{
 "topic": "Hypoglycemia",
 "slug": "hypoglycemia",
 "category_id": 15212,
 "passage_count": 14,
 "source_chars": 11633,
 "enough_material": true,
 "references": [
  {
   "title": "Caring for the Hospitalized Child",
   "author": "Section on Hospital Medicine, American Academy of Pediatrics;Jeffrey C. Gershel;Daniel A. Rauch;",
   "pages": [
    238
   ]
  },
  {
   "title": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "author": null,
   "pages": []
  },
  {
   "title": "Pediatric Nutrition Handbook",
   "author": "Kleinman, Ronald E.",
   "pages": [
    20,
    756,
    757
   ]
  },
  {
   "title": "Pediatric Nutrition (Ronald E. Kleinman, Frank R. Greer)",
   "author": null,
   "pages": [
    880,
    903,
    918
   ]
  },
  {
   "title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024",
   "author": null,
   "pages": [
    1028,
    1030
   ]
  },
  {
   "title": "Pediatric Board Study Guide",
   "author": null,
   "pages": [
    413
   ]
  },
  {
   "title": "Illustrated Textbook of Paediatrics (Tom Lissauer, Will Carroll)",
   "author": "Lissauer, Tom,Carroll, Will",
   "pages": [
    202
   ]
  },
  {
   "title": "Berkowitz's Pediatrics",
   "author": "Berkowitz, Carol D.;",
   "pages": [
    1189
   ]
  }
 ],
 "passages": [
  {
   "source": "Caring for the Hospitalized Child, p. 238",
   "text": "**211** ~~**CHAPTER 28**~~ ## **Hypoglycemia** ## **Introduction** Hypoglycemia is defined as a low glucose value that produces a neuroendocrine response and associated symptoms, with a rapid resolution after the return to euglycemia. For infants and children, hypoglycemia is a blood glucose value less than 60 mg/dL (, 3.3 mmol/L). Always obtain a critical sample (see Laboratory Workup section) if the blood glucose is less than 50 mg/dL (, 2.8 mmol/L). See Chapter 85, Hypoglycemia of the Newborn, for the care of infants less than 72 hours of chronological age. Most often, hypoglycemia is found in a patient who is known to have diabetes, or the hypoglycemia is physiological and associated with acute illness, fasting, sepsis, or inadequate oral intake (in cases of nausea and/or vomiting). In such situations, no specific workup is necessary."
  },
  {
   "source": "2021_Fleisher_&_Ludwig's_Textbook_of_Pediatric_Emergency_Medicine.epub",
   "text": "TABLE 89.4 CAUSES OF CHILDHOOD HYPOGLYCEMIA Decreased availability of glucose Decreased intake\u2014fasting, malnutrition, illness Decreased absorption\u2014acute diarrhea Inadequate glycogen reserves\u2014defects in enzymes of glycogen synthetic pathways Ineffective glycogenolysis\u2014defects in enzymes of glycogenolytic pathways Inability to mobilize glycogen\u2014glucagon deficiency Ineffective gluconeogenesis\u2014defects in enzymes of gluconeogenic pathway Increased use of glucose Hyperinsulinism\u2014islet cell adenoma or hyperplasia, ingestion of oral hypoglycemic agents, insulin therapy Large tumors\u2014Wilms tumor, neuroblastoma Diminished availability of alternative fuels Decreased or absent fat stores Inability to oxidize fats\u2014enzymatic defects in fatty acid oxidation Unknown or complex mechanisms Sepsis/shock Reye syndrome Salicylate ingestion Ethanol ingestion Adrenal insufficiency Hypothyroidism Hypopituitarism Clinical Considerations Clinical Recognition"
  },
  {
   "source": "Pediatric Nutrition Handbook, p. 756",
   "text": "* Because these disorders can be of variable severity and may not always present at birth, they are not invariably associated with fetal overgrowth. **704** Chapter 31 PEDIATRIC NUTRITION HANDBOOK ## **Children** The most common cause of hypoglycemia in children is insulin-induced hypoglycemia in individuals with type 1 diabetes mellitus. In other children, hypoglycemia can be categorized as ketotic fasting hypoglycemia, nonketotic fasting hypoglycemia, and reactive or postprandial hypoglycemia (Table 31.3). This categorization generally aids in diagnosis but should not limit clinical judgment. Mild reactive hypoglycemia is very common in the otherwise healthy population and is not considered a disease. ## Table 31.3 ## **Causes of Hypoglycemia in Children**"
  },
  {
   "source": "Pediatric Nutrition (Ronald E. Kleinman, Frank R. Greer), p. 880",
   "text": "## _Hypoglycemia_ Hypoglycemia in children with diabetes mellitus, defined as a blood glucose concentration less than 70 mg/dL, may result from a combination of excess insulin administration, decreased food intake, or increased physical Pediatric Nutrition, 8th Edition Nutrition Therapy For Children and Adolescents With **867** Type 1 and Type 2 Diabetes Mellitus activity. Hypoglycemia should always be treated immediately, and patients and family members need to be educated on signs and symptoms of low blood glucose concentration as well as appropriate treatment. Patients with diabetes mellitus should always carry a source of carbohydrate with them when away from home to treat hypoglycemia in addition to their blood glucose meter. The goal of treatment is to achieve rapid normalization of blood glucose without consuming excess carbohydrate and resultant rebound hyperglycemia."
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 1030",
   "text": "Management of individual hypoglycemia disorders is given in more detail in the following sections and in Table 113.7. ## **DISORDERS OF HYPOGLYCEMIA** Disorders of hypoglycemia can be classified by the metabolic fuel response to fasting (see Fig. 113.4). ## **Insulin- Mediated Disorders** Insulin- mediated disorders (see Table 113.4) are characterized by low plasma \u03b2- hydroxybutyrate and FFAs and a positive glycemic response to glucagon (Table 113.8). ## Hyperinsulinism HI is the most common cause of _persistent hypoglycemia_ in infants and children. HI is caused by dysregulated insulin secretion by the pancreatic \u03b2- cells, resulting in severe and recurrent hypoglycemia (Fig. 113.5). HI can be categorized into three main forms: (1) perinatal stress- induced, (2) congenital or monogenic (see Table 113.4), and (3) syndromic (see Table 113.5). Perinatal stress- induced HI (PSHI), the most common form of HI, occurs in the setting of stress on the fetus in utero or during delivery."
  },
  {
   "source": "Pediatric Nutrition Handbook, p. 757",
   "text": "_Hypoglycemia in Infants and Children_ **705** 6TH EDITION ## Table 31.3 _(Continued)_ ## **Causes of Hypoglycemia in Children** **Nonketotic Fasting Hypoglycemia** Glycogen storage disease type 1 (glucose-6-phosphate dehydrogenase defi ciency) Tyrosinemia Disorders of fatty oxidation and ketone synthesis: Carnitine transport and metabolism Beta-oxidation cycle Electron transfer 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) synthase or lyase defi ciency Insulin-like growth factor (IGF)-1, IGF-2 excess Insulinoma Sulfonylurea or other insulin secretogogue ingestion Exogenous insulin administration Persistent hyperinsulinemic hypoglycemia of infancy Reactive or postprandial hypoglycemia: \u201cMetabolic dumping syndrome\u201d Galactosemia Fructose intolerance (fructose-1-phosphate aldolase defi ciency) ## **Evaluation of Hypoglycemia** ## **Neonates**"
  },
  {
   "source": "Pediatric Nutrition (Ronald E. Kleinman, Frank R. Greer), p. 903",
   "text": "## _Children_ The most common type of hypoglycemia in children is insulin-induced hypoglycemia in individuals with type 1 diabetes mellitus. In other children, hypoglycemia can be categorized as ketotic fasting hypoglycemia, hypoketotic fasting hypoglycemia, or reactive or postprandial hypoglycemia. Postprandial hypoglycemia in young children is often associated with metabolic dumping syndrome (as occurs after fundal plication procedures), but in adolescents, it may be associated with obesity and high-carbohydrate eating habits (Table 31.3). This categorization generally aids in diagnosis but should not limit clinical judgment. Mild reactive hypoglycemia is common in the otherwise healthy adolescent population and is not considered a disease. Pediatric Nutrition, 8th Edition Hypoglycemia In Infants and Children **891** ## Table 31.2. ## **Causes of Hypoglycemia in Newborn Infants**"
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 1028",
   "text": "## **CLINICAL MANIFESTATIONS** Clinical features of hypoglycemia fall into two categories: (1) symptoms and signs associated with the activation of the autonomic nervous system and epinephrine release **(autonomic symptoms)** and (2) symptoms and signs caused by decreased cerebral glucose use **(neuroglycopenic symptoms)** (see Table 113.1). In newborns and infants, symptoms and signs of hypoglycemia may be subtler and include cyanosis, apnea, hypothermia, hypotonia, irritability, jitteriness, poor feeding, lethargy, and seizures. _It is important to note that neonates and infants are frequently asymptomatic when hypoglycemic_ . ## **DIAGNOSIS**"
  },
  {
   "source": "Pediatric Board Study Guide, p. 413",
   "text": "Management of hypoglycemia: (Table 12.3) - Usually induced by fasting - Inappropriately elevated insulin concentration (in the presence of hypoglycemia) ## **Beckwith\u2013Wiedemann Syndrome (See Genetic Chapter for More Details)** - May respond to diazoxide - Consider multiple endocrine neoplasia type 1 (MEN- 1) syndrome - Ketotic hypoglycemia in older children \u2013 The most common cause of childhood hypoglycemia and is a diagnosis of exclusion ## **Background** - Caused by deletion, gene mutations, or altered imprinting of the 11p15 region - Causes hyperplasia in pancreatic beta cells, hyperinsulinism, and hypoglycemia (Table 12.4) [Figure OCR, page 413, figure 1] Hyperinsulinism + Low ketones, low lactate + Inappropriately high insulin + Insulin >2 pU/mL if BG <60mg is diagnostic [Figure OCR, page 413, figure 2] Fatty acid oxidation defect * Noketonemianoketonuria + Appropriately suppressed insulin"
  },
  {
   "source": "Illustrated Textbook of Paediatrics (Tom Lissauer, Will Carroll), p. 202",
   "text": "## ~~**Hypoglycaemia**~~ Hypoglycaemia is particularly likely in the first 24 hours of life in babies with intrauterine growth restriction, who are preterm, born to mothers with diabetes mellitus, are large-for-dates, hypothermic, polycythaemic or ill for any reason. Growth-restricted and preterm infants have poor glycogen stores, whereas the infants of a diabetic mother have sufficient glycogen stores, but hyperplasia of the islet cells in the pancreas causes high insulin levels. Symptoms are jitteriness, irritability, apnoea, lethargy, drowsiness and seizures."
  },
  {
   "source": "Pediatric Nutrition (Ronald E. Kleinman, Frank R. Greer), p. 918",
   "text": "## **Summary** Hypoglycemia is the result of an alteration in the metabolic and hormonal interrelationships that balance glucose absorption, release, and production with glucose utilization. Symptomatic hypoglycemia is caused by decreased CNS energy levels (neuroglycopenia) and is reflected somewhat imperfectly in measures of blood sugar. It is the health care professional\u2019s task to recognize the signs and symptoms of hypoglycemia, document hypoglycemia using laboratory tests, and obtain appropriate studies to identify the etiology. Initial symptomatic treatment of hypoglycemia will preserve brain function, but long-term management depends on identification of the cause of the energy imbalance. ## **References** 1. Thornton P, Stanley CA, DeLeon DD, et al. Recommendations from the Pediatric Endocrine Society for evaluaton of persistent hypoglycemia in neonates, infants, and children. _J Pediatr._ 2015;167(2):238\u2013245"
  },
  {
   "source": "Berkowitz's Pediatrics, p. 1189",
   "text": "**1164 PART 15: CHRONIC DISEASES OF CHILDHOOD AND ADOLESCENCE** ## **Prognosis** Diabetic ketoacidosis is the major cause of morbidity and mortality in children and adolescents, followed by hypoglycemia. Clinical signs of hypoglycemia in older children include shakiness, blurred vision, and dysarthria. Concerns about the neurodevelopmental effect of hypoglycemia in young children have led to the recommendation of more liberal glycemic control in early onset disease. Diabetic ketoacidosis, precipitated by an intercurrent infection or poor compliance, is a metabolic derangement that always requires urgent medical attention and often necessitates hospitalization. Replacement of fluids, attention to electrolyte abnormalities, and insulin therapy are the mainstays of treatment in the face of this complication."
  },
  {
   "source": "Pediatric Nutrition Handbook, p. 20",
   "text": ". . . . . . . . 673 Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 693 **31[Hypoglycemia in Infants and Children]**[ . . . . . . . . . . . . . . . . . . . . ] **[701]** Introduction and Defi nition of Hypoglycemia . . . . . . . . . . . 701 Clinical Manifestations of Hypoglycemia . . . . . . . . . . . . . . 703 Etiology of Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . 704 Evaluation of Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . 706 Differential Diagnosis of Hypoglycemia . . . . . . . . . . . . . . . 708 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711"
  },
  {
   "source": "Cover, p. 8334",
   "text": "## **DIAGNOSIS OF HYPOGLYCEMIA** Symptoms of hypoglycemia are caused by responses to decreased metabolic substrate for the brain, including sympathetic nervous system activation and impaired cognition. They include shakiness, dizziness, sweating, pallor, sudden moodiness, headache, irritability or lethargy (especially in the infant), inattention, and seizures or permanent brain injury. A plasma glucose level below 50 mg/dL is commonly used as a threshold for stopping provocative tests for the diagnosis of hypoglycemia. The treatment goal for a child with a hypoglycemic disorder is to maintain blood glucose concentrations above 70 mg/dL. This therapeutic target of more than 70 mg/dL is particularly important in children with hypoglycemia due to hyperinsulinism, since these infants are unable to produce ketones as an alternative fuel for the brain when glucose is low. ## **THE CRITICAL SAMPLE AND FASTING TEST**"
  }
 ]
}