Is it safe to administer glucose 50% (dextrose 50%) to pediatric patients?

Administration of 50% Glucose (Dextrose) in Pediatric Patients

D50W (50% dextrose) should not be administered to children due to significant risks of rapid osmolarity changes, vascular damage, and cerebral edema; instead, D10W or D25W should be used with appropriate dilution for pediatric hypoglycemia management.

Risks of D50W in Pediatric Patients

D50W administration in children poses several serious risks that directly impact morbidity and mortality:

• Vascular damage: The high osmolarity of D50W (2,500 mOsm/L) can cause significant vein irritation and tissue damage if extravasation occurs
• Rapid osmolarity changes: Rapid administration of concentrated glucose can cause dramatic shifts in serum osmolarity
• Cerebral edema risk: Children are particularly susceptible to cerebral edema with rapid osmolarity changes 1
• Excessive glucose decline: Studies show that rapid glucose administration and correction can lead to dangerous rates of glucose decline exceeding 100 mg/dL/hour 2

Appropriate Glucose Concentrations for Children

The American Academy of Pediatrics guidelines recommend using age-appropriate glucose concentrations for pediatric patients 3:

• For D10W (10% dextrose): 2-4 mL/kg (200-400 mg/kg)
• For D25W (25% dextrose): 2-4 mL/kg (500-1000 mg/kg)
• Never D50W: The FDA label for glucose products notes that special caution must be exercised when administering dextrose to pediatric patients, particularly neonates and low birth weight infants 4

Hypoglycemia Management Algorithm for Children

1. Assess severity of hypoglycemia:

   • Mild-moderate: Blood glucose 40-70 mg/dL
   • Severe: Blood glucose <40 mg/dL or symptomatic

2. Choose appropriate concentration:

   • First choice: D10W at 0.5-1.0 g/kg (5-10 mL/kg) 3
   • Alternative: D25W at 0.5-1.0 g/kg (2-4 mL/kg) 3

3. Administration technique:

   • Use a dedicated IV line
   • Administer slowly to prevent rapid osmolarity shifts
   • Monitor blood glucose every 15-30 minutes initially

4. Follow-up management:

   • Provide maintenance glucose infusion (D10W) at 5-8 mg/kg/min
   • Investigate and treat underlying cause of hypoglycemia

Special Considerations

Neonates and Infants

Neonates and very small infants are at particularly high risk for complications with concentrated glucose solutions. The FDA label specifically warns that "in very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolarity and possible intracerebral hemorrhage" 4.

Diabetic Ketoacidosis

For children with DKA, a controlled approach to glucose correction is essential:

• Target glucose reduction rate should be 1.5 mmol/L/hr (27 mg/dL/hr) 5
• Avoid rapid glucose correction which increases the brain/subcutaneous glucose ratio, potentially contributing to cerebral edema 5

Monitoring Requirements

When administering glucose to pediatric patients:

• Frequent monitoring of serum glucose is required 4
• Consider continuous glucose monitoring in high-risk situations 6
• Monitor for signs of cerebral edema (headache, altered mental status, bradycardia)

Conclusion

The evidence clearly demonstrates that D50W should not be administered to pediatric patients. Instead, more dilute solutions (D10W or D25W) should be used with appropriate volume calculations to deliver the same glucose dose more safely, reducing the risk of adverse outcomes including cerebral edema and death.