Paediatric Acute care Guidelines PMH Emergency Department

Hypoglycaemia is a low Blood Glucose Level (BGL) and can be defined as:

  • < 2.6 mmol/L in neonates
  • < 2.5mmol /L in children

Background

General

Causes of Hypoglycaemia

Increased glucose utilisation:
  • Hyperinsulinism
  • Hypoglycaemic drug administration
  • Sepsis
  • Multiple trauma
Abnormalities in hormone secretion:
  • Growth hormone deficiency
  • Adrenal insufficiency
Abnormalities in fuel substrate metabolism (defects in metabolism or utilisation):
  • Metabolic disorders – inborn errors of carbohydrate, amino acid or fatty acid metabolism (e.g. MCAD)
  • Acquired defects – liver disease, alcohol and salicylate ingestion
Abnormalities of substrate availability:
  • Starvation
  • Ketotic hypoglycaemia

 

Assessment

  • Use of bedside glucometers are inaccurate in determining blood glucose levels below 4mmol/L
  • Laboratory (including satellite laboratory blood gas machine) estimation of glucose values are essential

History

 

Symptoms of Hypoglycaemia

Autonomic  Neurological
Pallor
Sweating
Tremor
Hunger
Weakness
Nausea
Anxiety
Abdominal pain
Confusion
Irritability
Drowsiness
Coma
Convulsions
Headache
Behaviour disturbance
Visual disturbance

 

Investigations

The following should be performed at the time when the child is hypoglycaemic and are the most useful investigations for unexplained hypoglycaemia

Bedside Glucometer
Bedside Glucometers are inaccurate in determining blood glucose levels below 4mmol/L. Laboratory (including satellite laboratory blood gas machine) estimation of glucose values are essential.
Critical Sample
This is the most useful investigation of unexplained hypoglycaemia in childhood and should be performed at the time when the child is hypoglycaemic.
The following samples should be taken:
Test Tube   Minimum Volume
Insulin, Growth Hormone, Cortisol Clotted (analysed immediately)  Red Top – black ring (6mL) 1 ml
Plasma glucose, ammonia, β-hydroxybutyrate, amino acids, acylcarnitines Lithium heparin (on ice) Green Top (4mL) 1.5 ml
Blood Gas Heparinised blood gas syringe    
Urine metabolic screen (taken as close to the event as possible) Standard urine collection container   5 ml


Results during Hypoglycaemia:

  • Insulin levels should be undetectable (Increased levels = hyperinsulinism)
  • Growth hormone and cortisol should be increased (No rise = deficiency)
  • Ketones should be present in urine (Lack of ketones = hyperinsulinism or MCAD)

 

Management

Resuscitation

For Severe Hypoglycaemia
  • 10% Dextrose 2mL/kg (200mg/kg) given IV over 5-10 minutes
  • Continue IV 10% Dextrose infusion at maintenance rates until BGL is normalised (> 5mmol/L for 2 hours)
  • Repeat BGL at 30 minutes, then at hourly intervals
  • Be aware of recurrent hypoglycaemia, especially as a result of oral hypoglycaemic drug ingestion
Note:
  • In some circumstances (e.g. hyperinsulinism) infusion concentrations greater than 10% Dextrose may be needed to maintain BGL’s
  • Central venous lines are preferred for infusions of high Dextrose concentrations as extravasation is extremely irritant

 

Nursing

Routine nursing care.

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