eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Hypoglycemia: Differential Diagnoses & Workup

Author: Hilarie Cranmer, MD, MPH, FACEP, Director, Global Women's Health Fellowship, Associate Director, Harvard International Emergency Medicine Fellowship, Department of Emergency Medicine, Brigham and Women's Hospital; Director, Humanitarian Studies Program, Harvard Humanitarian Initiative; Assistant Professor, Harvard University School of Medicine
Coauthor(s): Michael Shannon, MD, MPH,†, Professor, Department of Pediatrics, Harvard Medical School; Chief and CHB Chair, Division of Emergency Medicine, Children's Hospital
Contributor Information and Disclosures

Updated: Aug 10, 2009

Differential Diagnoses

Adrenal Insufficiency and Adrenal Crisis
Plant Poisoning, Hypoglycemics
Hypopituitarism
Shock, Septic
Hypothyroidism and Myxedema Coma
Toxicity, Alcohols
Munchausen Syndrome
Toxicity, Salicylate
Pediatrics, Reye Syndrome

Other Problems to Be Considered

Fasting
Malnutrition
Diarrhea
Enzymatic defects of glycogen synthetic pathways
Enzymatic defects of glycogenolytic pathways
Enzymatic defects of gluconeogenic pathways
Glucagon deficiency
Congenital hyperinsulinism (eg, nesidioblastosis, leucine sensitive hypoglycemia)
Defects of beta cell regulation
Large tumors
Decreased or absent fat stores
Enzymatic defects in fatty acid oxidation

Workup

Laboratory Studies

Fingerstick glucose levels or bedside testing may lead to overtreatment of hypoglycemia because the primary error with the chemically treated strips is an underestimation of the serum glucose value.

Interpretation of the critical sample.

Interpretation of the critical sample.

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Interpretation of the critical sample.

Interpretation of the critical sample.


  • Serum or plasma glucose levels
    • Serum glucose level is higher than whole blood glucose level. Whole blood measurements of glucose may underestimate the plasma glucose concentration by approximately 10-15% because RBCs contain relatively low concentrations of glucose. Arterial and capillary samples may overestimate the plasma glucose concentration by 10% in nonfasting patients.
    • Hold an extra tube of serum or plasma and refrigerate until laboratory glucose is known.
  • Serum insulin: When blood glucose is less than 40 mg/dL, plasma insulin concentration should be less than 5 and no higher than 10 microunits/mL.
  • Urine
    • Obtain first voided urine dipstick for ketones.
    • Failure to find large ketones with hypoglycemia suggests that fat is not being metabolized from adipose tissue (hyperinsulinism) or that fat cannot be used for ketone body formation (enzymatic defects in fatty acid oxidation).
    • Send urine for organic acid analysis.
  • Newborn screening: Electrospray ionization-tandem mass spectrometry in asymptomatic persons allows earlier identification of clearly defined inborn errors of metabolism. These include aminoacidemias, urea cycle disorders, organic acidurias, and fatty acid oxidation disorders. Earlier recognition of these inborn errors of metabolism has the potential to reduce morbidity and mortality rates in these infants.

Imaging Studies

  • The detection of adenomas by celiac angiography has limited success.
  • The chance of detecting a tumor blush must be balanced by the potential risk of causing vascular trauma in infants younger than 2 years.

More on Pediatrics, Hypoglycemia

Overview: Pediatrics, Hypoglycemia
Differential Diagnoses & Workup: Pediatrics, Hypoglycemia
Treatment & Medication: Pediatrics, Hypoglycemia
Follow-up: Pediatrics, Hypoglycemia
Multimedia: Pediatrics, Hypoglycemia
References
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References

  1. Ishiguro A, Namai Y, Ito YM. Managing "healthy" late preterm infants. Pediatr Int. Mar 27 2009;[Medline].

  2. [Guideline] Newborn Nursery QI Committee. Portland (ME): The Barbara Bush Children's Hospital at Maine Medical Center; 2004 Jul. Neonatal hypoglycemia: initial and follow up management. National Guideline Clearinghouse. 2004;[Full Text].

  3. Narchi H, Skinner A, Williams B. Small for gestational age neonates - are we missing some by only using standard population growth standards and does it matter?. J Matern Fetal Neonatal Med. Jun 29 2009;1-7. [Medline].

  4. Boluyt N, van Kempen A, Offringa M. Neurodevelopment after neonatal hypoglycemia: a systematic review and design of an optimal future study. Pediatrics. Jun 2006;117(6):2231-2243. [Medline].

  5. Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics. May 2000;105(5):1141-5. [Medline].

  6. Fleisher G, ed. Pediatric hypoglycemia. In: Textbook of Pediatric Emergency Medicine. Lippincott Williams & Wilkins; 2000.

  7. Halamek LP, Benaron DA, Stevenson DK. Neonatal hypoglycemia, Part I: Background and definition. Clin Pediatr (Phila). Dec 1997;36(12):675-80. [Medline].

  8. Losek JD. Hypoglycemia and the ABC'S (sugar) of pediatric resuscitation. Ann Emerg Med. Jan 2000;35(1):43-6. [Medline].

  9. Lteif AN, Schwenk WF. Hypoglycemia in infants and children. Endocrinol Metab Clin North Am. Sep 1999;28(3):619-46, vii. [Medline].

  10. Muller D, Zimmering M, Roehr CC. Should nifedipine be used to counter low blood sugar levels in children with persistent hyperinsulinaemic hypoglycaemia?. Arch Dis Child. Jan 2004;89(1):83-5. [Medline].

  11. Raghuveer TS, Garg U, Graf WD. Inborn errors of metabolism in infancy and early childhood: an update. Am Fam Physician. Jun 1 2006;73(11):1981-90. [Medline].

  12. Reid SR, Losek JD, Gideon Bosker, ed. Hypoglycemia in infants and children. In: The Textbook of Primary and Acute Care Medicine. 2003.

  13. Sperling MA, Behrman RE, Kliegman RM, et al, eds. Hypoglycemia. In: Nelson Textbook of Pediatrics. 15th ed. 1996.

  14. Stanley CA. Hyperinsulinism in infants and children. Pediatr Clin North Am. Apr 1997;44(2):363-74. [Medline].

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Further Reading

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Keywords

hypoglycemia, low blood sugar in children, low blood sugar in newborns, hypoglycemia in infancy, persistent hyperinsulinemic hypoglycemia of infancy, PHHI, brain damage, hyperinsulinism, sepsis, large for gestational age, LGA, small for gestational age, SGA, intrauterine growth restriction, infant of diabetic mother, gestational diabetes, chorioamnionitis, hypoxia, perinatal distress, isolated hepatomegaly, glycogen storage disease, microcephaly, anterior midline defects, gigantism, macroglossia, hemihypertrophy, Beckwith-Wiedemann Syndrome, inborn error of metabolism, galactosemia, lactic acidosis, personality disorder, polycythemia, treatment, diagnosis

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Contributor Information and Disclosures

Author

Hilarie Cranmer, MD, MPH, FACEP, Director, Global Women's Health Fellowship, Associate Director, Harvard International Emergency Medicine Fellowship, Department of Emergency Medicine, Brigham and Women's Hospital; Director, Humanitarian Studies Program, Harvard Humanitarian Initiative; Assistant Professor, Harvard University School of Medicine
Hilarie Cranmer, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Massachusetts Medical Society, Physicians for Human Rights, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Shannon, MD, MPH,†, Professor, Department of Pediatrics, Harvard Medical School; Chief and CHB Chair, Division of Emergency Medicine, Children's Hospital
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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