Hypoglycemia in theHypoglycemia in the

infant and childh infant and childh

It is a medical emergencyIt is a medical emergency

demanding immediate demanding immediate

investigation and treatment investigation and treatment

Definition of HypoglycemiaDefinition of Hypoglycemia

Plasma glucose value of less than Plasma glucose value of less than 50mg/dl(2.8 MMOL/Lit)50mg/dl(2.8 MMOL/Lit)

Lower limit acceptable during therapy forLower limit acceptable during therapy for Hypoglycemia is 70 mg/dl(the goal of Hypoglycemia is 70 mg/dl(the goal of Therapy is to maintain plasma glucose Therapy is to maintain plasma glucose

levels in the normal range of 70-100 mg/dl levels in the normal range of 70-100 mg/dl most of time )most of time )

Symptoms and signsSymptoms and signs

Adrenergic manifestationAdrenergic manifestation

Nevro glycopenic manifestationNevro glycopenic manifestation

Adrenergic manifestationAdrenergic manifestation

SweatingSweating ShakinessShakiness TachycardiaTachycardia AnxietyAnxiety WeaknessWeakness HangerHanger Naseua-vometingNaseua-vometing

Nevroglycopenia manifestationNevroglycopenia manifestation

HeadacheHeadache Visual disturbancesVisual disturbances LethargyLethargy Mental confusionMental confusion ConvulsionConvulsion HypothermiaHypothermia

Major causes of HypoMajor causes of Hypo

glicemia in the infantglicemia in the infant

and childhand childh

Hyper insulinismHyper insulinism Aut.R(newborn period)Aut.R(newborn period) AUT.D(infancy and childhood)AUT.D(infancy and childhood) With hyperammonia (infancy and childhood)With hyperammonia (infancy and childhood) Glucokinax activation(aut.D)Glucokinax activation(aut.D) SCHAD(loss of function mutation)SCHAD(loss of function mutation) ExerciseExercise FactitiousFactitious InsulinomaInsulinoma Auto immuneAuto immune

Criteria for diagnosing Hyper Criteria for diagnosing Hyper insulinism based on critical sampleinsulinism based on critical sample

Detectable insulin (>2MIU/ML)Detectable insulin (>2MIU/ML) Low FFA(<1.5 MMOL/LIT)Low FFA(<1.5 MMOL/LIT) Low ketons of plaama(<2.0 MMOL/ML)Low ketons of plaama(<2.0 MMOL/ML) Glgcemic response to 1mg intravenous Glgcemic response to 1mg intravenous

glucagon at the time of fasting glucagon at the time of fasting

Hypoglycemia(≥30mg/dl glucose rising in 20 Hypoglycemia(≥30mg/dl glucose rising in 20 min)min)

Ketotic HypoglycemiaKetotic Hypoglycemia

The most common form of childhood HypoglycemiaThe most common form of childhood Hypoglycemia Begins between 18 months to 5 years and spontaneous Begins between 18 months to 5 years and spontaneous

remits by the age of 8-9 yearsremits by the age of 8-9 years Low plasma alanine levelLow plasma alanine level Decrease glucose production during over night fastingDecrease glucose production during over night fasting Low insulin level-keton body elevatedLow insulin level-keton body elevated High level of counter regulatory hormonesHigh level of counter regulatory hormones Most patients are smaller than age-match control and Most patients are smaller than age-match control and

have a history of transient neonatal Hypoglycemiahave a history of transient neonatal Hypoglycemia

Hormone deficiencyHormone deficiency

GH deficiency due to panhypopitutrismGH deficiency due to panhypopitutrism

ACTH deficiency due to panhypopitutrismACTH deficiency due to panhypopitutrism

Metabolic diseaseMetabolic disease

GSD disorderGSD disorder GalactosemiaGalactosemia Organic acidemiaOrganic acidemia Gluconeogenesis defectGluconeogenesis defect ß oxidation defectß oxidation defect Fructose intoleranceFructose intolerance

Systemic diseaseSystemic disease SepsisSepsis Head injuryHead injury Acute hepatic failureAcute hepatic failure Multiple organe failureMultiple organe failure cyanotic congenital heart diseasecyanotic congenital heart disease CHFCHF CRFCRF DiarrheaDiarrhea MalariaMalaria

DrugsDrugs

EthanolEthanol Beta blockerBeta blocker AcetaminophenAcetaminophen SalicylateSalicylate SulfanamidSulfanamid QuinineQuinine Co-TMXCo-TMX PentamidinePentamidine

Alimentary Hypoglycemia(late dumping)Alimentary Hypoglycemia(late dumping)

In patient with nissen fundoplication and In patient with nissen fundoplication and gastrostomy tube replacement gastrostomy tube replacement

Hypoglycemia & hyperinsulinism 1-2 hours Hypoglycemia & hyperinsulinism 1-2 hours after feedingafter feeding

Treatment consist of acarbose-cachanel Treatment consist of acarbose-cachanel blocker octerotide-complex carbohydrate blocker octerotide-complex carbohydrate formulaformula

TreatmentTreatmentDrugDrug diazoxide diazoxide D/W 15% 2-4 cc/kg state fallow by 6-8 D/W 15% 2-4 cc/kg state fallow by 6-8

mg/ng/minmg/ng/minعوارضعوارض

پرموئیپرموئی1.1.

تهوعتهوع2.2.

هیپراورسیمیهیپراورسیمی3.3.

استخوانی 4.4. سن استخوانی افزایش سن افزایش

فشار 5.5. فشار افت افتI9GI9G کاهشکاهش6.6.

octerotide octerotide 2020 ساعت ساعت 1212--66هر هر U /kg /day U /kg /day

::عوارضعوارض ترشحترشح – استفراغ استفراغ – تهوع تهوعاسهالاسهالهپاتیتهپاتیت صفرا کیسه صفرا سنگ کیسه سنگ تزریق محل تزریق درد محل درد

surgerysurgery