How is pediatric hypoglycemia diagnosed and treated?

Updated: Feb 19, 2018
  • Author: Robert P Hoffman, MD; Chief Editor: Sasigarn A Bowden, MD  more...
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Answer

The ability to properly sort through the differential diagnoses of hypoglycemia depends on obtaining the critical sample at the time of hypoglycemia. This sample is used to measure the various metabolic precursors and hormones involved in glucose counterregulation, including glucose, insulin, growth hormone, cortisol, lactate, pyruvate, beta-hydroxybutyrate, free fatty acid, carnitine, branched-chain amino acid, and insulinlike growth factor-binding protein-1 (IGFBP-1) levels. (A urine sample for organic acid analysis is also critical.)

In hyperinsulinism, positron emission tomography (PET) scanning with [18F] dihydroxyphenylalanine (DOPA) has been shown to effectively distinguish focal from diffuse disease.

In hypopituitarism, head magnetic resonance imaging (MRI) should be performed to identify pituitary or hypothalamic neoplasms or congenital abnormalities.

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.

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. 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.

Surgery for hyperinsulinism is usually performed when medical therapy fails or when the patient is an older child with a possible insulin-producing tumor.

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.


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