3.2 Hypoglycaemia
Hypoglycaemia 02-Jun-2017
Treatment of hypoglycaemia
Prompt treatment of hypoglycaemia in children from any
cause is essential as severe hypoglycaemia may cause
subsequent neurological damage. Hyperinsulinism, fatty
acid oxidation disorders and glycogen storage disease are
less common causes of acute hypoglycaemia in children.
Initially glucose 10 – 20 g is given by mouth either in liquid
form or as granulated sugar or sugar lumps. If necessary this
may be repeated after 10 – 15 minutes. After initial treatment,
a snack providing sustained availability of carbohydrate (e.g.
a sandwich, fruit, milk, or biscuits) or the next meal (if it is
due) can prevent blood-glucose concentration from falling
again.
Proprietary products of quick-acting carbohydrate (e.g.
GlucoGel®,Dextrogel®,GSF-Syrup®,Rapilose®gel) are
available on prescription for patients to keep on hand in case
of hypoglycaemia.
Alternatively, approximately 10 g of glucose is available
from 2 teaspoons of sugar, or from 3 sugar lumps, and also
from non-diet versions of the following soft drinks: 110 mL
ofLucozade®Energy Original(also, see note below), 100 mL
ofCoca- Cola®, 19 mL ofRibena®Blackcurrant(to be
diluted).
Note: the carbohydrate content of commercially
available glucose-containing drinks is currently subject
to change—individual product labels should be checked.
Patients should be aware that for a time, both old and new
bottles and cans may be available—individual product labels
should be checked.
Hypoglycaemia which causes unconsciousnessor
seizures is an emergency. Glucagon below, a polypeptide
hormone produced by the alpha cells of the islets of
Langerhans, increases blood-glucose concentration by
mobilising glycogen stored in the liver. In hypoglycaemia, if
sugar cannot be given by mouth, glucagon can be given by
injection. Carbohydrates should be given as soon as possible
to restore liver glycogen; glucagon is not appropriate for
chronic hypoglycaemia. Glucagon can be issued to parents or
carers of insulin-treated children for emergency use in
hypoglycaemic attacks. It is often advisable to prescribe it on
an‘if necessary’basis for hospitalised insulin-treated
children, so that it can be given rapidly by the nurses during
a hypoglycaemic emergency. If not effective in 10 minutes
intravenous glucose should be given.
Alternatively, glucose intravenous infusion 10 %p. 590 can
be given intravenously into a large vein through a large-
gauge needle; care is required since this concentration is
irritant especially if extravasation occurs. Glucose
intravenous infusion 50 %isnotrecommended, as it is very
viscous and hypertonic. Close monitoring is necessary,
particularly in the case of an overdose with a long-acting
insulin because further administration of glucose may be
required. Children whose hypoglycaemia is caused by an oral
antidiabetic drug should be transferred to hospital because
the hypoglycaemic effects of these drugs can persist for
many hours.
Glucagon is not effective in the treatment of
hypoglycaemia due to fatty acid oxidation or glycogen
storage disorders.
Chronic hypoglycaemia
Diazoxide p. 466 is useful in the management of chronic
hypoglycaemia due to excessive insulin secretion, either
from a tumour involving the islets of Langerhans or from
persisting hyperinsulinaemic hypoglycaemia of infancy
(nesidioblastosis). Diazoxide has no place in the
management of acute hypoglycaemia. Chlorothiazide p. 111
reduces diazoxide-induced sodium and water retention and
has the added benefit of potentiating the glycaemic effect of
diazoxide.
If diazoxide and chlorothiazide fail to suppress excessive
glucose requirements in chronic hypoglycaemia then
octreotide p. 467 or nifedipine p. 109 can be added.
Octreotide suppresses secretion of growth hormone, but
growth is unlikely to be affected in the long term.Neonatal hypoglycaemia
Neonatal hypoglycaemia at birth is treated with glucose
intravenous infusion 10 %. Mild asymptomatic persistent
hypoglycaemia may respond to a single dose of glucagon.
Glucagon has also been used in the short-term management
of endogenous hyperinsulinism.GLYCOGENOLYTIC HORMONES
Glucagon
lINDICATIONS AND DOSE
Insulin-induced hypoglycaemia
▶BY SUBCUTANEOUS INJECTION, OR BY INTRAMUSCULAR
INJECTION
▶Neonate: 20 micrograms/kg.▶Child 1 month–1 year: 500 micrograms
▶Child 2–17 years (body-weight up to
25 kg): 500 micrograms, if no response within
10 minutes intravenous glucose must be given
▶Child 2–17 years (body-weight 25 kg and above): 1 mg, if no
response within 10 minutes intravenous glucose must
be given
Endogenous hyperinsulinism
▶BY INTRAMUSCULAR INJECTION, OR BY INTRAVENOUS
INJECTION
▶Neonate: 200 micrograms/kg (max. per dose 1 mg) for
1 dose.▶Child 1 month–1 year: 1 mg for 1 dose
▶BY CONTINUOUS INTRAVENOUS INFUSION
▶Neonate: 1 – 18 micrograms/kg/hour (max. per dose
50 micrograms/kg/hour), adjusted according to
response.▶Child 1 month–1 year: 1 – 10 micrograms/kg/hour, dose to
be adjusted as necessary
Diagnosis of growth hormone secretion (specialist use
only)
▶BY INTRAMUSCULAR INJECTION
▶Child: 100 micrograms/kg (max. per dose 1 mg) for
1 dose, dose may vary, consult local guidelines
Beta-blocker poisoning (cardiogenic shock unresponsive
to atropine)
▶INITIALLY BY INTRAVENOUS INJECTION
▶Child: 50 – 150 micrograms/kg (max. per dose 10 mg), to
be administered in glucose 5 % (with precautions to
protect the airway in case of vomiting), followed by (by
intravenous infusion) 50 micrograms/kg/hour
DOSE EQUIVALENCE AND CONVERSION
▶ 1 unit of glucagon = 1 mg of glucagon.lUNLICENSED USEDose and indication for cardiogenic
shock unresponsive to atropine in beta-blocker overdose
not licensed.
Unlicensed for growth hormone test and
hyperinsulinism.
lCONTRA-INDICATIONSPhaeochromocytoma
lCAUTIONSGlucagonoma.ineffective in chronic
hypoglycaemia, starvation, and adrenal insufficiency.BNFC 2018 – 2019 Hypoglycaemia 465
Endocrine system6