How to manage hypoglycemia (low blood sugar) in pediatric patients?

Management of Hypoglycemia in Pediatric Patients

Hypoglycemia in pediatric patients should be treated immediately based on severity, with oral glucose for mild to moderate cases and parenteral treatment for severe cases. 1

Definition and Recognition

• Hypoglycemia in pediatric patients is defined as blood glucose <70 mg/dL, with severe hypoglycemia characterized by altered consciousness requiring assistance 1
• Symptoms vary by age and can include:
  • Adrenergic symptoms: sweating, pallor, palpitations, tremors 2
  • Neuroglycopenic symptoms: headache, behavior changes, confusion, drowsiness 2
  • Nocturnal hypoglycemia may present with nightmares, restless sleep, or behavior changes upon waking 2
• Infants and young children have limited ability to detect and communicate symptoms, necessitating more frequent monitoring 1

Treatment Algorithm Based on Severity

Mild Hypoglycemia (patient can self-treat)

• Administer 15g of rapidly absorbed carbohydrate (10g for younger children) 2, 1
• Recheck blood glucose after 15 minutes 1
• Follow with protein-containing snack once blood glucose normalizes 2

Moderate Hypoglycemia (requires assistance but conscious)

• Administer 20-30g of glucose orally 2
• Target restoration of blood glucose to >80 mg/dL 2
• Monitor response and repeat treatment if necessary 1

Severe Hypoglycemia (altered consciousness)

• For children >25kg or ≥6 years with unknown weight: administer glucagon 1mg subcutaneously or intramuscularly 3
• For children <25kg or <6 years with unknown weight: administer glucagon 0.5mg subcutaneously or intramuscularly 3
• If no response after 15 minutes, repeat dose while awaiting emergency assistance 3
• In hospital settings: administer intravenous glucose 1
• Glucagon dose of 30 mcg/kg subcutaneously (maximum 1mg) will increase blood glucose within 5-15 minutes 2
• Lower dose of 10 mcg/kg results in smaller glycemic response with less nausea 2
• Mini-dose glucagon (20 mcg for children ≤2 years; 10 mcg/year of age for older children up to 150 mcg) can be effective for impending hypoglycemia 4

Special Considerations

Critically Ill Children

• Check blood sugar levels in every septic patient 2
• Aim to keep blood glucose >70 mg/dL (>4 mmol/L) by providing glucose calorie source 2
• Do not target upper blood glucose levels <150 mg/dL (<8.3 mmol/L) as this increases risk of hypoglycemia 2
• For critically ill children, target blood glucose range of 140-200 mg/dL is recommended 2

Diabetic Children

• Hypoglycemia unawareness can develop after repeated episodes, requiring more vigilant monitoring 2
• Prevention strategies include:
  • Frequent blood glucose monitoring, especially around exercise 1
  • Maintaining pre-exercise blood glucose between 90-250 mg/dL 1
  • Reducing prandial insulin by 10-50% before exercise 1
  • Considering bedtime snacks to prevent nocturnal hypoglycemia 1
  • For insulin pump users, lowering basal rates by 10-50% during exercise 1

Common Causes in Non-Diabetic Children

• Idiopathic ketotic hypoglycemia is the most frequent cause in children 1-5 years of age 5
• Gastroenteritis or other infectious diseases causing protracted fasting account for 86.32% of hypoglycemia cases in emergency departments 6
• Metabolic defects are rare (1.49%) but important to consider 6

Prevention of Recurrent Hypoglycemia

• For ketotic hypoglycemia: provide frequent snacks containing complex carbohydrates, particularly at bedtime 5
• For diabetic patients: education about ketone monitoring and 24-hour telephone availability 2
• For patients with recurrent episodes: evaluate for underlying endocrine or metabolic disorders 7

Monitoring During Treatment

• For severe cases requiring hospital management:
  • Monitor vital signs hourly (heart rate, respiratory rate, blood pressure, neurologic status) 2
  • Track fluid input and output 2
  • Monitor capillary glucose hourly 2
  • Repeat laboratory tests (electrolytes, blood glucose) every 2-4 hours 2

Post-Treatment Care

• When the patient has responded to treatment and can swallow, provide oral carbohydrates to restore liver glycogen and prevent recurrence 3
• For patients who have been fasting, provide oral carbohydrates after recovery 3
• Assess for frequency of hypoglycemia and awareness at follow-up visits 1