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Hypoglycemia during diarrhea in childhood. Prevalence, pathophysiology, and outcome
M L Bennish1, A K Azad, O Rahman
1International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka.
Insights
Hypoglycemia in children with diarrhea is common and deadly, affecting 4.5% of patients and causing 42.9% mortality. This study links childhood diarrhea-associated hypoglycemia to impaired gluconeogenesis, not hormone deficiency.
Area of Science:
- Pediatrics
- Endocrinology
- Infectious Diseases
Background:
- Diarrhea is a leading cause of childhood mortality globally.
- Hypoglycemia is a serious complication of severe illness in children.
- The specific mechanisms of hypoglycemia in children with diarrhea remain unclear.
Purpose of the Study:
- To determine the incidence and outcomes of hypoglycemia in children admitted to a diarrhea treatment center.
- To investigate the hormonal and metabolic profiles of hypoglycemic children with diarrhea.
Main Methods:
- Screened 2003 pediatric patients (<15 years) admitted for diarrhea.
- Defined hypoglycemia as blood glucose < 2.2 mmol/L.
- Measured plasma glucoregulatory hormones and gluconeogenetic substrates in hypoglycemic and normoglycemic patients.
Main Results:
- Hypoglycemia occurred in 4.5% of patients, with a 42.9% mortality rate.
- Hypoglycemic patients had shorter diarrhea duration but longer fasting periods.
- Elevated counterregulatory hormones (glucagon, epinephrine, norepinephrine) and lactate were observed, with low C-peptide and inadequate gluconeogenetic substrates.
Conclusions:
- Hypoglycemia is a significant cause of death in childhood diarrhea.
- The findings suggest impaired gluconeogenesis, rather than counterregulatory hormone deficiency, is the primary cause of hypoglycemia in this population.
- Early recognition and management of hypoglycemia in diarrheal illness are critical.
Abstract:
To determine the frequency and outcome of hypoglycemia during diarrhea in childhood, we screened 2003 consecutive patients less than 15 years of age who were admitted to a diarrhea treatment center in Dhaka, Bangladesh. Hypoglycemia, defined as a blood glucose concentration less than 2.2 mmol per liter, was found in 91 patients (4.5 percent), 39 (42.9 percent) of whom died. We also measured the plasma concentrations of glucoregulatory hormones and gluconeogenetic substrates in 46 of the patients with hypoglycemia who were 2 to 15 years old and in 25 normoglycemic patients matched with them for age and weight. The patients with hypoglycemia had had diarrhea for less time than the normoglycemic patients (median, 12 vs. 72 hours; P less than 0.05), and their last feeding had been 18 hours before admission, as compared with 9 hours for the normoglycemic patients (P less than 0.05). The groups were similar in terms of nutritional status, the proportion of patients who had fever, and the types of pathogens recovered from stool samples. The plasma C-peptide concentrations were low (less than 0.30 nmol per liter) in all the hypoglycemic patients. As compared with the normoglycemic patients, the patients with hypoglycemia had elevated median plasma concentrations of glucagon (44 vs. 11 pmol per liter; P = 0.001), epinephrine (3400 vs. 1500 pmol per liter; P = 0.012), norepinephrine (7500 vs. 2900 pmol per liter; P = 0.002), and lactate (3.5 vs. 2.1 mmol per liter; P = 0.020) and similar alanine and beta-hydroxybutyrate concentrations. Eighteen hypoglycemic patients with severe malnutrition had been ill longer than 26 better-nourished patients with hypoglycemia (median duration of illness, 18 vs. 10 hours; P = 0.023) and had lower median plasma concentrations of lactate (1.9 vs. 3.9 mmol per liter; P = 0.021) and alanine (173 vs. 293 micromol per liter; P = 0.040). We conclude that hypoglycemia is a major cause of death in association with diarrhea. Because the glucose counterregulatory hormones were appropriately elevated in the children with diarrhea and hypoglycemia, whereas the gluconeogenetic substrates were inappropriately low, we further conclude that the hypoglycemia observed in such patients is most often due to the failure of gluconeogenesis.