Anyone who has ever worked in or maybe even visited an Emergency Department knows that we LOVE acronyms. Students and trainees alike know that the answer to any “How would you manage this patient?” question in the ED must begin:
“Well, first I would check A-B-C…”
In the UK, we love acronyms so much in Emergency Medicine, we have given the three parts of the college membership exam letters corresponding to our favourite acronym (other colleges have, unimaginatively, used numbers).
What you might also be aware of, if you have worked in paediatrics, paed EM, attended any paediatric life support course or ever seen a paediatric patient, is the acronym D-E-F-G:
Don’t Ever Forget Glucose
Now, there are quite enough acronyms in clinical medicine and their use can definitely be confusing. But the point this one makes is valid: hypo- and hyperglycemia are great pretenders (much like syphilis), presenting with a variety of vague, seemingly disconnected symptoms, and checking a bedside glucose is a vital part of the assessment of the sick child.
Management of previously undiagnosed hyperglycemia is straightforward: whether or not there is ketoacidosis present, the child needs admission under the inpatient paediatric team. But what of paediatric hypoglycaemia? It’s not uncommon in children presenting with gastroenteritis, and is easily corrected. Do these patients also require inpatient admission?
This is the question posed to me on Twitter by Brian Burns (@HawkmoonHEMS), an Emergency Physician and HEMS doctor:
@_nmay Hi. 2 kids with gastro and low sugars, hypos resolved with ORT. Paediatrician stated all paed hypos irrespective of cause need inx.?
— brian burns (@HawkmoonHEMS) October 17, 2012
This question is really important, not least because it highlights an important mental divide: if you ask a paediatrician and an EM doctor how they would manage hypoglycaemia, their answers will very likely be vastly different. Should they be?
Beth Jameson, a fabulous registrar in paediatric metabolic disease at the Royal Manchester Children’s Hospital, gave a great presentation on metabolic disease to me and to my PICU colleagues. She sums up how she, as a paediatric specialist, would think about hypoglycaemia in this single slide.
The problem is that, as Emergency Physicians, we see hypoglycaemia reasonably often – usually in adult diabetic patients. We give them some jam on toast, a cup of sugary tea and they feel better, so we send them on their way. Can we take the same approach to paediatric patients? Well, if they have known insulin-dependent diabetes, then this approach might also be reasonable. A quick note or phone call to their diabetic specialist nurse is a useful safety net.
We also know how to treat life-threatening hypoglycaemia in obtunded patients; the latest (5th edition) APLS guidelines advocate 2ml/kg 10% dextrose followed by an intravenous infusion.
But let’s think about those patients who don’t have diabetes: can we send them home once their sugar responds, or do they all need investigation?
As with almost everything to do with neonates, be suspicious, be scared and refer the neonate with hypoglycaemia. Many of the nastiest metabolic diseases present in the neonatal period; there is no way that a hypoglycaemic neonate should be discharged from the Emergency Department. Alarm bells should be totally deafening you if the child is an ex-prem, febrile, jaundiced or there is a history of consanguinity. Obtain IV access and resuscitate the child, and correct the glucose as above (and if you can send an ammonia level the paediatricians will love you). Get expert paediatric help early.
Known Metabolic Disease
If you are unlucky or happen to work near a centre for metabolic disease, you might meet patients with known underlying metabolic disease. Many of these patients become hypoglycaemic with intercurrent illness. They will often carry details of an “emergency regime” with them, or know where to access it. In the UK, the British Inherited Metabolic Disease Group has a fantastic online Emergency Protocols resource, divided into children and adults and listed by disease. This should help you address the basics while you get expert input.
Beyond the Neonatal Period
Beyond the neonatal period, hypoglycaemia becomes more common. Children typically have poor glycemic stores, lasting around 12 hours in young children and 4 hours in infants. Most commonly, hypoglycaemia is seen in children with gastroenteritis. A recent early publication suggests an association between rotavirus infection and hypoglycaemia, in addition to an association between only giving sugar-free fluids at home to maintain hydration. Parents who bring their children to the Emergency Department with gastroenteritis frequently justify their attendance with a concern that the child is not eating. It is certainly not uncommon for children to have a reduced appetite during acute illness (and to “not keep anything down” if they are given porridge immediately after their last vomit) and this need not be problematic as long as the child is offered sugar-containing juice, remains alert and has a good urine output.
The problem is, previously undiagnosed metabolic and endocrine disease can be precipitated out by intercurrent illness and can be diagnosed at any age. How can we know in the Emergency Department whether the hypoglycaemia is due to rotaviral infection or underlying adrenal failure, or medium chain acyl dehydrogenase deficiency (MCADD)? Unfortunately, we can’t. We can, however, be sensible. In my practice, I try to take a sensible approach.
The Sick Child
I would normally refer to the inpatient team:
- Any child who does not have a good history of infective gastroenteritis. History is very important: remember particularly in toddlers the risk of accidental ingestion. Are there any medications in the house that the child might have been able to get hold of? Think of grandma’s gliclazide and quinine here.
- A child who appears unwell for any other reason. I refer you back to my personal unpleasant experience of watching a purpuric rash develop on the back of a child admitted with diarrhoea and vomiting, being observed because of hypoglycaemia at presentation. Sepsis kills.
- The child whom the parents are concerned about. You know they will come back anyway if the child vomits again. But parental concern is an important cue. Take them seriously.
- If the child does not respond to initial enteral correction of hypoglycaemia.
- If you are inserting an intravenous cannula (and consider sending a hypoglycaemia screen – see below).
Children who present to the department with hypoglycaemia should have a hypoglycaemia screen while their sugar level is low. It is done while they are hypoglycaemic to give a “true” lab glucose and also for a meaningful ketone level, as ketosis can be helpful in identifying underlying disease. In practice, this means stabbing a child’s veins without topical anaesthesia and is sometimes impossible because by the time you are aware of the child’s hypoglycaemia, someone has kindly given them some glucose or some jam.
If there has been documented hypoglycaemia, now corrected, in the setting of gastroenteritis with no other concerns, the child might be able to go home after a period of observation. It is really tricky to safely discharge these patients. Gastroenteritis as the cause is, realistically, a diagnosis of exclusion. I would certainly advocate admission to a paediatric observation ward if one is available, with topical local anaesthetic in situ so that a hypoglycaemia screen can be performed if the sugar falls again.
The Hypoglycaemia Screen
This will probably vary from hospital-to-hospital, but here are the basic ingredients. Please also check your local policy (don’t blame me!)
So ALL these patients need to have a hypoglycaemia screen?
I think probably, yes – sorry But I can’t see any way around it. It’s important to make a diagnosis of underlying illness if one exists, and without performing a hypoglycaemia screen it’s difficult to be completely sure.
Better safe than sorry – and I don’t feel that brave today.
Diagnosis and Management of Hypoglycaemia Beyond the Neonatal Period – here
The Investigation and Management of Neonatal Hypoglycaemia – here
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