Management
Refer to flowchart [PDF 362 KB] for a summary of the management of a child presenting to ED with hypoglycaemia.
Alert
Hypoglycaemia is a medical emergency. If left untreated it can cause convulsions, irreversible brain damage and death.
Acute management
Obtain IV/IO access rapidly for child with BGL <3.0 mmol/L on a glucometer.
Upon obtaining IV access:
- obtain formal BGL on blood gas machine, iSTAT or formal laboratory testing
- draw 5 mL of blood (ideally) for further investigations (See Investigations section)
- measure blood ketones using a blood ketone monitor
Management of child with formal BGL >2.6 mmol/L
- If low normal BGL, push fluids with initial high sugar content (apple juice, flavoured ice block) followed by more complex carbohydrates.
- If formal BGL is greater than 3.0mmol/L, do not send bloods for further investigation
Management of child with hypoglycaemia (formal BGL ≤2.6mmol/L)
Children with a history of prolonged fasting (over 30 hours) and blood ketones >4 can be managed as KH.
In addition to treating the hypoglycaemia, blood and urine should be collected from all remaining children to screen for an underlying disorder (refer to Investigation section).
Alert
Hypoglycaemia should be treated with Glucose 10% +Sodium Chloride 0.9% IV fluids.
A Glucose 5% infusion is usually not sufficient to maintain BGL or clear ketones.
| Management of hypoglycaemia in children |
|---|
| Initial bolus dose (IV) |
2 mL/kg of 10% glucose
|
| Following IV bolus | Commence an infusion of Glucose 10% + Sodium Chloride 0.9% at maintenance rate. Take a 1L bag of Glucose 5% with Sodium Chloride 0.9%, withdraw 100 mL of fluid from the bag and discard. Inject 100 mL of 50% glucose into the bag and mix well. Refer to QCH IV Fluid Guideline [PDF] (QH only). If dehydrated, commence maintenance fluids plus replacement of deficit over 24 hours. |
| Monitoring |
IV site hourly for signs of extravasation due to the hyperosmolality of the infusion (see Insertion and management of peripheral and central venous access devices [PDF] (QH only)
|
IM glucagon is unlikely to benefit a child with KH.
IO route is recommended if unable to obtain IV access.
Consider seeking senior emergency/paediatric advice as per local practice for child with a BGL ≤2.6, a history of fasting over 30 hours and blood ketones >4.
Seek senior emergency/paediatric advice as per local practice for child BGL ≤2.6 without a history of fasting over 30 hours and blood ketones >4. Additional investigations are required.
Ongoing management
Seek senior emergency/paediatric advice as per local practice if no clinical improvement following initial glucose bolus and IV fluid infusion. Consider seeking paediatric metabolic advice.
Seek relevant specialist advice as clinically indicated by results of the hypoglycaemia screen for ongoing investigations and management.
Review the IV fluid calculation and glucose concentration for children with ongoing symptoms of clinical concern following initial bolus and IV infusion. Consider alternate/concurrent diagnoses.
On admission to the ward or SSU:
- continue 10% glucose + 0.9% NaCl at maintenance rate (plus additional fluids to replace deficit if dehydrated).
- administer Ondansetron for children over 12 months of age with nausea or vomiting (note ketones alone can cause nausea which may not settle until ketones have cleared).
- encourage oral fluids (see below) and diet, preferably with foods containing carbohydrates.
- once tolerating oral intake IV fluids may be discontinued or changed to 5% glucose with 0.9% NaCl at a reduced rate.
- organise discharge medications (glucose gel and glucose 10% polymer, +/- ondansetron) early in admission.
| Ondansetron for the management of nausea or vomiting in children |
|---|
| Dose | Given orally or sublingually at a dose of 0.15 mg/kg (maximum 8 mg). Tablets and wafers are available in 4 mg and 8 mg doses. Recommended doses are as follows: - 8-15 kg: 2 mg
- 15-30 kg: 4 mg
- greater than 30 kg: 8 mg
Not recommended for children aged less than 6 months, weight less than 8 kg or with ileus. |
| Considerations |
Ondansetron prolongs the QT interval in a dose–dependent manner. Exercise caution in children who have or may develop prolongation of QTc (such as those with electrolyte disturbances, heart failure or on medications that may lead to a prolongation of the QTc).
|
Fluids
Appropriate oral fluids include:
- 10% glucose polymer (Polyjoule, CarbPlus, SOS formulas)
- 100% apple juice
The following fluids are unsuitable:
- glucolyte (2.5% glucose + 3% sucrose)
- hydralyte ice blocks (1.6% glucose)
Monitoring
Children with hypoglycaemia require routine observation as dictated by their clinical condition.
BGL monitoring
BGL monitoring is not required for children receiving a Glucose 10% infusion as the risk of hypoglycaemia is minimal unless hyperinsulinism is suspected.
Consider BGL monitoring for the following children:
- symptoms of clinical concern such as pallor, vomiting, tachycardia or drowsiness
- ketones that are absent or inappropriately low (consider hyperinsulinism and continue BGL monitoring until insulin level is known).
It is the treating doctor’s responsibility to document if BGL monitoring is required.
Ketone monitoring
Test urine for ketones after 12 – 24 hours of treatment to ensure urine ketones have cleared or are clearing. If ketones are present, continue to monitor 12 – 24-hourly until cleared.
