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Hypoglycemia PowerPoint Presentation

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Description : All about Pediatric Hypoglycemia

Tags : Hypoglycemia,Hypoglycemia Risk factors,Neonatal hypoglycemia,plasma glucose,risk of hypoglycemia,symptoms of hypoglycemia,ketotic hypoglycaemia

Published on : Jul 25, 2023 | Views : 2571 | Downloads : 4

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PRESENTED BY INTERN…. Soni Kumari MBBS (2016) Hypoglycaemia
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Introduction Definition Risk factors Etiology Symptom Sequelae Disorder Diagnosis Treatment CONTENTS
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Introduction • Hypoglycemia in infancy and childhood can result from a large variety of hormonal and metabolic defects. •Hypoglycemia occurs most frequently in the early neonatal period - often as a result of:- 1 . transient neonatal hyperinsulinemia in infants of diabetic mothers 2. inadequate energy stores ot meet hte disproportionately large metabolic needs fo premature or small for gestational age newborns.
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• Hypoglycemia during the first few days of life in an otherwise normal newborn is less frequent and warrants concern. •After the initial 2-3 days of life, hypoglycemia is far less common and is more frequently the result of 1 Endocrine disorders 2. Metabolic disorders 3. Sepsis must always be considered
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Definition of hypoglycemia Neonatal hypoglycemia, defined as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mol/L) thereafter Clinical hypoglycaemia is defined as (Whipple triad):- 1. a plasma glucose (PG) concentration low enough to cause symptoms (usually <60 mg/ dL in children > 1 month of life) 2. signs of impaired brain function 3. improvement of symptoms with glucose administration. Neonatal hypoglycemia is the most common metabolic problem in newborns.
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Neonates at risk of hypoglycemia Babies weighing less than 2.0 kg birth weight preterm babies, LGA (large for gestational age) babies especially those weighing more than 3.5 kg infants of diabetic mothers, those with delayed cry at birth, any sick neonate who is not sucking or accepting feeds are all at risk of developing hypoglycemia. The other risk factors for hypoglycemia are RDS, polycythemia, shock, and hypothermia
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Factors which increase the risk of hypoglycemia • Various factors which increase the risk of hypoglycemia are hypothermia & cold Stress, cold environment, wet baby and inadequate feeding.
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Etiology The causes of neonatal hypoglycemia include the following: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) Limited glycogen stores (eg, prematurity, intrauterine growth retardation) Increased glucose use (eg, hyperthermia, polycythemia, sepsis, growth hormone deficiency) Decreased glycogenolysis, gluconeogenesis, or use of alternate fuels (eg, inborn errors of metabolism, adrenal insufficiency) Depleted glycogen stores (eg, asphyxia-perinatal stress,starvation starvation
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Symptoms of hypoglycemia The symptoms of hypoglycemia are very nonspecific and can mimic any illness. The common symptoms are: Not looking well Lethargic, Weak cry, Poor feeding, Temperature instability like hypothermia, Poor respiratory effort: shallow breathing, apnea or cyanosis CNS symptoms like: excessive jitteriness, convulsions or hypotonia
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Non-Ketotic hypoglycemia Metabolic disorders Disorders of beta-oxidation of fatty acids 2. Insulinoma Ketotic hypoglycaemia Metabolic disorders Organic acidurias Inborn error of glycogenolysis Inborn error of gluconeogenesi Cortisol deficiency Growth hormone deficiency Starvation Disorders of Hypoglycemia:
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Sequelae Although the brain may be able to utilize ketones, glucose remains a required form of energy for CNS function. Younger infants and patients with more severe or prolonged hypoglycemia are at greatest risk for adverse outcomes because:- 1. The greatest development of the brain is in the first year of life The ability of a newborn to produce ketone bodies is limited. 2. The presence of hyperinsulinism, which inhibits hepatic glucose output, lipolysis, and ketogenesis. • Transient and asvmptomatic short-term hypoglvcemia has not been found to be associated with these severe sequelae. The body has a tightly regulated system through use of alternative fuels such as ketone bodies
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Failure to recognize and treat severe, prolonged hypoglycemia can result in serious long-term morbidity, including:: Retard brain development and function Intellectual disability Non-hypoglycemic seizures
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Diagnosis Establishing the etiology in a particular patient is important. Obtain a critical sample of blood and urine at the time of the hypoglycemic episode. In a child with unexplained hypoglycaemia:- A serum sample should be obtained before treatment for the measurement of :- glucose and insulin, GH, cortisol, FFAs, and B-hydroxybutyrate and acetoacetate. Measurement of serum lactate levels also should be considered A urine specimen should be obtained for measuring:- Ketones reducing substances.
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Asymptomatic hypoglycemia is diagnosed if BGL is less than 40 mg/ dL (to be confirmed by laboratory estimation) and the infant does not manifest any clinical features.(measure blood glucose within 2 hrs of birth preferably before feeds) Symptomatic hypoglycemia should be diagnosed in hypoglycemia (BGL is less than 40 mg/ dL) with clinical symptoms. Neonates generally present with nonspecific signs. Therefore, careful evaluation should be done to look for all possible causes of signs and symptoms.
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Screening for hypoglycaemia In newborns who are considered to be at high risk of persistent hypoglycemia disorders (e.g., genetic/ syndromic disorders or congenital hyperinsulinism), it is advisable to screen for hypoglycemia and also for the ability to maintain BGL >70 mg/ dL if one feed is missed (i.e., ability to tolerate fasting for 6-8hrs) before discharge. Some SGA & pre term infants may develop hypoglycaemia when feeding is not established.
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Schedule of blood glucose monitoring
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Management plan of infants with asymptomatic hypoglycemia
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Management of symptomatic hypoglycaemia To raise the blood sugar value to normal range, give 200 mg/kg of dextrose i.e. 2 ml /kg of 10% dextrose as bolus slowly over 3-5 minutes and start maintenance fluids with a dextrose infusion rate (DIR) of 6 - 8 mg/kg/min. The maximum strength of dextrose that can be given through a peripheral vein is 12.5%. Repeat Dextrostix after 15-30 minutes, if still low, repeat bolus and increase (DIR) by 1 - 2 mg/kg/min or the maintenance fluids by 10 - 20 ml/kg/day.
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For example in a low birth weight baby on first day of life give 80ml/kg/ day i.e. 80 x wt of the baby e.g. 1.8 kg i.e. 144 ml/day. Divide by 24 to obtain fluid per hour (144 24 = 6 ml hr). Take a measured volume set, fill 1/4th or 6 hrs fluid i.e. 24 mi and deliver at a rate of 6 micro drops/min (number of drops per minute is equal to rate of fluid/hour). The dextrose infusion rate can be calculated by the following formula: Fluid rate (ml/kg/day) × % of Dextrose to be used x 0.007 =DIR(mg/kg/min). e.g. If a baby is on 100 ml/kg/day of 10% dextrose, the DIR is 7 mg/kg/min. You may also use the reference charts to calculate the DIR.
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Resistant or Persistent Hypoglycemia: This condition is consider when infant fails to maintain normal BGL despite of GIR of 12mg/kg/min or when stabilisation is not achieved by 7 days of therapy. One should rule out hyperinsulinemic state or inborn errors of metabolism. Hyperinsulinemic hypoglycemia can be congenital (due to mutations affecting regulation of insulin secretion from pancreas) or, more commonly, acquired (maternal diabetes, birth asphyxia, polycythemia, Rh incompatibility and severe intrauterine growth retardation etc.)
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Criteria for diagnosis of hyperinsulinism Critical sample must be drawn at time of hypoglycemia (blood glucose <40 mg/dL) Detectable insulin (>2 m|U/L); usual level with hyperinsulinism are >5 to 10 mIU/L Low freefattyacids (< 1.5 mmol/L) Low ketone (plasma hydroxybutyrate < 2.0 mmol/ L) Inappropriate glycemic response to 0.1 mg/ kg intravenous glucagon at the time of hypoglycemia normally, BGL. rise > 30 mg / dL. in 20 minutes)
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In resistant or persistent hypoglycemia the following drugs should be considered: - Hydrocortisone: 5 mg/kg/day PO/IV*BD Glucagon: 0.2mg/kg dose SC/IM Diazoxide: 5 - 15 mg/kg/day PO*TDS Octreotide : Synthetic somatostatin in a dose of 5-35 mcg/kg/day SC*TDS/QID Do not use diazoxide or glucagon in small for gestational age infants
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Other management options in resistant hypoglycemia are: 1. Mammalian target of rapamycin (mTOR) inhibitors like sirolimus, everolimus" Usually given orally in doses of 0.5 mg/ m' / day divided in 1 to 2 doses targeting a drug level of 5-15 ng/ mL. Acts by inhibiting insulin production. Further trials are needed before incorporating in routine use 2. Surgical treatment (near total pancreatectomy): In infants who are unresponsive to medical treatment. Consider 18 F-fluro-L-DOPA, Positron Emission Tomography (PET) prior to this to detect focal lesions in pancreas.
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Follow-up and outcome The outcome of neonatal hypoglycemia is determined by factors like duration, severity of hypoglycemia, rate of cerebral blood flow, cerebral utilization of glucose, and co-morbidities. Special attention should be paid to neuro-developmental outcome, overall IQ, reading ability, arithmetic proficiency and motor performance. The infants need to be assessed at one month corrected age for vision. At 3, 6, 9, 12 and 18 months corrected age, they need to be followed up for growth, neuro- development, vision and hearing loss. MRI at 4-6 weeks provides a good estimate of hypoglycemic injury.
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Reference: Nelson Textbook of Pediatrics Ghai Essential Pediatrics-10th edition https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682370/ https://naomedical.com/blog/hypoglycemia-in-pediatrics-causes-symptoms-treatment/ https://www.uptodate.com/contents/approach-to-hypoglycemia-in-infants-and-children, https://www.chop.edu/conditions-diseases/hypoglycemia-children
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Thank You!!!