Hypoglycaemia in children ( <16 years ) - Investigation and Management of

Publication: 28/04/2008  --
Last review: 15/06/2020  
Next review: 05/06/2023  
Clinical Guideline
CURRENT 
ID: 1231 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Investigation and Management of Hypoglycaemia in children (<16 years)

Definition

A true (laboratory) blood glucose of <2.6mmol/L is defined as hypoglycaemia. This is 10-15% lower than capillary blood glucose i.e. bedside finger prick test. Therefore investigation and treatment of hypoglycaemia should be initiated at a value of <3.0mmol/L on the bedside test.

It is well recognised that hypoglycaemia whether asymptomatic or clinically evident (jittery, pale, sweaty, drowsy, fits) can result in permanent neurological damage. Therefore unexpected, persistent or severe hypoglycaemia should be investigated and treated urgently. For management of hypoglycaemia in the vulnerable newborn and diabetic children please refer to the following guidelines:

Guideline for management of hypoglycaemia on the neonatal unit

Management of hypoglycaemia in children and young people with diabetes 

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Clinical presentation and assessment

The following are typical symptoms and signs of hypoglycaemia in infants and children. The list is not exhaustive and a blood sugar should be checked in any child who is unwell.

Young infant

Child

Pallor
Sweating
Tachypnoea
Jitteriness
Apnoea

Hypotonia
Feeding difficulties
Irritability
Abnormal cry
Convulsions

Anxiety
Tremor
Palpitations
Weakness
Nausea and vomiting
Hunger

Abdominal pain
Headache
Confusion
Coma
Visual disturbance
Convulsions

The following are some of the important features to elicit from the history and examination.

History

Examination

Age at which symptoms started
Feeding history, previous fundoplication
Birth and post natal history and birth weight
Neonatal jaundice
Tolerance to fasting / illness
Drug ingestion
FH of diabetes mellitus / hypoglycaemia, Unexplained infant deaths and parental
consanguinity

Features of sepsis in a neonate
Hepatomegaly
Encephalopathy
Mid line defects
Growth pattern
Appearance of genitalia
Skin pigmentation

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Essential physiology

During hypoglycaemia, the metabolic pathways which help to maintain blood glucose are: glycogenolysis (glycogen breakdown), gluconeogenesis (generation of glucose from amino acids, glycerol and lactate), lipolysis (provides energy as well as substrate for gluconeogenesis) and ketogenesis (generation of ketones as alternative fuel for the brain). The counter-regulatory hormones (glucagon, growth hormone, cortisol and adrenaline) rise while insulin levels fall to undetectable levels during hypoglycaemia. Thus hypoglycaemia occurs if there is hyperinsulinism, a deficiency of one or more counter-regulatory hormones or a defect in any of the above metabolic pathways.

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Causes of persistent hypoglycaemia

Endocrine

Hyperinsulinism
Adrenal insufficiency
Hypopituitarism
Growth hormone deficiency
Hypothyroidism

Metabolic

Disorders of fatty acid oxidation and carnitine transport
Disorders of carbohydrate metabolism
Disorders of organic acid metabolism
Disorders of gluconeogenesis 

Other causes

Neonatal complications (e.g. birth asphyxia, secondary hyperinsulinism)
Drugs (e.g. insulin, alcohol, aspirin, chemotherapy)
Liver and multi-organ failure
Sepsis
Gastroenteritis
Tumours 

Idiopathic ketotic hypoglycaemia

This is the most common cause for hypoglycaemia in young children after the neonatal period.

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Management

Collect samples when the blood glucose is < 3.0 mmol/L. Insulin and C-peptide samples taken at higher blood glucose levels are rejected by the lab. Please inform the lab if a hypoglycaemia screen is being performed. Samples should be sent to the lab within 30 minutes of collection. If you are only able to get a small amount of blood ask the lab to freeze it and request tests after discussing with on-call consultant/endocrine team.
A hypoglycaemia kit (relevant bottles & Guthrie card) is kept in PUMA, L40 and A+E. Print the request form by logging in to ICE and selecting the following tabs: paediatric services; paediatric endocrine; hypoglycaemia.

Specimen type

Test

Amount

Bottle

Bedside testing: blood

Glucose
Ketones
Capillary gas

 

Capillary tube

Laboratory blood tests

Glucose, lactate

1 full paediatric tube

Fluoride oxalate (grey)

Free fatty acids,
3-hydroxybutyrate

1 full paediatric tube

Fluoride oxalate (grey)

Insulin, C-peptide

1 full paediatric tube

Serum gel (yellow)

Acylcarnitines

1 good spot filling the circle guide

Guthrie card (request acylcarnitine on ICE and send with request form. Check bloodspot card is in date)

Ammonia, amino acids

2 full paediatric tubes

Lithium heparin (green)

Cortisol
Urea and electrolytes, liver function tests,

1 full paediatric tube

Serum gel (yellow)

Bedside testing:
Urine

Ketones

 

Urine dipstick

Laboratory urine tests

Sugar chromatography,
amino acids and organic acids

5ml (>5ml is ideal, but send any sample available)

Universal container (white top)

*these blood tests must be taken at the time of hypoglycaemia

*these urine tests should be from the first sample during or immediately following hypoglycaemia

Other samples to consider include: blood alcohol and salicylates, blood growth hormone, blood cultures, urine toxicology screen.

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Treatment

Treat hypoglycaemia as per APLS and NLS guidelines

If the patient presents with gastroenteritis, manage as per Gastroenteritis CAT pathway.

IV access available

  • Hypoglycaemia screen should be undertaken before dextrose treatment if the child is clinically stable. Do not delay correction of hypoglycaemia whilst awaiting confirmation of lab glucose.
  • Administer IV bolus of 2 ml/kg of 10% glucose followed by IV maintenance fluids of 10% glucose with 0.9% sodium chloride (this is prepared by adding 50 ml of 50% glucose to pre-made 500 ml bag of 0.9% sodium chloride/5% glucose) with 1 hourly blood glucose monitoring.
  • Recheck blood sugar after 20 minutes. The aim is to maintain the blood glucose in the normal range 4-6mmol/L.
  • If blood sugar is still low, check that the cannula is patent, and check the dextrose infusion rate. It should be within 5-8mg/kg/min.

Dextrose infusion rate =

% of dextrose x rate (ml/hr) x 0.167

                    Wt (kg)

  • If blood sugar is persistently low despite maintenance fluids, increase the dextrose saline infusion rate in steps to 8/10/12 mg/kg/min. This can be done by increasing the dextrose concentration i.e.12.5% and 15% (only via central line) etc.
  • A persistent glucose requirement of >8mg/kg/min suggests congenital hyperinsulinism. Discuss with the Paediatric endocrine on-call team.
  • If adrenal insufficiency is suspected, IV hydrocortisone may be required: contact Paediatric endocrine on call team.
  • If the blood sugar is in the normal range on maintenance intravenous fluids, monitor hourly until it is stable for 24 hours and as guided by clinical condition of the child.

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No IV access

  • Call for senior help.
  • If not drowsy, can give carbohydrate (approximately 3g/kg) as per hypoglycaemia treatment box:

Approximate weight of child

Grams of carbohydrate

Glucose tablets

Polycal neutral (age <3 years)

Glucose liquid

Dextro gel (Age >2 years)

<10kg

5

1.5 tablets

10 ml

20 ml

1/3 of tube

30kg

10

3 tablets

15 ml

40 ml

2/3 of tube

50kg

15

4.5 tablets

25 ml

60 ml

1 tube

  • If drowsy give IM/SC Glucagon:
    • Neonate        20mcg/kg
    • Child <25kg  0.5mg
    • Child >25kg   1.0mg
  • Recheck blood sugar after 20 minutes.

After 20 minutes if blood glucose is still <3 mmol/L, obtain IV access and treat as per ‘IV access available’ guideline above.

If blood glucose >3mmol/L, gradually reintroduce feeds if safe to do so. Check pre-feed blood sugars. If <3mmol/L on hourly feeds start continuous nasogastric feeds and obtain IV access.

Prior to discharge

  1. Ensure that a clear cause for the hypoglycaemia has been elucidated prior to discharge, and that a management plan is available for the family.
  2. At least 4 hours between feeds must be safely tolerated without blood glucose dropping below 3 mmol/L (4mmol/L if non-ketotic hypoglycaemia).
  3. Discuss with paediatric endocrinology team if a controlled fast is felt to be required.
  4. Ensure family know how to treat hypoglycaemia with age appropriate treatment.
  5. Arrange appropriate out-patient follow up, depending on cause of hypoglycaemia.

Provenance

Record: 1231
Objective:
Clinical condition:

Hypoglycaemia

Target patient group: Children
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  • Elder CJ, Wright VJ, Wright NP. Time to end the routine testing of growth hormone and cortisol on hypoglycaemia screens? Archives of Disease in Childhood 2009;94(12):1000-1
  • Hussain K, Blankenstein O, Lonlay P, Christesen H. Hyperinsulinaemic hypoglycaemia: biochemical basis and the importance of maintaining normoglycaemia during management. Archives of Disease in Childhood 2007;92:568-570
  • British National Formulary for Children 2019
  • National metabolic biochemistry network guidelines for the investigation of hypoglycaemia in infants and children. January 2009. Scott C, Olpin C. http://www.metbio.net/docs/MetBio-Guideline-REBA404702-25- 05-2009.pdf
  • Advanced Paediatric Life Support: The Practical Approach. 6th Edition. BMJ books. Publisher: John Wiley and Sons. ISBN: 9781118947647

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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