Hypoglycaemia Management in Children, Emergency Department, Paediatrics (507)

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

Hypoglycaemia is defined as blood sugar level <2.6mmol/l (commonly referred to as BM). The maintenance of a normal blood sugar level is a complex process.

Hypoglycaemia is a sign of underlying disease that interferes with at least one of the following processes:

Carbohydrate intake
Carbohydrate absorption
Gluconeogenesis
Glycogenolysis

Gluconeogenesis is a metabolic pathway that results in the generation of glucose from non-carbohydrate substrates e.g pyruvate, lactate, glycerol. It mainly occurs in the liver but also to some extent in the cortex of the kidneys. The process occurs during periods of fasting, starvation, low-carb diets or intense exercise. It is often associated with ketosis.

Glycogenolysis is the breakdown of glycogen and takes place in the cells of muscle (to provide energy for contraction) and hepatocytes (to release glucose into the bloodstream for uptake by other cells).

Causes of hypoglycaemia

Inadequate glucose
intake/production?

Excessive glucose
consumption?

Systemic/Nutrition

Starvation
Malnutrition
Sepsis
Malabsorption

Metabolic

Ketotic hypoglycaemia “accelerated starvation”
Glycogen storage disease
Galactosaemia
Organic acidaemia
Carnitine deficiency
Acyl CoA Dehydrogenase deficiency

Endocrine

Hyperinsulinism
Hypopituitarism
Growth hormone deficiency
Hypothyroidism
Congenital adrenal hyperplasia

Hepatic

Hepatitis
Cirrhosis
Reye Syndrome

Toxic

Aspirin
Alcohol
Insulin
Valproate

Signs and symptoms

The signs and symptoms of hypoglycaemia vary greatly between individuals. Autonomic features tend to appear earlier (but are not always present!). Neurological features occur due to impaired glucose supply to the brain.

Symptoms

Signs

Mild

Moderate

Severe

Sweating
Headache
Anxiety
Jelly legs
Difficulty concentrating

Dizziness
Visual disturbance

Tremor
Pallor
Tachycardia
Change in behaviour
Lethargy
Slurred speech
Unsteady gait
Confused

Altered consciousness
Convulsions

Important points to cover in patient history

Past history

Similar episodes in the past (these may have been unrecognised as being caused by hypoglycaemia e.g seizures)
Neonatal hypoglycaemia

Family history

Unexplained infant deaths (consider inborn errors of metabolism)
Some hormone or insulin problems may be familial

Relation to foods

Milk (galactosaemia)
Juice (hereditary fructose intolerance)
Protein (amino acid or organic acid disorder)

Possible access to medicines/alcohol

Oral hypoglycaemia agents
Alcohol
Aspirin
B-Blockers
Insulin

Investigations

Bloods

Use Paediatric Hypoglycaemia grab bag - Found on all IV trolleys in RHC, Emergency Department.
Details for Paediatric Hypoglycaemia grab bag also found at end of this document.

These bloods are ideally taken before dextrose is given. Aim for 5ml – but minimum 1.5ml.

Bloods should be sent promptly after collection using the POD system. They should be selected as URGENT on Trakcare. It is not necessary to call the lab or sent samples on ice.

Urine

Urinary ketones & Urinary organic acid.

Management

Hypoglycaemia Management Flow Chart

Paediatric hypoglycaemia "Grab Bag"

For all patients requiring a 'hypo screen' for hypoglycaemia

‘PAEDS HYPOGLYCAEMIA ‐ TIME CRITICAL SAMPLES’ (Samples required PRIOR to administration of glucose)
TEST	TUBE TYPE	VOLUME REQUIRED
Glucose Free fatty acids (FFAs)	Fluoride oxalate (GREY)	500 microlitres (aim for half full)
Insulin C-peptide Beta OH butyrate Cortisol	Lithium Heparin (GREEN screw top)	1ml ideally 2mls (1 bottle, 2 if possible)
Lactate (Capillary blood gas)	Capillary blood gas tube (Processed in ED)	Aim for 1 full capillary tube

***SAMPLES MUST BE IN THE LAB WITHIN 15 MINUTES OF COLLECTION***
CONTACT LAB TO INFORM THEM OF URGENT HYPOGLYCAEMIA SAMPLES

'PAEDS HYPOGLYCAEMIA ADDITIONAL ESSENTIAL' (Sample can be taken AFTER administration of glucose)
TEST	TUBE TYPE	VOLUME REQUIRED
Ammonia U&Es LFTs CRP Acylcarnitine	Lithium Heparin (GREEN screw top)	1ml (1 bottle)
FBC	EDTA (Small PINK screw top)	500 microlitres (up to mark on bottle)
Blood culture	Age and volume dependent
URINARY organic acids	URINE in WHITE top universal container	5mls

How to order on Trakcare

‘PAEDS HYPOGLYCAEMIA ‐ TIME CRITICAL SAMPLES’
(Samples required PRIOR to administration of glucose)

To order the TIME CRITICAL SAMPLES then follow these steps:

Ensure patient highlighted on ED screen then click on 'NEW REQUEST' tab.
Click on "LABS - CHILD"
On the right side of the screen type the requested tests in section titled 'ITEM' then hit 'F6' key
Select appropriate test in pop-up screen

**ALWAYS SELECT THE "-CHILD" OPTION FOR THE TEST REQUESTED (WHEN AVAILABLE)**

HINTS:

For FFAs type 'free' then hit the F6 key
For C - Peptide ensure there is a space either side of the '-' before hitting F6
For Beta OH Butyrate type 'beta' then hit F6 key
Remember lactate is taken on a capillary gas tube and processed in the ED

'PAEDS HYPOGLYCAEMIA ADDITIONAL ESSENTIAL'
(Sample can be taken AFTER administration of glucose)

To order the ADDITIONAL ESSENTIAL SAMPLES then follow the same process as above.

**ALWAYS SELECT THE "-CHILD" OPTION FOR THE TEST REQUESTED (WHEN AVAILABLE)**

HINTS:

For Acylcarnitine ensure you select the option with 'BS' at the end.
For Urinary Organic Acids type 'organic' then hit F6 key

ONLY STICK ONE 'TRAKCARE' LABEL TO THE CORRESPONDING TUBE.
THE REMAINING LABELS SHOULD REMAIN ON THE REQUEST FORM AND ACCOMPANY THE SAMPLES TO THE LAB.

Last reviewed: 29/03/2021

Next review date: 30/04/2024

Author(s): Dr Gill Campbell, Paediatric Emergency Department.

Approved By: Paediatric Clinical Effectiveness & Risk Committee

Reviewer name(s): gillian.campbell10@nhs.scot, steven.foster@nhs.scot.

Document Id: 507