Contributor: Taylor Lynch, MD

Educational Pearls:

When it comes to hypoglycemia, the age dictates possible causes

• Neonate:

• Hormonal deficiency

• Congenital Adrenal Hyperplasia (21-hydroxylase deficiency, 11β-hydroxylase deficiency)

• Primary or Secondary Adrenal Insufficiency leading to cortisol deficiency 

• Hypopituitarism

• Inborn errors of metabolism

• Systemic infection (Under 30 days old should trigger a full infectious workup)

• Toddler

• Accidental ingestions

• Sulfonylureas such as glipizide or glyburide

• Older children

• Addison’s Disease (Hypocortisolism)

• Accidential or intentional ingestions

• Exogenous insulin

How is it diagnosed?

• Child or infant

• Glucose <60

• Newborn

• Glucose <45 and symptomatic or glucose <35 and asymptomatic

Treatment

• Awake: oral glucose

• Altered: IV glucose

• Rule of 50’s. The dose you give times the concentration should equal 50

• Neonate to 2 months get 5 mg/kg of D10W (5*10=50)

• 2 months to 8 years old get 2 mg/kg of D25W (2*25=50)

• Over 8 gets 1 mg/kg of D50W (1*50=50)

• Bonus fact: Rough estimate of weight for a child is 2*patients age plus 8

• Recheck sugar every 15 minutes

• If they stay hypoglycemic give another bolus and consider starting a drip at 1.5 maintenance dose of D10NS.

• If you don’t have an IV you can consider glucagon at 0.03 mg/kg IM, although you might be better off trying glucose gel buccally.

• If standard therapy still fails you can give hydrocortisone

• 25 mg IV for neonates and infants

• 50 mg IV for toddlers and smaller school aged children

• 100 mg for anyone older than that

How do you test for exogenous insulin?

• Check a c-peptide which would be low if a patient is taking exogenous insulin

References

1. Lang, T. F., & Hussain, K. (2014). Pediatric hypoglycemia. Advances in clinical chemistry, 63, 211–245. https://doi.org/10.1016/b978-0-12-800094-6.00006-6

2. Lee, S. C., Baranowski, E. S., Sakremath, R., Saraff, V., & Mohamed, Z. (2023). Hypoglycaemia in adrenal insufficiency. Frontiers in endocrinology, 14, 1198519. https://doi.org/10.3389/fendo.2023.1198519

3. Thompson-Branch, A., & Havranek, T. (2017). Neonatal Hypoglycemia. Pediatrics in review, 38(4), 147–157. https://doi.org/10.1542/pir.2016-0063

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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