see also:

• hypoglycaemia
• RCH guideline - hypoglycaemia in children

• hypoglycaemia in patients who are not taking oral hypoglycaemics or insulin is an uncommon presentation to ED
• Whipple's triad:
  • documentation of low blood sugar
  • presence of symptoms
  • reversal of these symptoms when the blood sugar level is restored to normal
• absence of Whipple's triad suggests hypoglycaemia is NOT the cause of symptoms

• hypoglycaemia is a common life-threatening issue in the newborn, especially small for dates infants, infants of diabetic mothers, erythroblastosis foetalis

• starvation-induced or stress-induced in children with inborn errors of metabolism:
  • inherited liver enzyme deficiencies that restrict hepatic glucose release:
    • deficiencies of glucose-6-phosphatase
    • fructose-1,6-diphosphatase
    • phosphorylase
    • pyruvate carboxylase
    • phosphoenolpyruvate carboxykinase
    • glycogen synthetase
  • inherited defects in fatty acid oxidation, including:
    • that resulting from systemic carnitine deficiency
    • inherited defects in ketogenesis (3-hydroxy-3-methylglutaryl-CoA lyase deficiency)
• following food:
  • galactosaemia
  • hereditary fructose intolerance
• accidental poisoning with oral hypoglycaemic agents
• excessive alcohol intake
• Reye's syndrome
• drugs (see under adults)
• nesidioblastosis (diffuse budding of insulin-secreting cells from pancreatic duct epithelium and pancreatic microadenomas of such cells) is a rare cause in infants and adults, but cases have been reported after gastric bypass surgery
• ingestion of too many unripe lychee, rambutan, longan or ackee on an empty stomach - these contain an amino acid which can cause hypoglycemia in children - more than 100 die each year in India

• ovedose with oral hypoglycaemic agents or insulin
• excessive alcohol intake
• other drugs which may cause hypoglycaemia:
  • haloperidol, pentamidine, quinine, salicylates, and sulphonamides
  • phenothiazines, tricyclic antidepressants, SSRI/SNRI antidepressants, bishydroxycoumarin, p-aminobenzoic acid, propoxyphene, hypoglycin, carbamate insecticide, disopyramide, isoniazid, methanol, methotrexate, cytotoxic agents, organophosphates, didanosine, trimethoprim, 6-mercaptopurine, thiazides, thioglycolate, ritodrine, disodium ethylenediaminetetraacetic acid (EDTA), clofibrate, ACE inhibitors, and lithium carbonate

• hypopituitarism
• Addison's disease
• large non-islet cell tumour
  • most commonly retroperitoneal or mediastinal malignant mesenchymal tumors
  • tumor secretes abnormal insulinlike growth factor (large IGF-II), which does not bind to its plasma binding proteins.
  • this increase in free IGF-II exerts hypoglycemia through the IGF-I or the insulin receptors.
• acquired severe liver disease
• sepsis
• congestive cardiac failure
• acute renal failure (ARF)
• severe dehydration and starvation (inanition)

• low plasma insulin:
  • ketotic hypoglycaemia of childhood
  • alcohol
  • some drugs (see above)
  • prolonged exercise
  • glycogen storage disease
  • ?glucagon deficiency
• high plasma insulin:
  • low plasma C peptide levels and presence of insulin antibodies:
    • insulin factitial hypoglycaemia
    • insulin autoimmune syndrome (rare)
  • elevated plasma C peptide levels and no insulin antibodies:
    • factitial sulphonylurea intake
    • insulinoma
      • may occur as an isolated abnormality or as a component of the multiple endocrine neoplasia type I (MEN) syndrome
    • insulin-receptor antibodies

• galactosaemia
• hereditary fructose intolerance
• Ackee fruit poisoning (Jamaican national fruit but unripe fruit contains hypoglycins and ingestion causes Jamaican vomiting sickness )

• early diabetes?
• alimentary hypoglycaemia (post-GIT surgery)
• gin and tonic
• rarely, insulinoma