pediatric hypoglycemia

Diagnosis and Management of Pediatric Hypoglycemia J. Paul Frindik, MD CDE Hypoglycemia • Two or more sequential blood glucose values less than 40-45 mg/dl • “Hypoglycemia” refers to symptoms or “low blood sugar” and is not a diagnosis. Hypoglycemia – Learning Objectives • Symptoms and Definitions • Causes of Hypoglycemia – Neonatal • Transient vs. Persistent • Treatment Options – Childhood • Management Management Questions in Acute Hypoglycemia • [2 am phone call]: “Doctor, I just checked a blood sugar on your patient, and it’s 45. What do you want me to do?” Management Questions in Acute Hypoglycemia • “Is the patient having a hypoglycemic episode?” • “What are the symptoms of hypoglycemia?” Symptoms of Hypoglycemia • Neonatal • Cyanosis, apnea • Respiratory distress • Poor feeding • Hypothermia • Seizures • Children • Inattention, “spells” • Lethargy • Hunger • Behavioral problems • Seizures Symptoms of Hypoglycemia • Non-specific and non-diagnostic • Correlation between an individual blood sugar value and – Acute clinical symptoms: YES – Long term clinical outcome: NO Pediatrics 105(5):1141-1145; 2000 Definitions of Hypoglycemia Whipple’s Triad Diagnosis of acute hypoglycemia requires 1. Clinical symptoms of hypoglycemia plus 2. Simultaneous low plasma glucose plus 3. Clinical signs must resolve when normoglycemia is established Ann Surg 101:1299-1310; 1935 Management Questions in Acute Hypoglycemia • “Is the patient having a hypoglycemic episode?” • “What are the symptoms of hypoglycemia?” • “Do I need to treat ? How? When ?” Definitions of Hypoglycemia Suggested Treatment Thresholds • Controversies Regarding Definition of Neonatal Hypoglycemia: Suggested Operational Thresholds M. Cornblath et. al., Pediatrics 105(5): 1141- 1145; 2000. • “Blood glucose levels at which clinical interventions should be considered” [...]... Neonatal Hypoglycemia Treatment 1 2 3 4 Anticipate hypoglycemia in infants at risk Early feeding, if possible Supplemental IV glucose as needed Medication (e.g steroids) rarely needed Neonatal Hypoglycemia Persistent • 5% of infants with hypoglycemia • Persistent (recurrent) hypoglycemia – Does not resolve within 5-7 days • Hormone deficiencies and excess • Metabolic diseases Persistent Neonatal Hypoglycemia. .. hypoglycemic episode?” “What are the symptoms of hypoglycemia? ” “Do I need to treat ? How? When ?” “Does this patient have an underlying medical condition causing low blood sugars?” Hypoglycemia – Learning Objectives • Symptoms and Definitions • Causes of Hypoglycemia – Neonatal • Transient vs Persistent • Treatment Options – Childhood Classification of Neonatal Hypoglycemia N e o n a ta l H y p o g ly c... divided t.i.d or continuous infusion via insulin pump 1 Glucagon 1 mg / 24 hrs continuous infusion 1 Pancreatectomy Hypoglycemia – Learning Objectives • Symptoms and Definitions • Causes of Hypoglycemia – Neonatal • Transient vs Persistent • Treatment Options – Childhood Hypoglycemia Childhood Hypoglycemia: Etiologies • Hormone Deficiencies – GH Deficiency – Cortisol Insufficiency • Primary adrenal • Secondary... hypoglycemics Childhood Hypoglycemia Diagnostic Clues Age less than 12 – 18 months: • Congenital pituitary / adrenal defects • Hyperinsulinemia • Metabolic diseases Childhood Hypoglycemia Diagnostic Clues Age over 12 – 18 months: • • • • Acquired pituitary / adrenal defects Islet cell adenoma (rare) Metabolic diseases (usually present earlier) “ketotic hypoglycemia Childhood Hypoglycemia Diagnostic...Definitions of Hypoglycemia Suggested Treatment Thresholds • Any symptomatic infant with plasma glucose less than 45 mg/dl • Asymptomatic at risk infants with – Plasma glucose < 36 mg/dl (feed if possible) – Plasma glucose < 20-25 mg/dl (IV glucose) • Therapeutic objective is plasma glucose over 45-60 mg/dl Pediatrics 105(5):1141-1145; 2000 Management Questions in Hypoglycemia • • • • “Is... fissures • Metabolic diseases (inborn errors of metabolism) Persistent Neonatal Hypoglycemia Suspect Hyperinsulinemia if: 1 Persistent IV glucose requirement of 1012 mg/kg/min plus 2 Absence of serum / urine ketones plus 3 Insulin level over 5-10 mcgU/ml with a simultaneous plasma glucose of less than 40 mg/dl Persistent Neonatal Hypoglycemia Treatment of Hyperinsulinemia 1 Diazoxide 10 – 25 mg / kg / day... y p o g ly c e m ia T r a n s ie n t H y p o g ly c e m ia P e r s is te n t H y p o g ly c e m ia Neonatal Hypoglycemia Transient • • • • Postnatal instability, inadequate fuel 2 – 3 per 1000 live births Occurs within first 12 hours after birth Resolves within 3 – 5 days Transient Neonatal Hypoglycemia High Risk Groups • Premature, SGA, smaller of twins • Respiratory distress, sepsis, other stress... Facial anomalies • Cleft palate • Central incisor • Nystagmus Persistent Neonatal Hypoglycemia Treatment of Hormone Deficiencies Diagnosis primary problem • Cortisol / ACTH deficiency Hydrocortisone: ~ 15 mg / M2 / day • Divided t.i.d or q.i.d P.O or I.V • GH deficiency Growth hormone 0.5 mg / day SQ Persistent Neonatal Hypoglycemia Etiologies 2 • Hormone excess (hyperinsulinemia) – B cell hyperplasia . Diagnosis and Management of Pediatric Hypoglycemia J. Paul Frindik, MD CDE Hypoglycemia • Two or more sequential blood glucose values less than 40-45 mg/dl • Hypoglycemia refers to symptoms. NO Pediatrics 105(5):1141-1145; 2000 Definitions of Hypoglycemia Whipple’s Triad Diagnosis of acute hypoglycemia requires 1. Clinical symptoms of hypoglycemia plus 2. Simultaneous low plasma glucose. Questions in Acute Hypoglycemia • “Is the patient having a hypoglycemic episode?” • “What are the symptoms of hypoglycemia? ” • “Do I need to treat ? How? When ?” Definitions of Hypoglycemia Suggested