Related Experiment Videos
Prospective multicenter study of sulfonylurea ingestion in children
H A Spiller1, D Villalobos, E P Krenzelok
1Kentucky Regional Poison Center, Louisville 40232-5070, USA.
Insights
Pediatric sulfonylurea ingestions often do not cause symptoms. Monitoring for hypoglycemia (low blood glucose) within the first 8 hours after ingestion can safely predict a benign outcome in children.
Area of Science:
- Pediatric Toxicology
- Emergency Medicine
- Clinical Pharmacology
Background:
- Many pediatric sulfonylurea ingestions do not lead to adverse effects.
- Over-admission of asymptomatic children results in unnecessary hospitalizations.
Purpose of the Study:
- To prospectively identify predictors of symptomatic hypoglycemia in pediatric sulfonylurea ingestions.
- To differentiate children at risk for hypoglycemia from those who will remain asymptomatic.
Main Methods:
- Analysis of sulfonylurea exposures in children <= 12 years old across 10 poison centers.
- Definition of hypoglycemia as blood glucose < 60 mg/dl.
- Evaluation of clinical outcomes based on ingestion dose, time, and management strategies.
Main Results:
- Hypoglycemia occurred in 30% of exposed children, typically within 8 hours.
- Oral supplementation alone was sufficient for most patients; IV dextrose was needed for some.
- Ingestion dose (<= 0.3 mg/kg vs > 0.3 mg/kg) was a significant predictor of hypoglycemia (p < 0.005).
Conclusions:
- Absence of hypoglycemia within 8 hours predicts a benign outcome.
- Clinical observation with oral feeding is a safe initial management strategy.
- Dose-based management using mg/kg is currently inappropriate; focus on monitoring for hypoglycemia.
Objective:
Sixty-eight percent of pediatric sulfonylurea ingestions reported to poison centers do not result in laboratory or behavioral effects. Consequently, if all exposed children are admitted overnight or for 24 hours for these exposures, it will result in 600 to 700 hospital admissions per year of children who will remain free of symptoms. We prospectively studied exposures reported to 10 regional poison centers to determine if it were possible to differentiate those patients who would have symptoms from those who would remain symptom free.
Methods:
We analyzed all sulfonylurea exposures in children < or = 12 years old reported to the participating poison centers. Hypoglycemia was defined as blood glucose (BG) concentration < 60 mg/dl.
Results:
Hypoglycemia developed in 56 (30%) of 185 exposed patients. Fifty-four of the 56 (96%) hypoglycemic patients had development of hypoglycemia within 8 hours of ingestion. Eighty-seven of the patients were initially managed with oral supplementation only; in 13 cases, treatment advanced to intravenous administration of glucose or glucagon with the onset of hypoglycemia. There was no statistical difference in medical outcome between patients monitored during oral supplementation versus during intravenous infusion of dextrose. Ingestions analyzed by time of day did not predict risk of hypoglycemia. Sufficient data were available for 103 (58%) of the 177 patients who ingested glyburide or glipizide to calculate a toxic dose/weight ratio. Of these 103 patients, 31 of 36 patients who ingested < or = 0.3 mg/kg remained symptom free, whereas 31 of 67 who ingested more than 0.3 mg/kg had BG concentrations < 60 mg/dl (p < 0.005, 95% confidence interval 0.05 to 0.58; sensitivity 86%, specificity 46%).
Conclusion:
A lack of onset of hypoglycemia (BG > 60 mg/dl) in the first 8 hours after ingestion is predictive of a benign outcome in accidental pediatric sulfonylurea ingestion. Clinical observation of children for onset of hypoglycemia during oral feeding alone appears safe. Some children with symptoms of hypoglycemia need to receive intravenous dextrose therapy. Time of day of ingestion is not predictive of risk of hypoglycemia. Finally, at this time it appears inappropriate to use a milligram per kilogram body weight dose as a guide for management decisions.