Approach Considerations
Short-term treatment of hypoglycemia consists of an intravenous (IV) bolus of dextrose 10% 2.5 mL/kg. The critical sample should be drawn before the glucose is administered. After the bolus is administered, an IV infusion that matches normal hepatic glucose production (approximately 5-8 mg/kg/min in an infant and about 3-5 mg/kg/min in an older child) should be continued. This should be adjusted to maintain the plasma glucose level at more than 3 mmol/L. Children with hyperinsulinemia may have much higher needs. Glucagon infusion at rates of 0.005-0.02 mg/kg/h should be used as a temporary treatment in children with hyperinsulinism in whom adequate amounts of dextrose cannot be given. It can cause a rash and decreased appetite if used over the long term.
Long-term care of children with hypoglycemia varies based on the etiology.
In infants with one of several disorders (eg, ketotic hypoglycemia, glycogen-storage disorder, free fatty acid metabolism defect, mild hyperinsulinism), hypoglycemia can be prevented with frequent feedings involving a specifically designed diet and a rapid response with parenteral dextrose when feeding is inadequate because of GI problems or other illnesses. Fructose must be avoided in children with fructose diphosphatase deficiency.
A hierarchical approach is used to treat hyperinsulinism. The first step is usually frequent feeding. The next step is typically the administration of diazoxide. Octreotide is usually the second-line medical therapy. The calcium channel blocker nifedipine is also useful. Surgery is recommended if these treatments fail or if an insulin-producing tumor is suspected. Surgery is a first-line option in infants with persistent hyperinsulinemic hypoglycemia of infancy with documented focal lesions that can be removed without complete pancreatectomy. (See Pancreatic Surgery.)
Growth hormone and cortisol replacement are specific treatments for children with hypoglycemia and hypopituitarism or adrenal insufficiency.
Infants who are born prematurely and those who are small for their gestational age should be given IV or oral feedings shortly after birth to prevent hypoglycemia.
A study by LeBlanc et al reported that after implementation of a quality-improvement initiative for neonates with at least one risk factor for hypoglycemia, which included the promotion of early skin-to-skin care, early breastfeeding, and, at 90 minutes, measurement of blood glucose in asymptomatic infants, the transfer rate for at-risk infants to the neonatal intensive care unit fell from 17% to 3%. Infants in the study were born at or after 35 weeks’ gestation. [19]
Consultations
Evaluation and treatment of a child with hypoglycemia requires a team approach. Typical consultations include a pediatric endocrinologist for initial evaluation and treatment, depending on the results of the evaluation. Consultation with a geneticist familiar with various metabolic disorders is helpful. A nutritionist is necessary to provide input and instruction regarding treatment for various metabolic disorders and to ensure proper caloric intake in children with inadequate stores.
Hypoglycemia in Patients With Diabetes
For hypoglycemia in patients with diabetes, treatment depends on the patient's mental status. If the patient is awake and alert, 15 g of simple carbohydrate (4 oz of most fruit juices, 3 tsp of sugar, glucose tablets) by mouth should be sufficient. Wait at least 15 minutes after the initial treatment before retesting, because overtreatment of low blood sugar levels in patients with diabetes is a common cause of hyperglycemia. If more than an hour will pass before the next regularly scheduled meal, an additional 15 g of complex carbohydrate with additional protein (bread, crackers, peanut butter) may be warranted.
If the patient's mental status is altered and aspiration is a concern, treatment depends on the patient's setting. At home, intramuscularly administered glucagon is the best choice and should be available to families or close associates of all insulin-treated patients with diabetes. In the hospital setting, IV dextrose 25% is appropriate treatment. Dextrose is not associated with the nausea and vomiting that may follow glucagon administration. Glucagon should be used if venous access is a problem. After the low-sugar–level reaction is treated, the patient's insulin, diet, and activity patterns should be examined to determine the cause. Adjustments should be made to prevent hypoglycemia from recurring.
Pancreatic Surgery
Surgery for hyperinsulinism is usually performed when medical therapy fails or when the patient is an older child with a possible insulin-producing tumor. If focal disease has been identified in an area of the pancreas that is amenable to removal without damage to the rest of the organ, surgery can be performed.
In diffuse disease, the usual initial operation in infants with persistent hyperinsulinemic hypoglycemia of infancy is to remove 95% of the pancreas. If this is unsuccessful, drug therapy may be added or a complete pancreatectomy may be performed. In the child with an insulin-producing tumor, only the tumor is removed. The surgeon locates the tumors intraoperatively using palpation or intraoperative ultrasonography.
Diet
As mentioned above, the dietary treatment for acute hypoglycemia is the rapid administration of at least 15 g of simple carbohydrates (4 oz of juice or most other beverages with sugar).
Dietary prevention of hypoglycemia depends on the underlying condition. In patients with a metabolic disease, avoidance of specific substances is usually necessary and is dependent on the specific condition. In patients with ketotic hypoglycemia, glycogen-storage disease, or another disorder that is not amenable to specific dietary, medical, or surgical interventions, the key is to avoid prolonged fasting and to provide a ready supply of long-acting complex carbohydrates on a regular basis.
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Normal hypoglycemic counterregulation.
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Interpretation of the critical sample.
