BNF for Children 2011-2012

BNFC 2011–2012 6.1.4 Treatment of hypoglycaemia 3616.1.4 Treatment ofhypoglycaemiaPrompt treatment of hypoglycaemia in children fromany cause is essential as severe hypoglycaemia maycause subsequent neurological damage. Hyperinsulinism,fatty acid oxidation disorders and glycogen storagedisease are less common causes of acute hypoglycaemiain children.Initially glucose 10–20 g is given by mouth either inliquid form or as granulated sugar or sugar lumps.Approximately 10 g of glucose is available from nondietversions of Lucozade c Energy Original 55 mL,Coca-Cola c 100 mL, and Ribena c Blackcurrant 19 mL(to be diluted), 2 teaspoons of sugar, and also from 3sugar lumps 1 . If necessary this can be repeated in 10–15minutes. After initial treatment, a snack providingsustained availability of carbohydrate (e.g. a sandwich,fruit, milk, or biscuits) or the next meal, if it is due, canprevent blood-glucose concentration from falling again.Hypoglycaemia which causes unconsciousness or seizuresis an emergency. Glucagon, a polypeptide hormoneproduced by the alpha cells of the islets of Langerhans,increases blood-glucose concentration bymobilising glycogen stored in the liver. In hypoglycaemia,if sugar cannot be given by mouth, glucagoncan be given by injection. Carbohydrates should begiven as soon as possible to restore liver glycogen;glucagon is not appropriate for chronic hypoglycaemia.Glucagon can be issued to parents or carers of insulintreatedchildren for emergency use in hypoglycaemicattacks. It is often advisable to prescribe it on an ‘ifnecessary’ basis for hospitalised insulin-treated children,so that it can be given rapidly by the nurses duringa hypoglycaemic emergency. If not effective in 10minutes intravenous glucose should be given.Alternatively, 5 mL/kg of glucose intravenous infusion10% (500 mg/kg of glucose) (section 9.2.2) can be givenintravenously into a large vein through a large-gaugeneedle; care is required since this concentration isirritant especially if extravasation occurs. Glucose intravenousinfusion 50% is not recommended, as it is veryviscous and hypertonic. Close monitoring is necessary,particularly in the case of an overdose with a long-actinginsulin because further administration of glucose maybe required. Children whose hypoglycaemia is causedby an oral antidiabetic drug should be transferred tohospital because the hypoglycaemic effects of thesedrugs can persist for many hours.Glucagon is not effective in the treatment of hypoglycaemiadue to fatty acid oxidation or glycogen storagedisorders.Neonatal hypoglycaemia Neonatal hypoglycaemiaat birth is treated with glucose intravenous infusion10% given at a rate of 5 mL/kg/hour. An initial dose of2.5 mL/kg over 5 minutes may be required if hypoglycaemiais severe enough to cause loss of consciousnessor seizures. Mild asymptomatic persistent hypoglycaemiamay respond to a single dose of glucagon. Glucagonhas also been used in the short-term managementof endogenous hyperinsulinism.1. Proprietary products of quick-acting carbohydrate (e.g.GlucoGel c , Dextrogel c , Hypo-Fit c ) are available onprescription for the patient to keep to hand in case ofhypoglycaemiaGLUCAGONCautions see notes above, insulinoma, glucagonoma;ineffective in chronic hypoglycaemia, starvation, andadrenal insufficiency; delayed hypoglycaemia whenused as a diagnostic test—deaths reported (ensure ameal is eaten before discharge)Contra-indications phaeochromocytomaSide-effects nausea, vomiting, diarrhoea, hypokalaemia,rarely hypersensitivity reactionsLicensed use unlicensed for growth hormone testand hyperinsulinismIndication and doseHypoglycaemia associated with diabetes. By subcutaneous, intramuscular, or intravenousinjectionNeonate 20 micrograms/kgChild 1 month–2 years 500 microgramsChild 2–18 years, body-weight less than 25 kg500 micrograms; body-weight over 25 kg 1 mgEndogenous hyperinsulinism. By intramuscular or intravenous injectionNeonate 200 micrograms/kg (max. 1 mg) as asingle doseChild 1 month–2 years 1 mg as a single dose. By continuous intravenous infusionNeonate 1–18 micrograms/kg/hour, adjustedaccording to response (max. 50 micrograms/kg/hour)Child 1 month–2 years 1–10 micrograms/kg/hour, increased if necessaryAdministration Do not add to infusion fluids containingcalcium—precipitation may occurDiagnosis of growth hormone secretion specialistcentre only (section 6.5.1). By intramuscular injectionChild 1month–18 years 100 micrograms/kg(max. 1 mg) as a single dose; dose may vary,consult local guidelinesBeta-blocker poisoning, see p. 29Note 1 unit of glucagon = 1 mg of glucagon1GlucaGen c HypoKit (Novo Nordisk) AInjection, powder for reconstitution, glucagon (rys) ashydrochloride with lactose, net price 1-mg vial withprefilled syringe containing water for injection =£11.521. A restriction does not apply where administration is forsaving life in emergencyChronic hypoglycaemiaDiazoxide is useful in the management of chronic hypoglycaemiadue to excessive insulin secretion, either froma tumour involving the islets of Langerhans or frompersisting hyperinsulinaemic hypoglycaemia of infancy(nesidioblastosis, see also glucagon above). Diazoxidehas no place in the management of acute hypoglycaemia.Chlorothiazide 3–5 mg/kg twice daily (section6 Endocrine system