Hypoglycemia

Blood sugar is less than 2.2mmol or

40mg/dl .
Serum glucose level is higher than the
blood glucose level.
The absence of classical symptoms of hypo.
Does not indicate normal blood sugar.
Glucose is the source of energy and stored
in the form of glycogen.
brain uses glucose, ketones and lactate.

 Glucose is maintained by glycogenolysis and

gluconeogenesis. This process produce 4-6mgof
glucose/kg/min.
Brain utilizes glucose at a rate of 4-5mg/100mg
of brain wt. per minute.
The brain of the new born around 420gmfor a
baby of 3.5kg weight.
Others maintaining blood sugar glucagon,
growth hormone, insulin, cortisol. there is no cut
of level between harm low blood sugar and safe
blood sugar.

 Glucose enters the brain by diffusion.

Babies can have less than 20 mg of sugar in
blood and no symptoms the explanation the
brain may uses ketones and lactate.
Asymptomatic for 2-3 days may not cause
brain damage but requires urgent treatment
Neuroglycopenia symptoms apnea,
Depression, convulsion and coma. When the
previous symptoms occur the likely the
patient will have brain damage

 Babies with high risk of hypoglycemia

require monitoring
Hypoglycemia impair brain function
and brain growth.
Severe hypoglycemia causes brain damage,
mental retardation and recurrent seizures
Half of patient less than 6 months of age
with recurrent hypoglycemia will end with
neurological sequel

 Features associated with cerebral

glucopenia:
Headaches' , mental confusion,
visual disturbance, personality
changes inability to concentrate,
dysarthria ,

 The signs and symptoms of

hypoglycemia in neonates and
children are the same.
Manifestation of hypoglycemia
Features associated with stimulation
of autonomic nervous system.
Anxiety, sweating, pallor, palpitation,
weakness, hunger, tremulousness,
vomiting.

 definition: blood sugar is less than

40-45 in neonates. In children is less
than 60mg/dl.
Serum glucose is 10-15% higher than
blood sugar.

 Half of the patient who is less than 6

months with recurrent hypoglycemia
will have severe permanent
neurological sequel

 Babies with high risk of

hypoglycemia require monitoring.
Permanent hypoglycemia impairs the
brain function and growth.
Severe hypoglycemia may end up
with severe mental retardation.

 In neonate absence classical

symptoms oh hypoglycemia does not
indicate normal blood sugar.

 Glucose is source of energy and

stored in the form glycogen.
Brain gets energy from glucose
,lactate and ketones.
o Glucose production from both
glycogenolysis and gluconeogenesis

 In case of low blood sugar the body

respond with increase of counter
regulatory hormone and decrease in
insulin level to very low level 20
mu/l.
There is no cut off level between safe
and dangerous level.
In general absence of symptoms of
neuroglycopenia is usually safe

 Glucose enters the brain by diffusion

process.
Babies with blood sugar is less than 20mg
without any symptoms. Asymptomatic
hypoglycemia for 2-3 is unlikely to brain
damage.
Babies with neuroglycopenic symptoms
(apnea, depression of consciousness and
or convulsion) are likely to have brain
damage

 Babies with high risk of

hypogllycemiarequire close monitoring.
Permanent hypoglycemia impairs the brain
function and growth.
Severe hypoglycemia leads to severe
developmental delay and recurrent
seizures.
Half of the patient who is less than 6
months of age with severe hypo will have
permanent brain damage.

 Manifestation of hypoglycemia in
children:
Features associated with activation
of autonomic nervous system
Anxiety, sweating, pallor, palpitation,
weakness, hunger, tremulousness,
nausea, vomiting.

 Features associated with cerebral

glucopenia:
Headaches, mental confusion, visual
disturbance, personality changes,
inability to concentrate, dysatheria,
staring , seizures, ataxia, lethargy,
coma, , stoke, hemiplegia, aphasia,
paresthesia, dizziness, amnesia.

 Assessment:
Majority of hypoglycemia happening after
over nigh fasting. Importantly minority occur
shortly after meals {hyperinsulinaemia}
Measure height and weight, small children
are prone to kenotic hypoglycemia.
Large liver with hypoglycemia in favor of
glycogen storage disease.
Presence of cataract indicate s
galactosaemia

 Abdominal mass in clinical

examination or ultrasound scan is a
suggestive of insulin releasing tumor.
Ketones in urine or plasma excludes
hyperinsulinaemia.

Finding in kenotic hypoglycemia

Low glucose

High growth
hormone

High betahydroxy
butyrate

Low insulin

High cortisol

Normal lactate

 This is a common in children from 18

36 months of age. The affected
children are very small with
prominent ketones in urine. There is
hormonal abnormalities. Parents
advised to avoid prolonged fasting.
This will resolve by time.

 Finding in growth and cortisol

hormone deficiency.
Low glucose

Low growth
hormone

High betahydroxy
butyrate

Low insulin

Low cortisol

Normal lactate

 In these conditions there other

features aid to diagnosis e.g. short
stature, micropenis, electrolyte
disturbance

 Finding in hepatic enzyme

defficiency:
Low glucose

High growth
hormone

High
betahydroxy
butyrate

Low insulin

High cortisol

High lactate

 In these condition there is enlarged

liver and metabolic acidosis.
Finding in hyperinsulinemia
{idiopathic hyperinsulinemia in
infancy, islet cell adenoma, beta cell
Glucose low
High growth
Betahydroxy
hyperplasia}
Insulin high

hormone

butyrate

Cortisol high

Lactate normal

 Investigations blood glucose should be done

several times.
Serum ketones
Plasma PH, bicarbonate, lactate.
Plasma growth hormone, cortisol.
Plasma assay.
Urine
Urine ketones
Urine for reducing substance

 Provoked stimulation test rarely

required in infancy but it could be
helpful in older children
Prolonged fasting
Glucagon stimulation test
Leucincie tolerance test

 C peptid assay is useful for cases of

exogenous insulin administration the
followings
Low blood sugar
Elevated insulin
Lack relation to fasting
Absent ketones
Suppressed c peptide

Causes of neonatal hypoglycemia

Small for date
Preterm
Birth asphyxia
Breast milk insufficiency
Hypothermia
IDM
Hemolytic anemia
Maternal glucose infusion

Other causes of hypoglycemia

Inborn error of metabolism
1- glycogen storage disease
2- fructose intolerance
3- galactosemia
4- inborn error of fatty acid oxidation(
medium chain acyl COA
dehydrogenase deficiency)

Other causes
Aminoacidopathies
a- maple syrup urine disease
b- propionic acidaemia
C- methyl malonic acidaemia
d- tyrosinosis

 Other causes of hypoglycemia

Acute alcoholic intoxication this
impairs gluconeogensis.
Salicylate over dose this may cause
hypo or hyperglycemia
This accelerate utilization of glucose

 Defects of fatty acid oxidation these

are various enzyme deficiency that
cause carnithine defects.
In this condition plasma carnithine
low.

 Dicarboxylic acid urea

Symptoms and signs like Reye
syndrome
Metabolic acidosis without ketosis,
hypotonia, seizures and acid odor.
Diagnosis can be made by enzyme
assay in the liver cells and culture
fibroblast

 Treatment
After taking blood investigation
Bolus of 10% glucose 3mls/kg to be given IV
then 10% dextrose infusion. This is for
neonate and for children
If neonate has asymptomatic hypoglycemia
Give oral feeding by bottle or tube then
check blood sugar an hour after if blood
sugar rise to accepted level then give
feeding every 2 hours.

 If blood sugar remains low then give IV

dextrose infusion.
Or if the baby can not tolerate oral feeding
or presence of symptoms then IV dextrose
If the remains hypoglycemic despite 10 %
dextrose infusion
Require to increase the concentration to
12.5% or even higher concentration
Treat the cause of hypoglycemia