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Question:

From Indianapolis, Indiana, USA:

I am a case manager at an insurance company who has searched the NIH archives et cetera for the answer to this question. I have a one year old male child who has had a previous admission to a hospital, not in the state I reside in, who was admitted with a blood sugar of 16 mg/dl [0.89 mmmol/L]. Presenting symptoms included seizures, unrespponsive, bradycardia, and other usual symptoms. He was given IV solutions of D10 and recovered quickly with no apparent ill results of this experience. He was taking nourishment previous to this incident.

The parents have taken the child to a physician who is proposing an admission to challenge his system to see if he is truly hypoglycemic. The plan includes admitting him as an inpatient to a hospital and withholding food until they can see how low his blood sugars will drop. They have not been told how low they will allow the blood sugar to drop, and they are planning more than a 48 hour admission. Is this a medically accepted treatment for the diagnosis of hypoglycemia and if so where may I find documentation on this?

Answer:

If the history that you give is authentic, it is very hard indeed not to accept that this little boy had a severe episode of hypoglycemia and the responsibility now is to determine why rather than to verify: I have to say then that, to my mind, to admit this child for the purpose of withholding food and water, to see if he becomes hypoglycemic again, if circumstances are as described, constitutes malpractice and clearly runs the risk of inducing further hypoglycemia and, with it, permanent and severe cerebral damage.

What is needed is for this infant to be admitted under the care of a pediatrician to a center where additional skills in pediatric endocrinology and metabolism, together with appropriate laboratory facilities, are available.

Another possibility, which is suggested by the implication that he has otherwise been quite healthy, is that this episode was in fact an instance of child abuse and that the hypoglycemia was insulin-induced. This theme is a very sensitive one to evaluate and is best done by members of a special team or by an experienced social worker.

DOB

Additional comments from Dr. Tessa Lebinger:

It sounds like you need more specific information regarding what happened at the first hospital and what exactly is being planned. If you are a case manager for an insurance company, I assume you must also have a pediatric endocrinologist who is available to review the details of specific cases.

It sounds like if the information you give is correct, this child truly had a hypoglycemic seizure. The most important thing right now is to determine the exact cause of this seizure to prevent a recurrence. Possible causes of a hypoglycemic seizure in a 1 year old include hormone deficiencies, insulin excess (either inappropriate production by the child's own pancreas or child abuse by the parents if they gave the child insulin to cause the seizure), and other rarer inborn errors of metabolism.

Different doctors will evaluate this problem differently depending on what initial workup was done. It is, however, acceptable medical practice to do an inpatient controlled fast to see how long it takes for the blood sugar to start to fall (and it is important to do this fast in the hospital so frequent monitoring can be done to avoid letting the blood sugar go so low and stay low so long, that the child could have another seizure). If the blood sugar falls, different diagnostic blood and urine tests should be obtained and possibly glucagon given subcutaneously to try and diagnose this child's problem. Sometimes, this is the only way to make a definite diagnosis safely and often decisions have to be made at the bedside during the test by the physician performing the test as to how long to carry out the test.

I suggest you ask the admitting doctor to send a summary of tests previously done and a general plan of evaluation to be done in the hospital. You can't pin the doctor down too specifically for details regarding the evaluation, as decisions need to be made as the tests evolve to provide the best and safest evaluation for this child.

TGL

DTQ-20000302152305
Original posting 30 Aug 2000
Posted to Hypoglycemia

  
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Last Updated: Tuesday April 06, 2010 15:09:14
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