hypoglycemia

Hypoglycemia refers to low blood sugar, or technically a lower than normal blood glucose level. It is rarely encountered in pediatric practice outside of the newborn nursery, where it is a commonplace event. Profound hypoglycemia in the newborn can cause brain damage. Aggressive blood glucose monitoring of asymptomatic (nothing appears to be wrong) infants has been the standard.

I think attitudes are softening in the era of cost-benefit analysis, since many babies seem to be subjected to large numbers of (in retrospect) needless blood glucose determinations compared to the actual number of significant problems identified.

Symptoms of hypoglycemia are generally related to the body's efforts to raise the blood glucose level back to where it should be. These symptoms are really just the manifestations of adrenaline (epinephrine) release, which is the chief signal the body uses to mobilise stored glucose into the bloodstream. The most noticable adrenaline effects are nervousness, light-headedness, increased heart rate, and a particularly urgent sense of hunger. Headache is sometimes a symptom of hypoglycemia; I believe the explanation is brain neuronal cell dysfunction.

In the newborn, symptoms of hypoglycemia include sweating, jitteriness, rapid breathing, rapid heart rate, pallor, or even apnea. Profound or very difficult to treat hypoglycemia in a newborn can signal the presence of rare but dangerous conditions such as galactosemia, growth hormone deficiency, insulin secreting tumors, or may reflect severe intrauterine growth restriction (IUGR).

Hypoglycemia is the opposite of hyperglycemia - high blood glucose - which is the hallmark of diabetes. True hypoglycemia in children older than newborns is reasonably rare and is not the cause of the myriad complaints and conditions for which it is blamed.

Reactive hypoglycemia

Reactive hypoglycemia refers to an excessive fall in the blood glucose level after a meal, especially a meal rich in simple (versus complex) carbohydrates. Excessive insulin is produced by the pancreas when it is "tricked" by all the simple sugar in circulation into producing enough insulin for a much larger meal than was actually consumed. This excess insulin drives the blood sugar below the normal level.

A random, that is, done just any old time, blood sugar test is generally worthless in diagnosing hypoglycemia, especially reactive htpoglycemia. Even a fasting morning blood sugar is usually not helpful. Only a timed series of tests after a standardised sugar meal will allow the diagnosis of reactive hypoglycemia to be made with accuracy.

ketotic hypoglycemia

The most common form of childhood hypoglycemia (one in 300 to 1000 live births) is ketotic hypoglycemia.It typically becomes evident between 18 months and 5 years of age, but has been reported as early as 9 months. It affects males and females equally.

Fasting overnight (12 to 18 hours) will cause hypoglycemia in a child with ketotic hypoglycemia. The hallmark of this condition is ketosis, meaning fruity-smelling ketones in the blood and urine - much the same as a diabetic who needs insulin. A normal child can fast for this period without either hypoglycemia or ketone formation (but will eventually become hypoglycemic after about 36 hours of fasting). The hypoglycemia is not constant, but appears when the child cannot eat because of illness.

The typical story is that of a child who is sick, perhaps with vomiting and diarrhea, who eats poorly the night before, and is difficult to arouse from sleep the next morning. The child may have a seizure or become comatose by mid-morning.

A fasting blood sugar readout in the morning of 60 (mg% or mg/dl) or less is highly suspicious of ketotic hypoglycemia. Your child's physician should definitely be consulted. A reading of 40 or less is pretty much diagnostic and should be treated (feeding!) and immediately investigated medically.

I include these numbers because many parents today have access to a blood glucose monitor and arrive at the office with the readouts in hand - I know this from direct experience!

Treatment of ketotic hypoglycemia is basically smaller, more frequent feedings of a high-protein, high-carbohydrate diet. During times of illness, parents test the child's urine for the presence of ketones with a simple dipstick test. Ketones appear in the urine several hours before hypoglycemia develops. If ketones appear, high carbohydrate drinks such as juices and sodas should be offered to the child. If these cannot be tolerated, the child may be given a short course of steroids or admitted to the hospital for intravenous glucose administration.

Luckily, ketotic hypoglycemia is usually outgrown by 8-9 years of age.

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