| Clinical features |
| Any patient with acute lethargy or coma should have an immediate measurement of blood glucose to determine if hypoglycemia is a possible cause. |
| Other findings of hypoglycemia are nonspecific* and vary by age: |
| Infants | Older children and adolescents |
- Irritability
- Lethargy
- Jitteriness
- Feeding problems
- Hypothermia
- Hypotonia
- Tachypnea
- Cyanosis
- Apnea
- Seizures
| - Neurogenic (autonomic) response:
- Sweating
- Tachycardia
- Palpitations
- Tremor
- Nervousness
- Hunger
- Paresthesias
- Pallor
| - Neuroglycopenic response:
- Irritability
- Confusion
- Uncharacteristic behavior
- Weakness
- Lethargy
- Loss of consciousness
- Seizures
- Coma
- Occasionally, transient focal neurologic deficits
|
| Diagnosis |
- Obtain rapid bedside point-of-care glucose concentration (and beta-hydroxybutyrate, if available as a point-of-care measurement).
- Confirm the presence of hypoglycemia with a plasma glucose measurement (drawn close in time to the point-of-care sample).
- Treat, as outlined below, if the bedside value is low (<70 mg/dL [3.89 mmol/L]) in symptomatic patients.
- For all infants and young children who are not being treated for diabetes mellitus or do not have a known cause for hypoglycemia, obtain a blood sample for additional diagnostic studies prior to glucose administration, if possible, and collect the first voided urine after the hypoglycemic event¶.
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| Treatment |
- Do not delay treatment if symptomatic hypoglycemia is suspected. However, every reasonable effort should be made to obtain a rapid plasma glucose measurement (fingerstick or point-of-care device) prior to administering glucose.
- Give glucose based on the patient's level of consciousness and ability to swallow safely (ie, alert enough to do so and with intact gag reflex), as follows:
- Conscious and able to drink and swallow safely:
- Administer 0.3 g/kg (10 to 20 g) of a rapidly absorbed carbohydrate. May repeat in 10 to 15 minutes.
- Options include any 1 of the following:
- Glucose tablets (5 g per tablet)
- Glucose gel (15 g per tube)
- Sweetened fruit juice – 12 g carbohydrate per 4 oz (120 mL)
- Regular soda (not diet) – 18 g carbohydrate per 6 oz (180 mL)
- Honey – 17 g carbohydrate per 1 tablespoon (15 mL)
- Table sugar (granulated sugar) – 12.5 g sugar per 1 tablespoon
- Altered mental status, unable to swallow, or does not respond to oral glucose administration within 15 minutes:
- Give an initial IV bolus of glucose of 0.25 to 0.5 g/kg of dextrose (maximum single dose 25 g)Δ. The volume and concentration of glucose bolus is infused slowly at 2 to 3 mL per minute and based on age:
- Infants and children up to 12 years – 2.5 to 5 mL/kg of D10W or 1 to 2 mL/kg of D25W. D10W is typically used in infants and children <5 years of age. (10% dextrose is 100 mg/mL; 25% dextrose is 250 mg/mL.)
- Adolescents ≥12 years – 1 to 2 mL/kg of D25W.
- Unable to receive oral glucose and unable to obtain IV access:
- Give glucagon 0.5 mg (for <25 kg body weight) or 1 mg (for ≥25 kg body weight) IM or SQ (maximum dose 1 mg)◊:
- Perform blood glucose monitoring every 10 to 15 minutes as the effects of glucagon may be transient.
- Establish vascular access as soon as possible; if unable to achieve access and hypoglycemia persists or is recurrent, ensure the airway is protected and, if not, secure it with rapid sequence intubation. Then, place a nasogastric tube and administer 0.2 to 0.25 g/kg dextrose using volume and concentration guidance for IV administration above.
- After initial hypoglycemia is reversed, provide additional glucose and treatment based on suspected etiology:
- For patients with type 1 diabetes mellitus – Give a normal diet; initiate IV dextrose-containing fluids if intake is inadequate.
- For patients with an underlying hypoglycemic disorder or with an unknown cause of hypoglycemia – Administer an IV infusion of dextrose 10%:
- For infants, start with initial GIR of 5 to 6 mg/kg/minute.
- For older children, start with GIR of 2 to 3 mg/kg/minute.
- Calculation to convert target GIR to infusion rate:
- Rate of dextrose infusion (mL/hr) = GIR (mg/kg/minute) × 6 × weight (kg) ÷ dextrose percentage of fluid (eg, 5 for D5W or 10 for D10W)
- Titrate infusion to maintain plasma glucose in a safe and appropriate range (70 to 120 mg/dL [3.89 to 8.33 mmol/L]).
- Patients who have ingested a long-acting hypoglycemia agent such as a sulfonylurea may require prolonged treatment until the effect wears off. Selected patients may also warrant treatment with octreotide. (Refer to UpToDate topic on sulfonylurea poisoning.)
- Measure a rapid plasma glucose 15 to 30 minutes after the initial IV glucose bolus, and then monitor every 30 to 60 minutes until stable (minimum of hours) to ensure that plasma glucose concentration is maintained in the normal range (>70 to 100 mg/dL [>3.89 to 5.55 mmol/L]).
- Obtain pediatric endocrinology consultation for patients with persistent hypoglycemia and for hypoglycemia of unknown cause.
- Obtain medical toxicology consultation for patients with ingestion of oral hypoglycemic agents by calling a regional poison control center§.
- Admit the following patients:
- Cannot maintain normoglycemia with oral intake
- Hypoglycemia of unknown cause
- Ingestion of long-acting hypoglycemic agents
- Recurrent hypoglycemia during the period of observation
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