I. Problem. A previously healthy 3-year-old boy is brought to the emergency department in the early morning after his parents found him difficult to arouse. The family had been traveling and the child had a prolonged fast. His blood glucose level is 28 mg/dL.
II. Immediate Questions
A. What constitutes a low serum glucose level in a patient of this age? Hypoglycemia in children is defined as follows.
1. Term neonate. Serum glucose < 50-60 mg/dL.
2. Infants and young children. Serum glucose < 45-60 mg/dL.
3. Older children and adolescents. Serum glucose < 60 mg/dL.
B. What is patient's mental status? An unconscious patient must first be stabilized. Quickly assess ABCs (airway, breathing, and circulation) and obtain access to draw samples for laboratory analysis and provide glucose.
C. Is patient diabetic? Excess insulin administration or administration of insulin in a patient who is not eating can induce hypo-glycemia.
D. Has patient had adequate intake? Was TPN abruptly discontinued? Often children who are sick have decreased oral intake and may not have had anything to eat or drink for several hours. Abrupt discontinuation of dextrose-containing fluids can also lead to hypoglycemia.
E. Is ingestion a possibility? Many different agents can induce hypoglycemia, including salicylates, alcohol, and oral hypo-glycemic agents.
F. Is patient a newborn, an infant of a diabetic mother, intrauter-ine growth retarded (IUGR), or small or large for gestational age (SGA or LGA)? Infants of diabetic mothers are often hyperin-sulinemic at birth and when glucose stores from the placenta are removed can become hypoglycemic. SGA infants (defined as < 10th percentile or < 2.5 kg at term) and LGA infants (defined as > 95th percentile or > 4.0 kg at term) are at increased risk of hypoglycemia.
G. What symptoms are associated with hypoglycemia? Symptoms include anxiety, diaphoresis, jitteriness, weakness, nausea, headache, and confusion. Infants with hypoglycemia can present with few symptoms.
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