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=== Hypoglycemia in Newborn Infants === | === Hypoglycemia in Newborn Infants === | ||
Hypoglycemia is a common problem in critically ill or extremely [[low birthweight infants]]. If not due to maternal hyperglycemia, in most cases it is multifactorial, transient and easily supported. In a minority of cases hypoglycemia turns out to be due to significant [[hyperinsulinism]], [[hypopituitarism]] or an [[inborn error of metabolism]] and presents more of a management challenge. | Hypoglycemia is a common problem in critically ill or extremely [[low birthweight infants]]. If not due to maternal hyperglycemia, in most cases it is multifactorial, transient and easily supported. In a minority of cases hypoglycemia turns out to be due to significant [[hyperinsulinism]], [[hypopituitarism]] or an [[inborn error of metabolism]] and presents more of a management challenge. | ||
*Transient neonatal hypoglycemia: | *Transient neonatal hypoglycemia: during the first two hours after delivery, blood glucose level the healthy newborn falls due to loss of the transplacental supply of glucose.<ref name="pmid25819173">{{cite journal| author=Stanley CA, Rozance PJ, Thornton PS, De Leon DD, Harris D, Haymond MW et al.| title=Re-evaluating "transitional neonatal hypoglycemia": mechanism and implications for management. | journal=J Pediatr | year= 2015 | volume= 166 | issue= 6 | pages= 1520-5.e1 | pmid=25819173 | doi=10.1016/j.jpeds.2015.02.045 | pmc=4659381 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25819173 }}</ref>Plasma glucose level is maintained by glycogenolysis during the first 8 hours then maintained by gluconeogenesis.<ref name="pmid10202173">{{cite journal| author=Stanley CA, Baker L| title=The causes of neonatal hypoglycemia. | journal=N Engl J Med | year= 1999 | volume= 340 | issue= 15 | pages= 1200-1 | pmid=10202173 | doi=10.1056/NEJM199904153401510 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10202173 }}</ref> | ||
* [[Prematurity]], [[intrauterine growth retardation]] and [[perinatal asphyxia]] | * [[Prematurity]], [[intrauterine growth retardation]] and [[perinatal asphyxia]] | ||
* Maternal hyperglycemia due to [[diabetes]] or iatrogenic glucose administration | * Maternal hyperglycemia due to [[diabetes]] or iatrogenic glucose administration | ||
* [[Sepsis]] | * [[Sepsis]] | ||
* Congenital hypopituitarism: cortisol and growth hormone regulate glucose level. | * Congenital hypopituitarism: cortisol and growth hormone regulate glucose level. | ||
* Maternal treatment with beta- | * Maternal treatment with beta-sympathomimetics, which interrupts glycogenolysis by blocking epinephrine's effect.<ref name="pmid27577580">{{cite journal| author=Bateman BT, Patorno E, Desai RJ, Seely EW, Mogun H, Maeda A et al.| title=Late Pregnancy β Blocker Exposure and Risks of Neonatal Hypoglycemia and Bradycardia. | journal=Pediatrics | year= 2016 | volume= 138 | issue= 3 | pages= | pmid=27577580 | doi=10.1542/peds.2016-0731 | pmc=5005024 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27577580 }}</ref> | ||
* Hypothermic infants who have diminished availability of glucose and increased rates of glucose utilization. | * Hypothermic infants who have diminished the availability of glucose and increased rates of glucose utilization. | ||
* Severe hepatic dysfunction | * Severe hepatic dysfunction leads to impairment of both glycogenolysis and gluconeogenesis. | ||
*[[Congenital hyperinsulinism]]: | *[[Congenital hyperinsulinism]]: | ||
**Infant of a diabetic mother is the most common cause of hypoglycemia due to hyperinsulinism. Prolonged intrapartum hyperglycemia in fetus leads to hypertrophied and hyperfunctioning beta cells causing | **Infant of a diabetic mother is the most common cause of hypoglycemia due to hyperinsulinism. Prolonged intrapartum hyperglycemia in fetus leads to hypertrophied and hyperfunctioning beta cells causing hyperinsulinism. It is transient and resolves two days after birth. | ||
**[[Beckwith-Wiedemann syndrome]] | **[[Beckwith-Wiedemann syndrome]] | ||
**[[Persistent hyperinsulinemic hypoglycemia of infancy]]: | **[[Persistent hyperinsulinemic hypoglycemia of infancy]]: it is a mutation in genes encoding enzymes that control intracellular metabolic pathways of the pancreatic beta cell. | ||
**Excess exogenous insulin given to newborns with hyperglycemia may result in hypoglycemia.<ref name="pmid19588439">{{cite journal| author=Sinclair JC, Bottino M, Cowett RM| title=Interventions for prevention of neonatal hyperglycemia in very low birth weight infants. | journal=Cochrane Database Syst Rev | year= 2009 | volume= | issue= 3 | pages= CD007615 | pmid=19588439 | doi=10.1002/14651858.CD007615.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19588439 }}</ref> | **Excess exogenous insulin given to newborns with hyperglycemia may result in hypoglycemia.<ref name="pmid19588439">{{cite journal| author=Sinclair JC, Bottino M, Cowett RM| title=Interventions for prevention of neonatal hyperglycemia in very low birth weight infants. | journal=Cochrane Database Syst Rev | year= 2009 | volume= | issue= 3 | pages= CD007615 | pmid=19588439 | doi=10.1002/14651858.CD007615.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19588439 }}</ref> | ||
**Neonatal conditions associated with | **Neonatal conditions associated with excessive insulin secretion include alloimmune hemolytic disease of the newborn, heart failure and sepsis.<ref name="pmid10331464">{{cite journal| author=Sue CM, Hirano M, DiMauro S, De Vivo DC| title=Neonatal presentations of mitochondrial metabolic disorders. | journal=Semin Perinatol | year= 1999 | volume= 23 | issue= 2 | pages= 113-24 | pmid=10331464 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10331464 }}</ref> | ||
** | **Polycythemia may lead to greater glucose utilization by the increased mass of red blood cells. | ||
*[[Inborn error of metabolism|Inborn errors of carbohydrate metabolism]]: | *[[Inborn error of metabolism|Inborn errors of carbohydrate metabolism]]: | ||
**Disorders of gluconeogenesis: fructose-1,6-bisphosphatase deficiency, pyruvate carboxylase deficiency. | **Disorders of gluconeogenesis: fructose-1,6-bisphosphatase deficiency, pyruvate carboxylase deficiency. | ||
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====Hypoglycemia in Young Children==== | ====Hypoglycemia in Young Children==== | ||
====Hypoglycemia in Older Children and Young Adult==== | |||
====Hypoglycemia in Older Children and Young | |||
====Hypoglycemia in Older Adults==== | ====Hypoglycemia in Older Adults==== | ||
* Drugs: they are the most common cause of hypoglycemia.<ref name="pmid19088155">{{cite journal| author=Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER et al.| title=Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2009 | volume= 94 | issue= 3 | pages= 709-28 | pmid=19088155 | doi=10.1210/jc.2008-1410 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19088155 }}</ref> | * Drugs: they are the most common cause of hypoglycemia.<ref name="pmid19088155">{{cite journal| author=Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER et al.| title=Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2009 | volume= 94 | issue= 3 | pages= 709-28 | pmid=19088155 | doi=10.1210/jc.2008-1410 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19088155 }}</ref> | ||
* Insulin or insulin secretagogue: sulfonylureas, glyburide and less common glipizide or glimepiride due to | * Insulin or insulin secretagogue: sulfonylureas, glyburide and less common glipizide or glimepiride due to longer duration of action.<ref name="pmid16324923">{{cite journal| author=Szoke E, Gosmanov NR, Sinkin JC, Nihalani A, Fender AB, Cryer PE et al.| title=Effects of glimepiride and glyburide on glucose counterregulation and recovery from hypoglycemia. | journal=Metabolism | year= 2006 | volume= 55 | issue= 1 | pages= 78-83 | pmid=16324923 | doi=10.1016/j.metabol.2005.07.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16324923 }}</ref>They suppress hepatic glucose production and stimulate glucose utilization causing hypoglycemia. | ||
* Other drugs in | * Other drugs in nondiabetic patients: quinolones, pentamidine, quinine, beta blockers, angiotensin-converting enzyme inhibitors, and IGF-1 especially in older patients with underlying renal or hepatic dysfunctions.<ref name="pmid25179404">{{cite journal| author=Parekh TM, Raji M, Lin YL, Tan A, Kuo YF, Goodwin JS| title=Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas. | journal=JAMA Intern Med | year= 2014 | volume= 174 | issue= 10 | pages= 1605-12 | pmid=25179404 | doi=10.1001/jamainternmed.2014.3293 | pmc=4878670 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25179404 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25686188 Review in: Ann Intern Med. 2015 Feb 17;162(4):JC13]</ref> | ||
* Alcohol: due to hepatic glycogen depletion in fasting patients. Alcohol can induce hypoglycemia alone or associated with other hypoglycemic drugs. | * Alcohol: due to hepatic glycogen depletion in fasting patients. Alcohol can induce hypoglycemia alone or associated with other hypoglycemic drugs. | ||
* Critical illnesses: hepatic, renal, or cardiac failure, sepsis. [34] It occurs due to impaired liver gluconeogenesis. Sepsis induced cytokines secretion cause | * Critical illnesses: hepatic, renal, or cardiac failure, sepsis. [34] It occurs due to impaired liver gluconeogenesis. Sepsis induced cytokines secretion cause suppression of gluconeogenesis.<ref name="pmid10807013">{{cite journal| author=Maitra SR, Wojnar MM, Lang CH| title=Alterations in tissue glucose uptake during the hyperglycemic and hypoglycemic phases of sepsis. | journal=Shock | year= 2000 | volume= 13 | issue= 5 | pages= 379-85 | pmid=10807013 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10807013 }}</ref> | ||
* Hormone deficiency: cortisol in acquired [[adrenal insufficiency|adrenal insufficiency or]] acquired [[hypopituitarism]] | * Hormone deficiency: cortisol in acquired [[adrenal insufficiency|adrenal insufficiency or]] acquired [[hypopituitarism]] | ||
* Nonislet cell tumor: Hypoglycemia usually occurs as a result of tumor production of IGF-2. | * Nonislet cell tumor: Hypoglycemia usually occurs as a result of tumor production of IGF-2. | ||
* [[Insulinoma]] | * [[Insulinoma]] | ||
* Reactive hypoglycemia: | * Reactive hypoglycemia: | ||
*[[Gastric bypass|Post gastric bypass]] hypoglycemia: rapid jejunal emptying with exaggerated insulin response. | *[[Gastric bypass|Post gastric bypass]] hypoglycemia: rapid jejunal emptying with exaggerated insulin response. | ||
* Insulin [[autoimmune hypoglycemia:]] it occurs in patients who have antibodies directed to endogenous insulin or to the insulin receptor.<ref name="pmid19440117">{{cite journal| author=Lupsa BC, Chong AY, Cochran EK, Soos MA, Semple RK, Gorden P| title=Autoimmune forms of hypoglycemia. | journal=Medicine (Baltimore) | year= 2009 | volume= 88 | issue= 3 | pages= 141-53 | pmid=19440117 | doi=10.1097/MD.0b013e3181a5b42e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19440117 }}</ref> | * Insulin [[autoimmune hypoglycemia:]] it occurs in patients who have antibodies directed to endogenous insulin or to the insulin receptor.<ref name="pmid19440117">{{cite journal| author=Lupsa BC, Chong AY, Cochran EK, Soos MA, Semple RK, Gorden P| title=Autoimmune forms of hypoglycemia. | journal=Medicine (Baltimore) | year= 2009 | volume= 88 | issue= 3 | pages= 141-53 | pmid=19440117 | doi=10.1097/MD.0b013e3181a5b42e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19440117 }}</ref> | ||
Revision as of 19:51, 21 July 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Carlos A Lopez, M.D. [2] Mohammed Abdelwahed M.D[3]
Overview
Causes of hypoglycemia depends on age; neonatal causes are: transient neonatal hypoglycemia, Prematurity, intrauterine growth retardation, perinatal asphyxia., sepsis, congenital hypopituitarism, beta sympathomimetic drugs, congenital hyperinsulinism, infant of a diabetic motherBeckwith-Wiedemann syndrome and inborn errors of carbohydrate metabolism.
Cause of adult hypoglycemia are: Insulin or insulin secretagogue drugs, alcohol, hepatic, renal, or cardiac failure, sepsis, Nonislet cell pancreatic tumors, insulinoma, reactive hypoglycemia, post gastric bypass hypoglycemia, autoimmune hypoglycemia
Causes of hypoglycemia
Hypoglycemia in Newborn Infants
Hypoglycemia is a common problem in critically ill or extremely low birthweight infants. If not due to maternal hyperglycemia, in most cases it is multifactorial, transient and easily supported. In a minority of cases hypoglycemia turns out to be due to significant hyperinsulinism, hypopituitarism or an inborn error of metabolism and presents more of a management challenge.
- Transient neonatal hypoglycemia: during the first two hours after delivery, blood glucose level the healthy newborn falls due to loss of the transplacental supply of glucose.[1]Plasma glucose level is maintained by glycogenolysis during the first 8 hours then maintained by gluconeogenesis.[2]
- Prematurity, intrauterine growth retardation and perinatal asphyxia
- Maternal hyperglycemia due to diabetes or iatrogenic glucose administration
- Sepsis
- Congenital hypopituitarism: cortisol and growth hormone regulate glucose level.
- Maternal treatment with beta-sympathomimetics, which interrupts glycogenolysis by blocking epinephrine's effect.[3]
- Hypothermic infants who have diminished the availability of glucose and increased rates of glucose utilization.
- Severe hepatic dysfunction leads to impairment of both glycogenolysis and gluconeogenesis.
- Congenital hyperinsulinism:
- Infant of a diabetic mother is the most common cause of hypoglycemia due to hyperinsulinism. Prolonged intrapartum hyperglycemia in fetus leads to hypertrophied and hyperfunctioning beta cells causing hyperinsulinism. It is transient and resolves two days after birth.
- Beckwith-Wiedemann syndrome
- Persistent hyperinsulinemic hypoglycemia of infancy: it is a mutation in genes encoding enzymes that control intracellular metabolic pathways of the pancreatic beta cell.
- Excess exogenous insulin given to newborns with hyperglycemia may result in hypoglycemia.[4]
- Neonatal conditions associated with excessive insulin secretion include alloimmune hemolytic disease of the newborn, heart failure and sepsis.[5]
- Polycythemia may lead to greater glucose utilization by the increased mass of red blood cells.
- Inborn errors of carbohydrate metabolism:
- Disorders of gluconeogenesis: fructose-1,6-bisphosphatase deficiency, pyruvate carboxylase deficiency.
- Disorders of carbohydrate metabolism: hereditary fructose intolerance, galactosemia.
- Disorders of fatty acid metabolism: medium or long-chain acyl-CoA dehydrogenase deficiency).[6]
Hypoglycemia in Young Children
Hypoglycemia in Older Children and Young Adult
Hypoglycemia in Older Adults
- Drugs: they are the most common cause of hypoglycemia.[7]
- Insulin or insulin secretagogue: sulfonylureas, glyburide and less common glipizide or glimepiride due to longer duration of action.[8]They suppress hepatic glucose production and stimulate glucose utilization causing hypoglycemia.
- Other drugs in nondiabetic patients: quinolones, pentamidine, quinine, beta blockers, angiotensin-converting enzyme inhibitors, and IGF-1 especially in older patients with underlying renal or hepatic dysfunctions.[9]
- Alcohol: due to hepatic glycogen depletion in fasting patients. Alcohol can induce hypoglycemia alone or associated with other hypoglycemic drugs.
- Critical illnesses: hepatic, renal, or cardiac failure, sepsis. [34] It occurs due to impaired liver gluconeogenesis. Sepsis induced cytokines secretion cause suppression of gluconeogenesis.[10]
- Hormone deficiency: cortisol in acquired adrenal insufficiency or acquired hypopituitarism
- Nonislet cell tumor: Hypoglycemia usually occurs as a result of tumor production of IGF-2.
- Insulinoma
- Reactive hypoglycemia:
- Post gastric bypass hypoglycemia: rapid jejunal emptying with exaggerated insulin response.
- Insulin autoimmune hypoglycemia: it occurs in patients who have antibodies directed to endogenous insulin or to the insulin receptor.[11]
- Accidental, surreptitious, or malicious hypoglycemia
References
- ↑ Stanley CA, Rozance PJ, Thornton PS, De Leon DD, Harris D, Haymond MW; et al. (2015). "Re-evaluating "transitional neonatal hypoglycemia": mechanism and implications for management". J Pediatr. 166 (6): 1520–5.e1. doi:10.1016/j.jpeds.2015.02.045. PMC 4659381. PMID 25819173.
- ↑ Stanley CA, Baker L (1999). "The causes of neonatal hypoglycemia". N Engl J Med. 340 (15): 1200–1. doi:10.1056/NEJM199904153401510. PMID 10202173.
- ↑ Bateman BT, Patorno E, Desai RJ, Seely EW, Mogun H, Maeda A; et al. (2016). "Late Pregnancy β Blocker Exposure and Risks of Neonatal Hypoglycemia and Bradycardia". Pediatrics. 138 (3). doi:10.1542/peds.2016-0731. PMC 5005024. PMID 27577580.
- ↑ Sinclair JC, Bottino M, Cowett RM (2009). "Interventions for prevention of neonatal hyperglycemia in very low birth weight infants". Cochrane Database Syst Rev (3): CD007615. doi:10.1002/14651858.CD007615.pub2. PMID 19588439.
- ↑ Sue CM, Hirano M, DiMauro S, De Vivo DC (1999). "Neonatal presentations of mitochondrial metabolic disorders". Semin Perinatol. 23 (2): 113–24. PMID 10331464.
- ↑ Worthen HG, al Ashwal A, Ozand PT, Garawi S, Rahbeeni Z, al Odaib A; et al. (1994). "Comparative frequency and severity of hypoglycemia in selected organic acidemias, branched chain amino acidemia, and disorders of fructose metabolism". Brain Dev. 16 Suppl: 81–5. PMID 7726385.
- ↑ Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER; et al. (2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.
- ↑ Szoke E, Gosmanov NR, Sinkin JC, Nihalani A, Fender AB, Cryer PE; et al. (2006). "Effects of glimepiride and glyburide on glucose counterregulation and recovery from hypoglycemia". Metabolism. 55 (1): 78–83. doi:10.1016/j.metabol.2005.07.009. PMID 16324923.
- ↑ Parekh TM, Raji M, Lin YL, Tan A, Kuo YF, Goodwin JS (2014). "Hypoglycemia after antimicrobial drug prescription for older patients using sulfonylureas". JAMA Intern Med. 174 (10): 1605–12. doi:10.1001/jamainternmed.2014.3293. PMC 4878670. PMID 25179404. Review in: Ann Intern Med. 2015 Feb 17;162(4):JC13
- ↑ Maitra SR, Wojnar MM, Lang CH (2000). "Alterations in tissue glucose uptake during the hyperglycemic and hypoglycemic phases of sepsis". Shock. 13 (5): 379–85. PMID 10807013.
- ↑ Lupsa BC, Chong AY, Cochran EK, Soos MA, Semple RK, Gorden P (2009). "Autoimmune forms of hypoglycemia". Medicine (Baltimore). 88 (3): 141–53. doi:10.1097/MD.0b013e3181a5b42e. PMID 19440117.