{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T16:17:45Z","timestamp":1778084265011,"version":"3.51.4"},"reference-count":76,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"5","license":[{"start":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T00:00:00Z","timestamp":1778025600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,6]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n                  <jats:p>Critically ill children with low blood glucose concentrations in low-income settings suffer a high risk of mortality independent of other signs of disease severity and despite administration of the currently recommended treatment of hypoglycemia. This study explores other pathways that may relate to the high mortality risk, namely electrolyte derangements, metabolic acidosis, and hyperketonemia. Children ages 1 month to 5 years old presenting with one or more WHO emergency signs were recruited upon arrival to the Pediatric Accident and Emergency Department at Queen Elizabeth Central Hospital in Malawi between November 2022 and June 2024. A total of 12 hypoglycemic (blood glucose &lt;2.5 mmol\/L), 36 low glycemic (blood glucose 2.5\u20134.9 mmol\/L), and 201 normoglycemic (blood glucose 5.0\u201310.0 mmol\/L) children were enrolled. Low glycemic children had increased odds of acidosis (adjusted odds ratio [aOR] = 5.84, 95% CI: 1.17\u201329.2 for moderate acidosis; aOR = 27.1, 95% CI: 6.08\u2013120.9 for severe acidosis). Among children with acidosis, there were increased odds of hypokalemia (aOR = 24.5, 95% CI: 2.91\u2013205.88), hyponatremia (aOR = 2.58, 95% CI: 1.33\u20134.99 for moderate acidosis; aOR = 3.62, 95% CI: 1.71\u20137.68 for severe acidosis), and hypernatremia (aOR = 9.42, 95% CI: 2.50\u201335.5 for severe acidosis). There were no increased odds of potassium or sodium derangements in those with low glucose concentrations. Low blood glucose concentrations were associated with metabolic acidosis, which in turn, was associated with hypokalemia and hyponatremia\/hypernatremia. However, there was no direct association between low blood glucose and electrolyte derangements.<\/jats:p>","DOI":"10.4269\/ajtmh.25-0635","type":"journal-article","created":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T15:01:44Z","timestamp":1774969304000},"page":"981-988","source":"Crossref","is-referenced-by-count":0,"title":["Low Blood Glucose and Its Relation to Electrolyte Derangements and Metabolic Acidosis in Critically Ill Children in Malawi"],"prefix":"10.4269","volume":"114","author":[{"given":"Ance","family":"Kreslins","sequence":"first","affiliation":[{"name":"Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden;"},{"name":"Astrid Lindgren Children\u2019s Hospital, Karolinska University Hospital, Stockholm, Sweden;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fatsani","family":"Ngwalangwa","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences, Blantyre, Malawi;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Josephine","family":"Langton","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital and Kamuzu University of Health Sciences, Blantyre, Malawi;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ethwako","family":"Mlia Phiri","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Child Health, Queen Elizabeth Central Hospital and Kamuzu University of Health Sciences, Blantyre, Malawi;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carina","family":"King","sequence":"additional","affiliation":[{"name":"Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Helena","family":"Hildenwall","sequence":"additional","affiliation":[{"name":"Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden;"},{"name":"Astrid Lindgren Children\u2019s Hospital, Karolinska University Hospital, Stockholm, Sweden;"},{"name":"Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2795","reference":[{"key":"b1","article-title":"Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses.","year":"2013"},{"key":"b2","article-title":"Guidelines for the Treatment of Malaria.","year":"2015"},{"key":"b3","series-title":"Am J Trop Med Hyg","first-page":"232","article-title":"Blood glucose as a predictor of mortality in children admitted to the hospital with febrile illness in Tanzania","volume":"89","author":"Nadjm","year":"2013"},{"key":"b4","series-title":"Arch Dis Child","first-page":"621","article-title":"Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: Prevalence and outcome","volume":"88","author":"Osier","year":"2003"},{"key":"b5","series-title":"J Trop Pediatr","first-page":"96","article-title":"Hypoglycaemia in a Nigerian paediatric emergency ward","volume":"52","author":"Elusiyan","year":"2006"},{"key":"b6","series-title":"PLoS One","first-page":"e65193","article-title":"Childhood dysglycemia: Prevalence and outcome in a referral hospital","volume":"8","author":"Sambany","year":"2013"},{"key":"b7","series-title":"PLoS One","first-page":"e102530","article-title":"Pre-hospital risk factors for inpatient death from severe febrile illness in Malian children","volume":"9","author":"Willcox","year":"2014"},{"key":"b8","series-title":"PLoS One","first-page":"e0150076","article-title":"High mortality risk in hypoglycemic and dysglycemic children admitted at a referral hospital in a non malaria tropical setting of a low income country","volume":"11","author":"Barennes","year":"2016"},{"key":"b9","series-title":"Trop Med Int Health","first-page":"232","article-title":"Blood glucose and prognosis in children with presumed severe malaria: Is there a threshold for \u2018hypoglycaemia\u2019?","volume":"15","author":"Willcox","year":"2010"},{"key":"b10","series-title":"Am J Trop Med Hyg","first-page":"670","article-title":"Risk factors for mortality in severely ill children admitted to a tertiary referral hospital in Malawi","volume":"101","author":"Ngwalangwa","year":"2019"},{"key":"b11","series-title":"Lancet Glob Health","first-page":"e1546","article-title":"Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): A pragmatic, randomised controlled trial","volume":"8","author":"Baker","year":"2020"},{"key":"b12","series-title":"Acute Crit Care","first-page":"644","article-title":"Characteristics and timing of mortality in children dying in pediatric intensive care: A 5-year experience","volume":"37","author":"Botan","year":"2022"},{"key":"b13","series-title":"J Pediatr Crit Care","first-page":"99","article-title":"Metabolic acidosis as a predictor of outcome in critically ill children\u2014A single-center prospective observational study","volume":"11","author":"Datta","year":"2024"},{"key":"b14","series-title":"Clin Infect Dis","first-page":"948","article-title":"The prognostic value of measures of acid\/base balance in pediatric falciparum malaria, compared with other clinical and laboratory parameters","volume":"41","author":"Newton","year":"2005"},{"key":"b15","series-title":"Malar J","first-page":"282","article-title":"Identifying prognostic factors of severe metabolic acidosis and uraemia in African children with severe falciparum malaria: A secondary analysis of a randomized trial","volume":"20","author":"Mzumara","year":"2021"},{"key":"b16","series-title":"Annu Rev Nutr","first-page":"1","article-title":"Fuel metabolism in starvation","volume":"26","author":"Cahill","year":"2006"},{"key":"b17","series-title":"Diabetes Care","first-page":"217","article-title":"Vital signs, QT prolongation, and newly diagnosed cardiovascular disease during severe hypoglycemia in type 1 and type 2 diabetic patients","volume":"37","author":"Tsujimoto","year":"2014"},{"key":"b18","series-title":"Diabetes","first-page":"1469","article-title":"Mechanisms of abnormal cardiac repolarization during insulin-induced hypoglycemia","volume":"52","author":"Robinson","year":"2003"},{"key":"b19","article-title":"Guideline: Updates on Paediatric Emergency Triage, Assessment and Treatment: Care of Critically-Ill Children.","year":"2016"},{"key":"b20","series-title":"Diabetes Technol Ther","first-page":"755","article-title":"Accuracy of a simplified glucose measurement device\u2014The HemoCue Glucose 201RT","volume":"17","author":"Segerhag","year":"2015"},{"key":"b21","series-title":"Eur J Endocrinol","first-page":"275","article-title":"Comparison of the accuracy of the HemoCue glucose analyzer with the Yellow Springs Instrument glucose oxidase analyzer, particularly in hypoglycemia","volume":"153","author":"Stork","year":"2005"},{"key":"b22","series-title":"Ann Clin Lab Sci","first-page":"231","article-title":"Evaluation of the i-STAT Portable Clinical Analyzer for point-of-care blood testing in the intensive care units of a university children\u2019s hospital","volume":"32","author":"Papadea","year":"2002"},{"key":"b23","series-title":"Point Care","first-page":"4","article-title":"Evaluation of the FreeStyle precision pro blood Glucose and \u03b2-Ketone monitoring system","volume":"28","author":"Brannan","year":"2015"},{"key":"b24","article-title":"Integrated Management of Childhood Illness\u2014Chart Booklet.","year":"2014"},{"key":"b25","series-title":"Trans R Soc Trop Med Hyg","first-page":"161","article-title":"Coma scales for children with severe falciparum malaria","volume":"91","author":"Newton","year":"1997"},{"key":"b26","article-title":"i-STAT EG6+ Cartridge.","year":"2022"},{"key":"b27","series-title":"Malar J","first-page":"423","article-title":"Predictors of hyperlactataemia among children presenting with malaria in a low transmission area in The Gambia","volume":"12","author":"Bhaskaran","year":"2013"},{"key":"b28","series-title":"Crit Care","first-page":"508","article-title":"Clinical review: The meaning of acid\u2013base abnormalities in the intensive care unit part I\u2014Epidemiology","volume":"9","author":"Gunnerson","year":"2005"},{"key":"b29","series-title":"Nat Rev Nephrol","first-page":"274","article-title":"Metabolic acidosis: Pathophysiology, diagnosis and management","volume":"6","author":"Kraut","year":"2010"},{"key":"b30","series-title":"Crit Care","first-page":"536","article-title":"Effect of withholding early parenteral nutrition in PICU on ketogenesis as potential mediator of its outcome benefit","volume":"24","author":"De Bruyn","year":"2020"},{"key":"b31","series-title":"Indian J Child Health","first-page":"128","article-title":"Profile of serum electrolytes in critically Ill children: A prospective study","volume":"5","author":"Agarwal","year":"2018"},{"key":"b32","series-title":"IOSR J Dental Med Sci","first-page":"12","article-title":"Patterns of electrolyte abnormalities in children 0\u201315 years of age admitted to pediatric emergency and intensive care units of a tertiary hospital","volume":"17","author":"Elala","year":"2018"},{"key":"b33","series-title":"J Intensive Care Med","first-page":"269","article-title":"Potassium abnormalities in a pediatric intensive care unit: Frequency and severity","volume":"29","author":"Cummings","year":"2014"},{"key":"b34","series-title":"BMC Pediatr","first-page":"310","article-title":"Hyponatremia and its associated factors in children admitted to the pediatric intensive care unit in eastern Ethiopia: A cross-sectional study","volume":"23","author":"Berhanu","year":"2023"},{"key":"b35","series-title":"PLoS One","first-page":"e0161320","article-title":"Sodium disturbances in children admitted to a Kenyan hospital: Magnitude, outcome and associated factors","volume":"11","author":"Ibinda","year":"2016"},{"key":"b36","series-title":"Clin Infect Dis","first-page":"9","article-title":"Perturbations in electrolyte levels in Kenyan children with severe malaria complicated by acidosis","volume":"40","author":"Maitland","year":"2005"},{"key":"b37","series-title":"Lancet Glob Health","first-page":"e194","article-title":"Malaria guidelines fall short in diagnosing acute kidney injury","volume":"12","author":"Batte","year":"2024"},{"key":"b38","series-title":"J Am Soc Nephrol","first-page":"1981","article-title":"Effects of pH on potassium: New explanations for old observations","volume":"22","author":"Aronson","year":"2011"},{"key":"b1","article-title":"Pocket Book of Hospital Care for Children: Guidelines for 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Malawi","volume":"101","author":"Ngwalangwa","year":"2019"},{"key":"b11","series-title":"Lancet Glob Health","first-page":"e1546","article-title":"Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): A pragmatic, randomised controlled trial","volume":"8","author":"Baker","year":"2020"},{"key":"b12","series-title":"Acute Crit Care","first-page":"644","article-title":"Characteristics and timing of mortality in children dying in pediatric intensive care: A 5-year experience","volume":"37","author":"Botan","year":"2022"},{"key":"b13","series-title":"J Pediatr Crit Care","first-page":"99","article-title":"Metabolic acidosis as a predictor of outcome in critically ill children\u2014A single-center prospective observational study","volume":"11","author":"Datta","year":"2024"},{"key":"b14","series-title":"Clin Infect Dis","first-page":"948","article-title":"The prognostic value of measures of acid\/base balance in pediatric falciparum malaria, compared with other clinical and laboratory parameters","volume":"41","author":"Newton","year":"2005"},{"key":"b15","series-title":"Malar J","first-page":"282","article-title":"Identifying prognostic factors of severe metabolic acidosis and uraemia in African children with severe falciparum malaria: A secondary analysis of a randomized trial","volume":"20","author":"Mzumara","year":"2021"},{"key":"b16","series-title":"Annu Rev Nutr","first-page":"1","article-title":"Fuel metabolism in starvation","volume":"26","author":"Cahill","year":"2006"},{"key":"b17","series-title":"Diabetes Care","first-page":"217","article-title":"Vital signs, QT prolongation, and newly diagnosed cardiovascular disease during severe hypoglycemia in type 1 and type 2 diabetic patients","volume":"37","author":"Tsujimoto","year":"2014"},{"key":"b18","series-title":"Diabetes","first-page":"1469","article-title":"Mechanisms of abnormal cardiac repolarization during insulin-induced hypoglycemia","volume":"52","author":"Robinson","year":"2003"},{"key":"b19","article-title":"Guideline: Updates on Paediatric Emergency Triage, Assessment and Treatment: Care of Critically-Ill Children.","year":"2016"},{"key":"b20","series-title":"Diabetes Technol Ther","first-page":"755","article-title":"Accuracy of a simplified glucose measurement device\u2014The HemoCue Glucose 201RT","volume":"17","author":"Segerhag","year":"2015"},{"key":"b21","series-title":"Eur J Endocrinol","first-page":"275","article-title":"Comparison of the accuracy of the HemoCue glucose analyzer with the Yellow Springs Instrument glucose oxidase analyzer, particularly in hypoglycemia","volume":"153","author":"Stork","year":"2005"},{"key":"b22","series-title":"Ann Clin Lab Sci","first-page":"231","article-title":"Evaluation of the i-STAT Portable Clinical Analyzer for point-of-care blood testing in the intensive care units of a university children\u2019s hospital","volume":"32","author":"Papadea","year":"2002"},{"key":"b23","series-title":"Point Care","first-page":"4","article-title":"Evaluation of the FreeStyle precision pro blood Glucose and \u03b2-Ketone monitoring system","volume":"28","author":"Brannan","year":"2015"},{"key":"b24","article-title":"Integrated Management of Childhood Illness\u2014Chart Booklet.","year":"2014"},{"key":"b25","series-title":"Trans R Soc Trop Med Hyg","first-page":"161","article-title":"Coma scales for children with severe falciparum malaria","volume":"91","author":"Newton","year":"1997"},{"key":"b26","article-title":"i-STAT EG6+ Cartridge.","year":"2022"},{"key":"b27","series-title":"Malar J","first-page":"423","article-title":"Predictors of hyperlactataemia among children presenting with malaria in a low transmission area in The Gambia","volume":"12","author":"Bhaskaran","year":"2013"},{"key":"b28","series-title":"Crit Care","first-page":"508","article-title":"Clinical review: The 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