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Hypoglycemia in children may be due to inadequate oral intake, excess insulin, low levels of hyperglycemic hormones (e.g., cortisol or growth hormone), inborn errors of metabolism, or systemic infection. Prompt recognition and treatment of hypoglycemia are essential to avoid potentially severe and permanent neurologic injury, and bedside glucose testing should be considered in any neonate, infant, or child with altered mental status.

Clinical Features

Hypoglycemic children may manifest symptoms related to adrenergic hormone release including tachycardia, diaphoresis, tremors, anxiety, irritability, and tachypnea. Severe hypoglycemia may result in apnea or seizures, particularly in neonates and infants, who may not manifest typical signs and symptoms of older children and adults. Neonates and infants with hypoglycemia may also present with altered mental status and nonspecific symptoms such as poor feeding, an abnormal or high-pitched cry, temperature instability, and irritability or lethargy. Hypoglycemia often accompanies critical illness (sepsis) and the features of that illness may dominate the clinical picture, thereby masking the signs of hypoglycemia.

Diagnosis and Differential

Hypoglycemia is defined as a plasma glucose concentration less than 45 mg/dL in symptomatic children and less than 35 mg/dL in asymptomatic neonates. Bedside glucose testing is the most important diagnostic test in any neonate or infant who is critically ill or has altered mental status. Abnormal results should be confirmed with a venous sample, but treatment should not be delayed for confirmatory results. Urine testing for ketones is important, as ketonuria is associated with ketotic hypoglycemia, adrenal insufficiency, and other inborn errors of metabolism. Absent urine ketones are associated with hyperinsulinemic states, infants of a diabetic mother, as well as disorders of fatty acid oxidation and mitochondria.

Emergency Department Care and Disposition

  1. For neonates administer 10% dextrose 5 mL/kg IV/IO/PO/NG. Treat infants with the same dose of 10% dextrose, or 25% dextrose 2 mL/kg IV/IO/PO/NG. Give older children 2 mL/kg of 25% dextrose IV/IO/PO/NG.

  2. Administer maintenance dextrose for persistent hypoglycemia using 10% dextrose at 1.5 times maintenance.

  3. When intravenous access is not immediately available, consider glucagon 0.03 mg/kg IM or subcutaneous (maximum 0.5 mg).

  4. If adrenal insufficiency is suspected, give hydrocortisone 25 mg IV/IM for neonates and infants, 50 mg for toddlers and school-age children, and 100 mg for everyone else. Steroids should be given early in patients with hypopituitarism and adrenal insufficiency.

  5. Consider empiric antibiotics for suspected sepsis.


Inborn errors of metabolism are challenging childhood disorders representing a broad spectrum of diseases with nonspecific signs and symptoms. Delay in accurate diagnosis and treatment can lead to significant morbidity and mortality. Despite the myriad etiologies, the principles of initial emergency department (ED) diagnosis and management are relatively simple. The sudden acute deterioration of a healthy neonate should always prompt consideration of metabolic disease, and making a definitive diagnosis is less ...

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