxidation. Prolonged or recurrent hypoglycaemia, especially when
associated with symptoms and clinical signs can cause long term neurological damage or
death. Thus, prompt recognition and treatment are essential.
Becky Smith
Page 1
Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
Symptoms
The following are typical symptoms and signs of hypoglycaemia but please be aware that this
list is not exhaustive and a blood sugar should be checked in any unwell child.
Neonate
Pallor
Sweating
Tachypnoea
Jitteriness
Apnoea
Hypotonia
Feeding difficulties
Irritability
Abnormal Cry
Convulsions
Infant and older child
Anxiety
Tremor
Palpitations
Weakness
Nausea and vomiting
Hunger
Abdominal Pain
Headache
Confusion
Coma
Visual disturbance
Convulsions
Emergency management and Investigation of Hypoglycaemia
History
Age
Feeding History
Birth history and weight
Neonatal jaundice
Tolerance to fasting/ illness
Drug ingestion
Family history and parental consanguinity
Becky Smith
Page 2
Signs
Features of sepsis
Hepatomegaly
Encephalopathy
Optic atrophy / cataracts
Genitalia appearance
Skin pigmentation
Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
Management of A B C
BM < 2.6 mmol/L
Insert cannula
Initial bloods (see list)
Send lab glucose to confirm
Put urine bag on to collect next urine passed
DO NOT DELAY CORRECTION OF HYPOGLYCAEMIA WHILST
AWAITING CONFIRMATION OF LABORATORY GLUCOSE
IV Access?
Yes
No
IV Bolus 10%
dextrose 5mls/kg
Drowsy?
No
Yes
<1year - milk feed
>1 year – 60ml lucozade
Give im glucagon
0.5mg <3yr
1mg >3yr
If not immediately able to recommence feeds/or if unwell - commence an IV
glucose infusion using 10% dextrose/0.45% saline at a rate of 2.4 –4.8ml/kg/hr
Recheck BM at 5 min interval until blood sugar stable >3mmol
If unable to maintain BM >3mmol must have IV access

BM < 2.6mmol/l



Check cannula patent
repeat 5ml/kg bolus 10% dextrose
Increase rate up to 6ml/kg/hr
10%/0.18%dextrose saline
Increase percentage dextrose in
infusion -Central venous access if
>12.5% dextrose
If adrenal insufficiency suspected
give Hydrocortisone 4mg/kg max.
100mg iv and inform consultant on
call
Monitor U&E’s regularly (see IV
fluid guidelines)



Becky Smith
Page 3






BM>2.6mmol/l
Continue maintenance
fluids, if commenced
Gradually reintroduce feeds
IF BM falls to less than 3
mmol/l within 60 mins of a
feed use continuous feeds
Check pre-feed blood sugar
If continuing IVI monitor
U&E’s regularly (see IV
fluid guidelines)
Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
Investigations for Hypoglycaemia
Labels can be printed from NOTIS using the order set
‘Hypoglycaemia’
A specimen collection set is available as a package in the
Emergency Department and on the Paediatric wards

ONE x Fluoride oxalate (GREY) tube to be sent for:
o
o
o
o
o
o





Glucose
Lactate
Plasma free fatty acids and ketones
Beta hydroxybutyrate
Alanine
Carnitine
THREE x Lithium heparin (GREEN) tube to be sent for:
o Ammonia (single tube, inform lab as urgent and take to lab immediately)
o Cortisol
o Insulin and c-peptide
o GH
o Amino acids
o U&E
o LFT
o Alcohol
o Salicylates
o
Capillary Blood Gas
Blood Cultures
Urine (20mls sample required) dip for urine ketones and send for reducing
substances organic and amino acids
Guthrie card blood spot - for acylcarnitine.
Glucose Infusion Calculator
Glucose rate in mg / kg / min =
% dextrose solution x ml/hr
Weight x 6
To make up dextrose solutions of different concentrations add
Final dextrose
concentration required
10%
12.5%
15%
20%
Becky Smith
Add
37ml of 50% dextrose to a 500ml bag of dextrose 5% / 0.45%
saline
Available from Pharmacy ( no saline in bag will need U&E
monitoring)
Available from pharmacy
Page 4
Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
Fasting Provocation Test for hypoglycaemia
A fasting provocation test is occasionally indicated to help establish a diagnosis. This should
never be completed without consulting a paediatric endocrinologist and a separate protocol is
available for this.
Interpreting the Results of the Hypoglycaemia Screen
Low Ketones
Fatty acid oxidation defects
Fatty acid: 3 hydroxybutyrate level >2 suggests
Fatty acid oxidation defect
Raised Insulin
Hyperinsulinism of infancy
Beckwith- Weidman syndrome
Pancreatic islet cell adenoma
Insulin poisoning
Maternal diabetes
Hyperammonia
Maple syrup urine disease
Proprionic acidaemia
Methylmalonic acidaemia
Tyrosinaemia
Liver dysfunction
Hyperinsulinism
Metabolic acidosis
Fatty acid oxidation defects MCAD, LCAD
Defects in ketogenesis
Sepsis
Glycogen storage disorders
Organic acid disorders
Deranged LFT's
Sepsis
Liver disease
Glycogen storage disease
Galactosaemia
Fat oxidation defects
Hereditary fructose intolerance
Low cortisol
Adrenal insufficiency
Congenital adrenal hyperplasia
ACTH deficiency/ Hypopituitarism
Low sodium +
High Potassium
Adrenal disorders
GH deficiency
Panhypopituitarism
Isolated GH deficiency
Raised lactate
Metabolic liver disease
Prolonged convulsion
Glycogen storage disorders
Sepsis
Urine
Specific amino or organic acid disorders
Acylcarnitine
Abnormal in fatty acid oxidation defects
Becky Smith
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Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
Discharge Plan for Patient Admitted with Recurrent
Hypoglycaemia
Prior to discharge please ensure the following have been completed:

Ensure dietetic input to agree a written management plan for the parents to take home
(see sample attached)

Check the family know how to treat hypoglycaemia with polycal solution / 60ml lucozade /
3 dextrose tablets as age appropriate and have im glucagon if needed

Obtain an OPTIUM Blood Glucose monitor (from the diabetic nurse cupboard, keys on
CSSU, or from Pharmacy) and ensure the family have been trained in how to use it.

Prescribe any necessary medications, specialised feeds and the OPTIUM glucose strips
and thin lancets needed to operate the blood glucose monitor

Provide a written discharge summary for the GP including the information about
treatments and the blood glucose monitor supplies that will need to be provided on a
repeat prescription by the GP.

Arrange out-patient follow-up with the paediatric endocrine team.
Summary

Hypoglycaemia is a common finding in paediatrics and should be investigated and treated
promptly.

All unwell children should have a blood sugar level checked.

Children with a blood sugar reading <2.6mmol/l should be treated according to the above
flow chart with appropriate investigations and ideally an intravenous dextrose infusion.
Care needs to be taken to monitor serum electrolyte levels as well as the glucose
regularly

Children with a reduced level of consciousness should not be given oral treatment or
feeds.

All children should be observed until they have achieved a period of stable
normoglycaemia on their usual feed regime.
Becky Smith
Page 6
Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
Management Plan for Home Management of
Hypoglycaemia (Low blood sugar levels)
This management plan is for...............................................................
Low blood glucose
(hypoglycaemia) levels
Less than .......... mmol/l
Ideal blood glucose range
.......... mmol/l - .......... mmol/l
Usual symptoms are:
Treatment to be given if blood
sugar reading is low:
Recheck blood sugar level after
If blood sugar still low
If blood sugar level now normal
What to do when unwell
If your child still has a low blood sugar that has not responded to
treatment or if you have any queries please contact
…………………………………………………………………………………………
IF YOUR CHILD IS UNCONCIOUS, FITTING OR DOES NOT RESPOND TO
THE TREATMENT ABOVE CALL 999 AND ASK FOR AN AMBULANCE.
Becky Smith
Page 7
Nov 2007
Paediatric Clinical Guideline
9.1 Endocrine: Hypoglycaemia
References
1.
2.
3.
4.
5.
6.
7.
Morris AAM; Thekekara A; Wilks Z; Clayton PT; Leonard JV; Aynsley-Green A;
Evaluation of fasts for investigating hypoglycaemia or suspected metabolic disease.
Archives of Disease in Childhood. 1996;75(2):115-119
Wong CP; Forsyth RJ; Kelly TP; Eyre JA: Incidence, aetiology and outcome of nontraumatic coma: a population based study. Archives of Disease of Childhood.
2001;84(3):193-199
Bonham JR. Investigation of hypoglycaemia in childhood. Ann Clin Biochem
1993;30:238-247
Aynsley-Green A. Glucose, the brain and the paediatric endocrinologist. Hormone
Res 1996;46:8-25
Glycaemic emergencies. BNF June 2004
Hypoglycaemia of the newborn. Review of the literature. WHO 2006
National metabolic biochemistry network. Guidelines for the investigation of
hypoglycaemia in infants and children. November 2004.
Becky Smith
Page 8
Nov 2007