Hypoglycaemia

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of hypoglycaemia in the Emergency Department.

Key points

In non-diabetics hypoglycaemia is a low Blood Glucose Level (BGL) and can be defined as:
- < 2.6 mmol/L in neonates
- < 3.0 mmol /L in children
All patients who present with symptoms which may be due to hypoglycaemia (e.g. seizures, altered conscious level) should have a bedside glucometer reading with initial assessment.
Neonates <14 days who present with poor feeding or are unwell should have bedside glucometer performed routinely with initial assessment.

Causes of hypoglycaemia

Increased glucose utilisation

Hyperinsulinism
Hypoglycaemic drug administration
Sepsis
Multiple trauma

Abnormalities in hormone secretion

Growth hormone deficiency
Adrenal insufficiency

Abnormalities in fuel substrate metabolism (defects in metabolism or utilisation)

Metabolic disorders - inborn errors of carbohydrate, amino acid or fatty acid metabolism (e.g. Medium-Chain Acyl-Coenzyme A Dehydrogenase (MCAD) deficiency)
Acquired defects - liver disease, alcohol and salicylate ingestion

Abnormalities of substrate availability

Starvation
Ketotic hypoglycaemia

Assessment

Symptoms of hypoglycaemia

Autonomic	Neurological
Pallor Sweating Tremor Hunger Weakness Nausea Anxiety Abdominal pain	Confusion Irritability Drowsiness Coma Convulsions Headache Behaviour disturbance Visual disturbance

Investigations

Bedside Glucometer

Bedside glucometers are inaccurate in determining precise blood glucose levels below 4mmol/L.
A “Lo” reading should prompt management of hypoglycaemia. Laboratory (including satellite laboratory blood gas machine) estimation of glucose values are essential.

Critical Sample

This is the most useful investigation of unexplained or severe hypoglycaemia in childhood and should be performed at the time when the child is hypoglycaemic.
The following samples should be taken (but should not delay treatment):

Test	CollectionTube / Container		Minimum Volume
Insulin, growth hormone, cortisol	Clotted (analysed immediately)	Red top - black ring	1mL
Plasma glucose, ammonia, β-hydroxybutyrate, amino acids, acylcarnitines	Lithium heparin (on ice)	Green Top (4mL)	1.5 mL
Blood gas	Heparinised blood gas syringe
Urine metabolic screen (taken as close to the event as possible)	Standard urine collection container		5mL

Results during hypoglycaemia

Insulin levels should be undetectable (increased levels = hyperinsulinism)
Growth hormone and cortisol should be increased (no rise = deficiency)
Ketones should be present in urine (lack of ketones = hyperinsulinism or MCAD).

Management

Intravenous glucose

Birth to 18 years:

Initial bolus: glucose 10% 2mL/kg (200mg/kg) given IV over 5-10 minutes.^3,6
Commence IV glucose 10% infusion at maintenance rates until BGL is normalised (> 5mmol/L for 2 hours).⁶
Repeat BGL at 30 minutes, then at hourly intervals.³
Be aware of recurrent hypoglycaemia, especially as a result of oral hypoglycaemic drug ingestion.

Note:

In some circumstances (e.g. hyperinsulinism) infusion concentrations greater than glucose 10% may be needed to maintain blood glucose level.
Central Venous Access Devices (CVADs) are preferred for infusions of high glucose concentrations as extravasation is extremely irritant.

Glucagon

Intramuscular glucagon
- Neonates: 0.1mg/kg, maximum dose 1mg (Refer to KEMH Glucagon Monograph (WA Health only))⁴
- <25kg: 0.5mg⁵
- >25kg: 1mg⁵
Use when patient does not have IV access or there is a delay in obtaining IV access

Mild Hypoglycaemia

Patient is conscious with no symptoms
Oral feed or glucose:
- <1yr – milk
- >1yr – oral glucose (15-30g) or 125-250mL juice, followed by complex carbohydrate

References

Thornton PS, Stanley CA, De Leon DD, Harris D, Haymond MW, Hussain K, Levitsky LL, Murad MH, Rozance PJ, Simmons RA, Sperling MA, Weinstein DA, White NH, Wolfsdorf JI J. Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children. Pediatr. 2015;167(2):238. DOI: 10.1016/j.jpeds.2015.03.057
Haymond M W. Hypoglycemia in infants and children. Endocrinol Metab Clin North Am. 1989;18(1):211. DOI: 10.1016/s0889-8529(05)70091-8
Uptodate. Management and outcome of neonatal hypoglycaemia: parenteral dextrose infusion. Accessed Nov 2020 from https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/management-and-outcome-of-neonatal-hypoglycemia?search=hypoglycemia%20in%20children&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3
Truven Health Analytics. Glucagon. In: NeoFax [Internet]. Greenwood Village (CO): Truven Health Analytics; 2019 [cited 2019 Oct 10]. Available from: https://neofax.micromedexsolutions.com/
AMH Children’s Dosing Companion. Glucagon. July 2020. https://childrens-amh-net-au.pklibresources.health.wa.gov.au/monographs/glucagon
Advanced Paediatric Life Support, Australia and New Zealand 6ed: A Practical Approach to Emergencies; 2017

Endorsed by:	Director, Emergency Department	Date:	Nov 2020
		Review date:	Dec 2023

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