Hypoglycaemia Flashcards
Define hypoglycaemia in children
Blood glucose <2.6mmol/L in children who do not have Diabetes Mellitus
<4 with DM
What is the aetiology of hypoglycaemia
Insulin excess:
- Exogenous
- Hypoglycaemic hyperinsulinism of infancy (PHHI)
- Sulphonylurea use
- Autoimmune (insulin receptor Abs)
- Beckwith-Wiedemann syndrome
- skipping meals
Non-insulin driven
- Liver disease
- Ketotic hypoglycaemic of childhood
- Inborn errors of metabolism e.g. galactosaemia
- Endocrine e.g. Addison’s, CAH
- Sepsis
- Drugs e.g. alcohol, steroids, beta-blockers, ACEi
What are the risk factors for neonatal hypoglycaemia
Within the first 48hrs of life
Maternal DM or GDM (hyperplasia of pancreatic islet cells from exposure to elevated maternal gucose)
IUGR (poor glycogen stores)
Pre-term (poor glycogen stoor)
Large of dates
Hypothermic, polycythaemia, ill
Maternal beta-blocker use in the third trimester/time of delivery
What are the symptoms and signs of hypoglycaemia
Mild: sweating, palpitations, tremor, pallor, hunger, tingling lips, anxiety, irritability
Moderate: behavioural change, headache, drowsy, difficulty concentrating, Impaired vision, confusion, agitation
Severe: severe cognitive impairment, convulsions, LOC, coma
What are the signs of neonatal hypoglycaemia
Within 48hrs:
Jitteriness
Irritability
Apnoea
Lethargy, drowsiness
Seizures
Abnormal feeding behaviour (not waking for feeds, not sucking effectively, unsettled, demanding frequent feeds), especially after a period of feeding well
What are the signs of nocturnal hypoglycaemia
Fatigue
Headache
“hangover” feeling
What investigations should be done for hypoglycaemia
Bedside:
- BM: <4/3.5
- First urine: ?organic acids, toxicology
- Heel prick
Bloods:
- Blood glucose
- Insulin
- C-peptide
- GH
- Cortisol
- Ketones
- Blood gas
- Ammonia
- Amino acids
What is the management for hypoglycaemia in children
- A-E
- Able to swallow → 0.3/kg oral fast-acting carbohydrate/glucose (glucose/dextrose tablets, glucogel (40%))
- Re-assess after 10-15 minutes
- No improvement → repeat carb/glucose
- Reduced consciousness → IM glucagon ± IV glucose (<8yo = <500micrograms)
- No improvement → emergency hospital transfer → IV glucose (dextrose) 10%
Recurrent, severe → islet or pancreas transplant
Note: clinical symptoms and signs may lag behind improvement in blood glucose
What advice should be given regarding hypoglycaemia
Ensure all meals contain carbohydrate e.g. bread, potatoes, pasta
If there is no meal due and there are symptoms of hypoglycaemia, have a carbohydrate-containing snack e.g. sandwich, two plain biscuits, banana
How to recognise hypoglycaemic episodes:
Importance of self-monitoring of blood glucose levels
What is the management for nocturnal hypoglycaemia
Review the knowledge of blood glucose monitoring and diabetes self-management skills
Review their current insulin regimen, evening eating habits, and any changes to exercise/physical activity
Advise monitoring of blood glucose levels overnight (2-3am is when it is most likely)
What is the management for neonatal hypoglycaemia
2–2.6mmol/L: recheck level until satisfactory (at least 3 prefeed levels >2mmol/L)
<2mmol/L: give dextrose gel to the mouth and check level (after 30 mins)
<1.0 mmol/L or <2.0 mmol/L and clinical signs or has not responded adequately to two doses of glucose gel: IV dextrose (10%)
How is neonatal hypoglycaemia prevented
Early and frequent milk feeding
Feed asap after birth and as often as possible
Don’t allow >3 hours between feeds
Continue until effective feeding → glucose measurements >2 on 2x occasions
Skin-to-skin, keep baby warm
Don’t wait for baby to cry: early hunger signs include rapid eye movements, mouth and tongue movements, sucking on a fist
Feed as long as , or as much as baby wants
What are the complications and prognosis for hypoglycaemia
Developmental delay
Hypertonic IV glucose treatment → cerebral oedema
If untreated/severe, hypoglycaemia poses a high risk to infants who have high energy requirements and relatively poor reserves of glucose from glycogen, but require it for brain growth.
