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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 124-126

Is hypoglycaemia in acute ill children presenting to emergency department investigated properly?


Pediatric Department, Tawam Hospital, Al Ain, UAE

Date of Web Publication24-Sep-2018

Correspondence Address:
Noura Al Hassani
Tawam Hospital, PO Box 15258, Al Ain
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_2_18

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  Abstract 


Background: Infants and children presenting to the emergency department with hypoglycemia are a diagnostic emergency and require urgent treatment. We hypothesize that pediatric patients who present with hypoglycemia associated with other acute illnesses are not being investigated properly for the hypoglycemia etiology. Methods: The medical records of all pediatric patients with the diagnosis of hypoglycemia, blood glucose level of <3mmol/L (54mg/dl) and not known to have metabolic or endocrine illness, who presented to the emergency department at Tawam Hospital from Jan 2012 until December 2014, were retrospectively reviewed. Patient's demographic data had been collected in addition to associated diagnosis, hypoglycemic related symptoms, glucocheck, serum glucose, urine ketones, workup and management. Data were analyzed using Excel 2010. Results: Among 514 subjects reviewed, 197 were included. 52% were male and 81% were less than five years of age. The most common associated diagnosis was acute gastroenteritis (AGE), 152 (77%). 46 (23%) had associated hypoglycemic related symptoms, although nonspecific. None of the subjects had specific investigations for hypoglycemia at time of presentation. 16 (8%) were identified as high risk for having pathologic cause for hypoglycemia, however 4 (25%) referred for metabolic and/or endocrinology services. Urine was checked only in 50 (25%) subjects, 45 (90%) of them tested positive for ketones. Conclusion: Evidence based clinical practice guidelines are needed in managing children with hypoglycemia associated with acute illness who are not known to have metabolic or endocrine diseases. In addition, parent's education on proper care of children with AGE is required to prevent hypoglycemia.

Keywords: Acute illness, children, emergency department, hypoglycaemia, investigations


How to cite this article:
Hadi S, Al Hassani N, Abushkhaeidem M, Al Khaaldi A, Khayat A. Is hypoglycaemia in acute ill children presenting to emergency department investigated properly?. Hamdan Med J 2018;11:124-6

How to cite this URL:
Hadi S, Al Hassani N, Abushkhaeidem M, Al Khaaldi A, Khayat A. Is hypoglycaemia in acute ill children presenting to emergency department investigated properly?. Hamdan Med J [serial online] 2018 [cited 2019 Nov 21];11:124-6. Available from: http://www.hamdanjournal.org/text.asp?2018/11/3/124/236267




  Introduction Top


Clinical hypoglycaemia is defined as a plasma or serum glucose concentration low enough to cause symptoms and/or signs including impairment of brain function.[1] Although 'accelerated starvation' previously known as 'ketotic hypoglycaemia' that occurs after a prolonged fast is the most common cause of hypoglycaemia in children beyond infancy,[2] definitive diagnosis requires exclusion of other metabolic and endocrine causes. Infants and children presenting to the emergency department with hypoglycaemia are a diagnostic emergency and require urgent treatment as the impact of hypoglycaemia on their developing brains cannot be underestimated.[3]

We hypothesise that paediatric patients who present with hypoglycaemia associated with other acute illnesses but with risk factors for pathological causes of hypoglycaemia are not being appropriately investigated for the aetiology of hypoglycaemia. It is also possible that aetiologies and risk factors attributing to hypoglycaemia among our paediatric population are unique. The main aim of this study is to emphasise the need of an evidence-based clinical practice guidelines on evaluation and management of hypoglycaemia in unknown metabolic or endocrine paediatric patients presenting with an acute illness.


  Methods Top


Ethical clearance was obtained from our Regional Institutional Review Board. The medical records of paediatric patients with the diagnosis of hypoglycaemia, who presented to the emergency department at Tawam Hospital facility, were retrospectively reviewed. The study period was from 1st January 2012 to 31st December 2014. All patients with age of 1 month to 13 years with blood glucose level of <3 mmol/L (54 mg/dl) and not known to have metabolic or endocrine illness were included in the study.

We reviewed 514 patients. One hundred and ninety-seven patients were included as they fulfilled our inclusion criteria. Most of the excluded patients had blood glucose equal or >3 mmol/L (54 mg/dl), while the rest was known to have a metabolic or endocrine illness or there was lack of sufficient data. The medical records for the included patients were reviewed retrospectively. Data extracted from the medical records including patient age, gender, associated diagnosis, symptoms related to hypoglycaemia, growth parameters, glucocheck, venous serum glucose, urine ketones, diagnostic workup and management. Data were analysed using Excel 2010.


  Results Top


A total of 197 patients who met the inclusion criteria were studied. Of these, 103 (52%) were male and 94 (48%) were female. 160 (81%) were 1 to 5 years of age while eight (4%) were <1 year and 29 (15%) more than 5 years.

Growth parameters were documented in 173 (88%) patients, 39 (22%) of them had weight for length ratio or body mass index at or <5th percentile. The most common associated diagnosis was acute gastroenteritis (AGE) in 152 (77%) patients.

Forty-six (23%) of total patients had associated symptoms; although non-specific, that could be related to hypoglycaemia such as decreased activity, weakness and lethargy or unresponsiveness. All those symptomatic patients (100%) were <5 years of age.

Almost all patients were treated symptomatically using intravenous boluses of dextrose-containing solutions. None of them had specific investigations for hypoglycaemia at the time of presentation before correcting the hypoglycaemia. Most of the patients were admitted to the hospital for observation and further management mainly for associated diagnosis, and they were discharged on improvement. However, very few of them had further attention to the aetiology of hypoglycaemia during their admission.

Sixteen (8%) were considered to be at high risk for having underlying pathologic cause for hypoglycaemia. These patients had one or more of the followings: non-ketotic hypoglycaemia, persistent metabolic acidosis, recurrent episodes of hypoglycaemia or more severe symptoms on presentation such as seizure or altered level of consciousness.

Among the 197 patients, only eight (4%) were referred for metabolic and/or endocrinology services for further investigations. Four of these patients were among the ones who were considered to be high-risk patients. The decision for referral did not seem to be based on any guidelines or the presence of risk factors but rather based on physician judgement.

Among the referred eight patients, one had been diagnosed with medium-chain acyl-CoA dehydrogenase deficiency. Urine was not tested for ketones at the time of presentation; however, the persistent metabolic acidosis triggered the metabolic referral.

Only 50 (25%) of the total their urine was checked for ketones. Forty-five (90%) of them had positive ketones indicating the likelihood of accelerated starvation or ketotic hypoglycaemia. On further analysis of those with ketotic hypoglycaemia, 42 (91%) were <5 years of age. Eight (18%) had weight at or below the 5th percentile, 27 (60%) patients were female and 80% had associated diagnosis of AGE.


  Discussions Top


Hypoglycaemia in non-diabetic children is common during the emergency department presentation with acute illness.[2] There is no agreed definition of hypoglycaemia in children, while some authorities accept 40 mg/dl among non-diabetic patients, <45 mg/dl for neonate others define hypoglycaemia as blood glucose level of <60 or ≤65 mg/dl while some report cut-off values of <80 mg/dl.[4] In this study, we considered a blood glucose level of <3 mmol/L (54 mg/dl) is hypoglycaemia; therefore, many of the patients with the diagnosis of hypoglycaemia had been excluded from the study.

The cause of hypoglycaemia in critically ill children is not well understood but includes cytokine-induced impairment of gluconeogenesis, impaired counter-regulatory hormone response and depletion of glucose stores in starvation.[4]

None of our patients had specific investigations for hypoglycaemia at the time of presentation before starting dextrose-containing intravenous fluid in the emergency room. In addition, those with high risk for having underlying pathologic cause for hypoglycaemia were not recognised or investigated during their hospital stay. This might be due to lack of awareness of high-risk factors among our health providers.

Eight of the total 179 patients referred for metabolic and/or endocrinology services for further investigations were based on provider judgement without following the evidence-based clinical practice guidelines of hypoglycaemia in unknown metabolic or endocrine disease. Such guidelines should encompass the clear definition of hypoglycaemia in paediatrics patients, guidelines for treatment and indications for further investigation and referrals.

This study shows that accelerated starvation or ketotic hypoglycaemia is more common in children under 5 years of age; however, weight at or below the 5th percentile has not been recognised as a risk factor and the male gender. These findings are not consistent with results of other reviews in the literature.[2],[5] This might be due to that only 25% of total patients were investigated for urine ketones.

AGE was the most common associated illness in this study. The association between hypoglycaemia and AGE was observed in many previous studies.[6],[7],[8] We did not look at the cause behind the association between AGE and hypoglycaemia; however, it could be due to the delayed presentation with severe dehydration and prolong starvation as well as underestimation of complications of AGE due to lack of appropriate education provided to families on handling children with vomiting and diarrhoea. Therefore, parents awareness about hypoglycaemia in AGE is required by providing them educational pamphlets in simple language on taking care of children with AGE to recognise and prevent the dehydration and hypoglycaemia in addition when to seek medical advice.


  Conclusion Top


Hypoglycaemia with acute illness in children not known to have metabolic or endocrine diseases but with risk factors for pathological causes of hypoglycaemia is not appropriately investigated in our facility. Evidence-based clinical practice guidelines for the management of hypoglycaemia in acutely ill children for physicians are needed as well as parent's education on proper care of children with AGE to prevent hypoglycaemia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mukherjee E, Carroll R, Matfin G. Endocrine and metabolic emergencies: Hypoglycaemia. Ther Adv Endocrinol Metab 2011;2:81-93.  Back to cited text no. 1
    
2.
Daly LP, Osterhoudt KC, Weinzimer SA. Presenting features of idiopathic ketotic hypoglycemia. J Emerg Med 2003;25:39-43.  Back to cited text no. 2
    
3.
Josefson J, Zimmerman D. Hypoglycemia in the emergency department. Clin Pediatr Emerg Med 2009;10:285-91.  Back to cited text no. 3
    
4.
Uleanya ND, Aniwada EC, Nwokoye IC, Ndu IK, Eke CB. Relationship between glycemic levels and treatment outcome among critically ill children admitted into emergency room in Enugu. BMC Pediatr 2017;17:126.  Back to cited text no. 4
    
5.
Priyambada L, Raghavan S. (Idiopathic) Ketotic hypoglycemia in children. Indian J Emerg Pediatr 2009;1:95-7.  Back to cited text no. 5
    
6.
Reid S, McQuillan S, Losek J. Hypoglycemia complicating dehydration due to acute gastroenteritis. Clin Pediatr (Phila) 2003;42:641-6.  Back to cited text no. 6
    
7.
Reid SR, Losek JD. Hypoglycemia complicating dehydration in children with acute gastroenteritis. J Emerg Med 2005;29:141-5.  Back to cited text no. 7
    
8.
Kaiser P, Borte M, Zimmer KP, Huppertz HI. Complications in hospitalized children with acute gastroenteritis caused by rotavirus: A retrospective analysis. Eur J Pediatr 2012;171:337-45.  Back to cited text no. 8
    




 

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