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Hypoglycemia :chocolate_bar: (:green_heart: Treatment (1.:fleur_de_lis…
Hypoglycemia :chocolate_bar:
:icecream:
Def
Plasma glucose
≤ 50 mg/dL
Note that: Whole blood glucose จะต่ำกว่า Plasma glucose 10-15%
:!: NB ≤ 72 hrs if
≤ 40 mg/dL
as NB age 48-72 hrs can cause Transient hypoglycemia
:lollipop:
Epidemiology
Common in children
May present with หมดสติ or ชัก
:man_with_gua_pi_mao::skin-tone-4:
must Ddx
with
Pathology in brain
or
Fluid or mineral imbalance
:candy:
Causes
:watermelon:
Transient hypoglycemia
Inadequate substrate that produce glucose
or
Impaired enzyme in glucose production
can be found in
Preterm infant
SGA
One of twin that weight lesser
Respiratory distress infant
Mom with Toxemia
Transient hyperinsulinism
found in
Erythryoblastosis fetalis of infant
Infant of DM Mother
:watermelon:
Other causes
Hyperinsulinism
Congenital: Persistent hyperinsulinemic hypoglycemia of infancy (
PHHI
)
Mutation of gene related to insulin secretion process
Severe
symptoms pt usu hv
symptoms since birth
&
LGA
Some has normal birth weight but got hypoglycemia in childhood
Symptomatic PHHI need
high dose of glucose iv
(
20-25 mg/kg/min
) to maintain normal blood glucose
During hypoglycemia:
negative ketone
in urine
:star2:
Beckwith-Wiedemann syndrome
Insulinoma
Insulin administration (Munchausen by proxy)
Sulfonylurea ingestion
Hormone deficiency
Pan
hypopituitarism
Def
iciency of
≥ 2
life-threatening hormones
Isolated growth hormone deficiency
ACTH/Cortisol deficiency
Cortisol def
Got hypoglycemia symptoms during
stress
(eg. Fever, prolonged fasting)
Cause: Congenital adrenal hyperplasia (m/c cause)
treated immediately with glucose + corticosteroid
Isolated ACTH def
(rare)
Mostly found with Def of other hormone (panhypopituitarism)
Cause: Corticosteroid administration, Suprasellar tumor, Post-op of suprasellar tumor surgery
Ketotic hypoglycemia
:star2: :star2:
โหงวเฮ้งมักเป็นใน
Usu found in 18 month - 5 yr old and resolve spontaneously when age 8-9 yr
Usu found in เด็กนน.น้อย, กล้ามเนื้อน้อย
Usu found in Sick pt
Causes: Unclear (tho pt found lesser substrate in same age)
Disorders of Carbohydrate metabolism
Glycogen storage disease (
GSD
)
Genetic ds caused by enzyme deficiency ➯ can’t produce glycogen or can’t glycogenolysis
when body needed
➯ Hypoglycemia
Many types
Symptoms:
mostly not found during birth ➯ Found ตอนอายุหลายเดือน
usu present with Failure to thrive or Hepatomegaly
Galactosemia
Hereditary fructose intolerance
Disorders of Gluconeogenesis (eg. Pyruvate carboxylase deficiency)
Defects in Fatty acid oxidation, Carnitine metabolism, and Ketone synthesis
(eg. Medium-chain acyl CoA dehydrogenase deficiency)
Defect
in Fatty a oxidation & Carnitine metabolism
Abnormal of Fatty a oxidation & Carnitine metabolism
➯ body can’t change free fatty a (FFA) into acetyl CoA
➯ Liver can’t produce ketone
Symptoms
usu. found before 1 yr old
usu. found during sick or poor feeding
: N/V, ซึมลง, สับสน, ชัก จนถึง หมดสติหรือตาย
:star2: consider in Sick child with hypoglycemia that can’t eat with trace/negative ketone in UA
Disorders of protein metabolism (eg. Methylmalonic acidemia, maple syrup urine disease)
Others:
Nonpancreatic tumor hypoglycemia
Late dumpling (Alimentary hypoglycemia)
Organ failure & critical illness
Alcohol-induced hypoglycemia
Salicylate intoxication
Propanolol ingestion
Malnutrition
Malaria
Diarrhea
:green_heart:
Treatment
:star2: need to
Treat Low glucose level & Causes of hypoglycemia
1.:fleur_de_lis:
Treating hypoglycemia acutely
First step:
Dextrose 0.2-0.5 g/kg
by
10% Dextrose 2-4 mL/kg :baby::skin-tone-2:
or
25% Dextrose 1-2 mL/kg :children_crossing:
IV bolus within 10 mins
Newborn :baby::skin-tone-2:
Glucose production rate
fr liver
(GPR)
= 5-8 mg/kg/min
Prefer
10% dextrose
Child/เด็กโต :children_crossing:
GPR = 3-5 mg/kg/min
Prefer
25% dextrose
Second step:
10% Dextrose infusion rate 6-8 mg/kg/min
(Note that: 10% dextrose 5 ml/kg/hr จะให้ glucose infusion rate (
GIR
) = 8 mg/kg/min
Third step: after giving Dextrose for
15 mins
➯ repeat blood glucose test
➯ If still hypoglycemia, give Dextrose again
&
:arrow_up: GIR ➯ Check blood glucose เป็นระยะ—ช่วงแรกควรตรวจ q 1 hr, keep Plasma glucose 70-120 mg/dL
If high GIR ➯ need to give
25% Dextrose
➯
must on Central venous catheter
:warning: beware of giving
Dextrose IV bolus
in Hyperinsulinism
cuz
it will stimulate insulin secretion :arrow_up: ➯ may result in
Reactive hypoglycemia
ต่างประเทศมี
Glucagon
drug To help :arrow_up: blood glucose in
hypoglycemia fr receiving excessive insulin
(eg. hypoglycemia in DM who injecting insulin)
Can gives
Glucagon
in ภาวะเร่งด่วนที่ไม่สามารถให้Dextrose IV ได้ทันที
Dose: 0.03 mg/kg (max dose < 1 mg) IM
SEs: N/V
:fleur_de_lis:
Additional treatment
for specific cause/
Treating
continuously/in long run
depends on cause of hypoglycemia
PPHI
Rx depends on
severity of ds
Severe symptoms
usu so
Near-pancreatectomy
Some NBs are response to decreasing-secretion-of-insulin-
drugs
— choice :strawberry:
Diazoxide
5-15 mg/kg/day bid or tid
SEs: คั่งของน้ำและเกลือ, ภาวะขนดก (hypertrichosis)
Octreotide
begins at 2-5 microg/kg/day ➯ :arrow_up:until reaching 20 microgram/kg/day ฉีดใต้ผิวหนัง divided q 6-8 hr
SEs
: ท้องเสีย, gallstone, abnormal growth development
Some uses Ca channel blocker to :arrow_up: blood sugar
ACTH/Cortisol def & GH deficiency
➯ that have
adrenal crisis
:strawberry:
Hydrocortisone
IV 50-100 mg/m2 ทันที
then,
Hydrocortisone
50-100 mg/m2/day divided into q 6 hrs
If blood glucose ค่อยๆลดdoseลง & pt รับประทานอาหารได้ ➯ change into
Hydrocortisone
(Cortef) per oral 10-15 mg/m2/day bid or tid
or
Prednisolone
2.5-3 mg/m2/day divided into 1-2 times a day
note that
*Prednisolone
is Corticosteroid that have efficacy beyond x4 of Hydrocortisone
➯
Isolated ACTH def
(rare)
Most pt usu
panhypopituitarism
Should do further
Inx
to see whether there’s
deficiency
of
other hormones
GH
TSH
Gonardotropin
Vasopressin
Pan
hypothyroidism or Hypopituithyroidism definition = got ≥ 2 hormones def
GH def
: GH 0.1 - 0.3 mg/kg/week sc (subcutaneous) OD
Addison ds:
Hydrocortisone
or
Prednisolone replace as mentioned
and
Fludrocortisone acetate
0.05-0.2 mg/day too
ACTH/cortisol def
: If sick / fever / more injury ➯ must :arrow_up: hydrocortisone dose --
stress dose
(≥ 30mg/m2/day) divided q 8 hr to prevent adrenal crisis
:star2:
Ketotic hypoglycemia
Prevention: Avoid prolonged fasting
If sick and eat less ➯ eat simple carbohydrate or อาจให้แป้งข้าวโพดดิบ
(Raw corn flour) 1 g/kg with Milk before sleep
Advice parent about how to check ketone in urine
ไปหาหมอ when
can't eat & found ketone in urine
GSD
:<3: important is
Enough energy
by Frequent high carbs food to prevent hypoglycemia
Age
ทารก: may use nasogastric tube for feeding q 2 hr & glucose infusion rate 6 - 8 mg/kg/min at night
child > 1 yr: raw corn flour 1-2g/kg q 4 hr
or
some give q 6 hr at night
Defect in Fatty acid oxidation & Carnitine metabolism
give
Carnitine 100 mg/kg/day 3-4 times/day
and
avoid prolonged fasting
If sick or eat lesser than usual ➯ eat frequently q 4 hr
If vomiting and can't eat ➯ need to admit in hospital by
10% dextrose IV
using
glucose infusion rate 10 mg/kg/min
(high dose)
:explode:Recall that
Life-threatening hormones
(must have in each person) include
ACTH, Vasopressin, TSH
ACTH
def may led to ➯ Adrenal crisis
Vasopressin
def may led to ➯ Adrenal insufficiency ➯ E'lyte imbalance ➯ Death
TSH
def may led to ➯ Hypothyroid ➯ Death
:fleur_de_lis:
Advice
Cause of hypoglycemia
Hypoglycemia symptoms and initial treatment
Hypoglycemia pt should avoid prolonged fasting
If sick and can't eat ➯ หาหมอ + admit for glucose infusion via IV
:dango:
Evaluation
Rate of hypoglycemia
Quickly
Stimulate Epinephrine secretion :arrow_up: : ➯ sweating, มือสั่น, tachycardia, หงุดหงิด, อ่อนเพลีย, hunger, N/V
Slowly
or
For a long time
Until
Cerebral glucopenia happens
➯ headache, มึนงงสับสน, ซึม, บุคลิกเปลี่ยน, ไม่มีสมาธิ, ชัก, หรือหมดสติ
If these symptoms happen ➯
quickly Rx
Suspected symptoms of hypoglycemia ➯ check capillary blood glucose ทันที ➯ if low capillary blood glucose then check plasma glucose + send critical sample + Rx ทันที
Consults specialists
in case of suspected PPHI, hypopituitarism, adrenal insufficiency, inborn errors of metabolism, persistent hypoglycemia without cause
:fireworks:
Dx
:bookmark_tabs:
Hx
:baby::skin-tone-2:
Birth Hx
Birth weight, fetal health, GA, Maternal health during preg, Maternal drug use during preg
If Preterm or SGA or being ill at birth ➯ hypoglycemia could be transient
If maternal DM ➯ mayb hypoglycemia from hyperinsulinism
If pt got Hx of hypoglycemia at birth
with
Prolonged jaundice
must consider Congenital hypopituitarism
If LGA at birth consider Hyperinsulinism
:family:
FxHx
FxHx of hypoglycemia must consider
PHHI
Hx of cousin marriage
(แต่งงานในเครือญาติ) or
unknown cause of baby death
consider
Inborn error of metabolisms
:monkey:
U/D and drug uses
U/D like Congenital adrenal hyperplasia, Hypopituitarism
Hx of frequent use of corticosteroids then ขาดยา
Hx of frequent use of corticosteroids and got
stress but no increasing dose of
corticosteroids
Drugs use that cause hypoglycemia eg Insulin, Sulfonylurea, Salicylate
:eight_spoked_asterisk:
Hypoglycemic symptoms
ต้องซัก
Timings
:timer_clock::star2:
Hx of
When
hypoglycemia happens
after eating
Any sickness
that makes infant ทานอาหารได้น้อยลง
Type of food
eaten before Symptoms
Timings
If hypoglycemia within 4 hrs after meal ➯ Usu found in
GSD
or
Hyperinsulinism
If hypoglycemia happens after illness, กินได้น้อยลง for 10-12 hr may
caused from
Fatty acid oxidation disorder
Disorder of gluconeogenesis
Cortisol deficiency
Ketotic hypoglycemia
If hypoglycemia happens after drinking fruit juice for the first time ➯ considers Hereditary fructose intolerance
:bookmark:
PE
Weight Height HC
Signs of malnutrition
Short considers
GH def
Macro- or Microcephaly may got
pathology in brain
eg Holoprosencephaly, Hydrocephalus, and mayb Hypopituitarism
Macrosomia + ขนดก + ขนตามใบหู considers
PHHI
Congenital anomalies
Cleft lips/palate or Other midline defects (eg Single central incisor, Optic nerve hypoplasia) may got
Congenital hypopituitarism
LGA + macroglossia (ลิ้นใหญ่) + omphalocele + horizontal grooves on ears must considers
Beckwith-Wiedemann syndrome
Skin color
Hyperpigmentation consider
Addison ds
Liver size
Hepatomegaly considers
GSD
, disorder of
Gluconeogenesis
, defect of
fatty acid oxidation
Hepatomegaly + Jaundice + Failure to thrive + Slow deve consider
Galactosemia, Hereditary fructose intolerance
Abnormal heart
Murmur, gallop, or cardiomyopathy consider defect of
Fatty acid oxidation
and disorder of
Carnitine transport
External genitalia
If male newborn got microphallus and/or undescended testes consider
hypopituitarism
Ambiguous genitalia with Hyperpigmentation consider
Congenital adrenal hyperplasia
:male-scientist::skin-tone-6:
Labs
Critical sample
:zap:
Blood :small_red_triangle:
Elytes,Glucose
:snowflake:
Lactate, Ammonia
These two must be frozen then send to lab immediately
Insulin, Growth hormone, Cortisol
Ketone
Liver function test
Free fatty acids
Urine :small_red_triangle:
Ketones, reducing substances
:oden:Tho keep some extra blood and urine for sending investigation ~for suspected
Inborn errors of metabolism
case
Procedures
:oden:
Blood 3 ml into Heparinized tube ➯ Tilt tube to mix heparin and blood well together ➯ ปั่นแยก Plasma ➯ Freeze plasma in freezer ➯ Check
Plasma amino acids
Urine 15 cc into clean container ➯ get em in freezer ➯ Check
Urine organic acid
Drop of blood on filtered paper ➯ keep at room temperature ➯ check
acylcarnitine profile
:strawberry:
Common
problem in Dx hypoglycemia
Didn’t collect Critical sample
while pt having hypoglycemia
or
Collect Critical sample with
incorrect procedure
Pt need to do
fasting study
— con:
complicated & risky
as it will cause hypoglycemia in pt
Suspected hypoglycemia ➯ Check Capillary blood glucose ➯ if CBG < 50 mg/dL then confirm with Plasma glucose &
Critical sample
:zap:—important in sending to
find causes of hypogly