Hypoglycemia is a medical term which refers to abnormally low blood sugar level that may arise from many causes and can affect any age group. The most common cause of moderate to severe hypoglycemia is due to a complication of treatment of diabetes mellitus either with parenteral insulin for insulin dependent diabetes mellitus (IDDM) or oral antidiabetic medications for non-insulin dependent diabetes mellitus (NIDDM) respectively. Endocrinologists are the specialists who manage disorders of blood and glucose metabolism as well as other disorders related to the endocrine system.
The individual’s symptoms may be attributed to hypoglycemia if the Whipple’s triad is met namely: the symptoms are known to be caused by hypoglycemia; at the time the symptoms occur, the blood glucose is low and there is an immediate reversal or improvement of symptoms when the glucose returns to normal level.
Hypoglycemia is commonly defined as plasma glucose levels below 70 mg/dl or 3.9 mmol/L. However, the precise level of how low enough should be the glucose level; to be considered hypoglycemic may be dependent several factors. These factors may include: the method of measurement utilized, the person’s age, presence or absence of effects, and the purpose of the definition.
The causes of hypoglycemia may be grouped by age. Enumerated below is a list of the more common causes and factors which may contribute to hypoglycemia. Hypoglycemia in newborn infants (transient neonatal hypoglycemia) may be due to: prematurity, intrauterine growth retardation (IUGR), perinatal asyphxia; maternal hyperglycemia and fasting for a prolonged period of time; congenital hypopituitarism; congenital transient or persistent hyperinsulinism; inborn errors of carbohydrate metabolism such as glycogen storage disease.
In younger children, hypoglycemia may be due to prolonged fasting (e.g. diarrhea especially rotavirus gastroenteritis); idiopathic ketotic hypoglycemia ; isolated somatotropin (growth hormone) deficiency, hypopituitarism ; disorders with excess insulin such as hyperinsulinism; insulin injected for type 1 diabetes mellitus; gastric dumping syndrome (after gastrointestinal surgery); accidental use of too much sulfonylureas (an oral antidiabetic drug) , propanonol and ethanol; other congenital metabolic disorders.
In older children and young adults, the most common cause of severe hypoglycemia is insulin injected for insulin dependent diabetes mellitus or type 1 DM.
Signs and symptoms of hypoglycemia may be attributed to adrenergic, glucagon or neuroglycopenic manifestations. Adrenergic manifestations may include the following: shakiness, anxiety, nervousness, tremor, palpitations, tachycardia , sweating, feeling of warmth, pallor, coldness, clamminess and dilated pupils.
Most of the glucagon manifestations are gastrointestinal in nature such as hunger, borborygmus, nausea, vomiting and abdominal discomfort. Some of the neuroglycopenic manifestations are the following: abnormal mentation with impaired judgment, easy fatigability, weakness, dizziness, lethargy, delirium, confusion that may lead to stupor and coma, amnesia, staring, "glassy" look, blurred vision, diplopia (double vision), automatic behavior, also known as automatism , difficulty speaking, slurred speech , ataxia, uncoordinated muscle movement, focal or general motor deficit, paralysis, one-sided body weakness (hemiparesis) , paresthesias (tingling sensation or sensation of pins and needles), headache, abnormal breathing and sometimes generalized or focal seizures.
Not all of the aforementioned symptoms occur in each case of hypoglycemia and there is no consistent chronological order as to the appearance of the symptoms. In neonates, hypoglycemia manifests as irritability, jitteriness, myoclonic seizures, cyanosis, respiratory distress, apnea (absence of breath), sweating, hypothermia, somnolence, decreased muscle tone, feeding difficulties, and seizures or "spells". Most of the time severe hypoglycemia can cause seizures or unconsciousness but can be reversed without obvious damage to the brain. Cases of death or permanent brain damage occurs to those with episodes of prolonged, untreated unconsciousness, which already interferes breathing and those with severe concomitant disease.
Clinical history and physical examination is vital in determining the cause of hypoglycemia. There are two best guides that aid to ascertain the cause of unexplained hypoglycemia namely: the circumstances and the critical blood sample extracted during the time of hypoglycemia, before it is reversed by any treatment.
The management of hypoglycemia involves an immediate attempt to raise the blood sugar to its normal level then determine the underlying cause, and taking preventive measures to avoid future episodes. The blood glucose can be raised to normal levels within minutes by taking 10-20 grams of carbohydrate which can be given either as a food or drink if the person is conscious with intact swallowing reflex. Starch, a complex carbohydrate is quickly digested to glucose, but adding fat or protein delays the digestion. Symptoms should start to show improvement within 5 minutes, although full recovery may only be evident around 10-20 minutes.
If an individual is suffering with the severe effects of hypoglycemia namely seizures and unconsciousness that they cannot be given anything by mouth, an intravenous infusion of glucose or a rapid injection of glucagon can be given to reverse the condition immediately.
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