The Journal of Emergency Medicine, Vol. 47, No. 5, pp. 524–526, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.06.032
Clinical Communications: Pediatrics ACCIDENTAL ACUTE ALCOHOL INTOXICATION IN INFANTS: REVIEW AND CASE REPORT Gabriella Minera, DO* and Evan Robinson, BS† *Arrowhead Regional Medical Center, Colton, California and †Western University of Health Sciences, Pomona, California Reprint Address: Evan Robinson, BS, Western University of Health Sciences, Pomona, CA
, Abstract—Background: Acute alcohol intoxication in children younger than 18 months old is both rarely documented and rarely fatal. Previous case reports suggest hypoglycemia and faster than normal rates of alcohol elimination found in children with acute alcohol intoxication compared with adults, but data are lacking. Case Report: A 2-monthold infant presented with a decreased mental status after accidental ingestion of alcohol. He was diagnosed with acute alcohol intoxication, with a blood alcohol level of 330 mg/dL and was hyperglycemic (167 mg/dL). Alcohol elimination rate was calculated to be 21.6 mg/dL/h, similar to that in adults. To our knowledge, this case is the second youngest documented patient with accidental alcohol intoxication via ingestion in the United States. We present a rare case report of acute alcohol intoxication in an infant and a review of the literature. Why Should an Emergency Physician Be Aware of This?: Although rare in the literature, poison control data suggests that alcohol poisoning in very young children is not rare. Emergency physicians should be prepared for the management of infants with alcohol poisoning. This case report and review brings attention to this subject and briefly discusses ethanol metabolism in infants. Ó 2014 Elsevier Inc.
Prevention records for infant deaths due to accidental alcohol poisoning found only one reported death from 1995 to 2007 (representing available online infant death records) (1 4). However, in 2012 alone, 1349 ethanol exposures to children 5 years old and younger were reported to the American Association of Poison Control Centers (5). A literature search was performed, excluding cases involving children older than 18 months, which limited results to seven. One of these was iatrogenic, bringing the tally to six accidental cases of infants (18 months or younger). We report a case of a 9-week-old boy with accidental alcohol intoxication and review the current literature. CASE REPORT A 9-week-old male was brought into our emergency department by his mother after he began acting strangely and she noticed that he smelled of alcohol. He was delivered by cesarean section at 36 weeks, with a medical history of a patent ductus arteriosus and umbilical hernia. The mother admitted that the night before she had gone to a party and taken home some vodka in a water bottle. The next morning, the infant’s grandmother accidentally used approximately 90 mL of the vodka to prepare the patient’s baby formula (Enfamil), mistaking it for water. On examination, he appeared dazed but tracked eyes appropriately. His heart rate was 160 beats/min, respirations were 22 breaths/min, temperature was 97.7 F, oxygen saturation was 99% on room air, and weight 9.5 kg.
, Keywords—acute alcohol intoxication; infant alcohol poisoning; accidental alcohol poisoning
INTRODUCTION Reports in the scientific literature of accidental alcohol intoxication in an infant are rare, and deaths are exceedingly so. Results of Centers for Disease Control and
RECEIVED: 8 October 2013; FINAL SUBMISSION RECEIVED: 8 April 2014; ACCEPTED: 30 June 2014 524
Accidental Acute Alcohol Intoxication
A complete blood panel, toxicology screen, basic chemistry panel, and fingerstick glucose were obtained. The patient was started on normal saline 0.9% at 90 cc/h and then switched at the recommendation of poison control to dextrose 5% and normal saline solution (D5NS) at 90 cc/h, 50 min after presentation. Serum blood alcohol was found to be 330 mg/dL. Three hours later, it was 0.27 mg/dL, and at 24 h was < 0.01 mg/dL. Fingerstick glucose was 167 mg/dL at admission, 160 mg/dL 1 h later, and 98 mg/dL (serum) 3 h later (Figure 1). Potassium was elevated at 6.5 mEq/L, and 5.1 mEq/L 3 h later. Chloride was 111 mEq/dL, bicarbonate was 18 mmol/dL, blood urea nitrogen was 5 mmol/dL, creatinine was 0.3 mg/dL, phosphate was 6.8 mg/dL, and aspartate transaminase was 43 IU/L. One hour after admission, the infant was reported to be ‘‘more fussy and appropriate,’’ and appeared ‘‘happy’’ interacting with his mother. The patient continued to be in no distress and was transferred to the pediatrics unit for observation. The i.v. fluids were discontinued and the patient was discharged home to the mother’s care approximately 24 h after initial presentation. Follow-up occurred 4 days later without incident. DISCUSSION Case reports of acute alcohol intoxication in an infant are lacking in the literature. Two cases were due to unintentional mixing of alcohol with baby formula. In Italy, a case was reported where white wine was mixed in a 1-month-old’s formula. He had a blood alcohol level (BAC) of 75 mg/dL on admission, with symptoms of decreased level of consciousness, tremors, and lowgrade fever. The patient was developmentally normal at 1-year follow-up (6). In the United States, a case was reported where vodka was mixed in a 7-month-old’s formula. He had a BAC of 183 mg/dL on admission, appeared in no apparent
Figure 1. Measured serum glucose concentration (ACCUChek and laboratory) over time. Concentration decreased at approximately 13.8 mg/dL/h.
525
distress, but was described as tachycardic, tachypneic, and mildly hypotensive (7). One case was due to accidental ingestion of medication containing ethanol. In Britain, an 18-month-old female was brought to the emergency department after drinking approximately 200 mL paracetamol elixir that contained 10% by volume of 96% ethanol. The authors used an algorithm to estimate the BAC to be 187 mg/dL. On examination, she had a Glasgow Coma Scale score of 3 and was hypotensive. She recovered within 24 h (8). Three cases involved ethanol poisoning via absorption. A 6-month-old male was brought to the emergency department after his family reportedly gave him a sponge bath for 13 h using 750 mL of 70% ethanol on his trunk and extremities. They stated they were following their primary care provider’s instructions after a diagnosis of otitis media the previous day. On arrival, the infant was comatose and in critical condition, hypothermic (94.2 F), tachycardic, and tachypneic. The BAC was 220 mg/dL and blood glucose was 22 mg/dL. He recovered by 24 h (9). A 15-day-old infant was discovered to have a BAC of 440 mg/dL at a French hospital after the parents attempted to ‘‘sterilize’’ his umbilical cord by applying ethanol-soaked dressings. After several hours, the infant recovered with symptomatic treatment only, including i.v. dextrose and intubation with subsequent extubation at 48 h. This study reported an elimination rate of 20 mg/dL/h and a half-life of 17 h. Of note, this patient did have a history significant for a prior anoxic brain injury secondary to two apneic episodes at 13 days of life (10). A 1-month-old female was transferred to an Italian pediatrics department for suspected meningoencephalitis due to unexplained lethargy and was later found to have a BAC of 362 mg/dL. The parents reported using ethanol (95% by volume) soaked gauze to promote umbilical cord detachment (found to be necrotic with hyperemia in contiguous skin). On examination, she was lethargic/ hypotonia, tachycardic, tachypneic, and mildly hypotensive. At 18 h, her BAC was 31 mg/dL, and she was generally improved and being nursed by her mother (11). Previous cases have attempted to identify the elimination rate of ethanol in young children. In our patient, using the two data points for BAC, an elimination rate of 21.6 mg/dL/h (Figure 2) can be extrapolated, close to the rate seen in older children, adolescents, and adults. This supports a previous retrospective study by Simon et al. performed in 1994 (12). This conflicts with a case that described an elimination rate of 49.7 mg/dL/h in a 7-month-old. It is possible that the pharmacokinetic profile in this patient was more primarily first order due to the lower BAC compared with our patient. Both studies are limited by the number of data points, so it is difficult to
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on glucose metabolism appear variable and should be monitored frequently. An infant with unexplained decrease in level of consciousness should have ethanol intoxication considered as a possible diagnosis and a BAC ordered. Intravenous D5NS is the recommended fluid in infants with acute ethanol intoxication. In summary, we report a case of acute alcohol intoxication in a 2-month-old infant with no significant adverse outcomes. REFERENCES Figure 2. Alcohol elimination over time. Solid line represents blood samples acquired over an approximately 24-h period. The dashed line is fitted to the first two data points, as blood alcohol concentration (BAC) had likely reached zero before the last collection.
draw concrete conclusions about the normal ethanol metabolism of infants at this time. The effect of ethanol ingestion on glucose levels has been studied by Madison and Cummins, demonstrating hypoglycemia after alcohol ingestion (13,14). However, a more recent prospective study of 378 patients demonstrated no difference in rates of hypoglycemia between acutely intoxicated patients and controls (15). Interestingly, it did find rates of hyperglycemia in intoxicated patients were about half that of the control group. The observation of hypoglycemia after ethanol ingestion could be due to inhibition of gluconeogenesis, as has been observed in diabetic patients with ethanol ingestion (16). Additionally, it could be the result of ethanol redirecting microcirculation in the pancreas, leading to increased insulin release (17). Our patient was initially hyperglycemic (167 mg/dL) and became normoglycemic within 3 h. This might suggest that the effect of alcohol on glucose regulation is not predictable in infants, and the acutely intoxicated infant requires frequent glucose monitoring. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Acute alcohol intoxication in an infant appears to be highly under-reported in scientific journals, considering the number of cases in children younger than 6 years old reported to poison control. In 2012 alone, there were 1349 reports to poison control for ethanol exposure in children 5 years old and younger (5). In infants, the rates of alcohol elimination and the effect of alcohol
1. National Center for Health Statistics. Linked birth/infant death records 2007. Hyattsville, MD: National Center for Health Statistics; 2007. 2. National Center for Health Statistics. Linked birth/infant death records 2003 2006. Hyattsville, MD: National Center for Health Statistics; 2006. 3. National Center for Health Statistics. Linked birth/infant death records 1999 2002. Hyattsville, MD: National Center for Health Statistics; 2002. 4. National Center for Health Statistics. Linked birth/infant death records 1995 1998. Hyattsville, MD: National Center for Health Statistics; 1998. 5. Mowry JB, Spyker DA, Cantilena LR, Bailey JE, Ford M. 2012 Annual report of the American Association of Poison Control Centers ’ National Poison Data System (NPDS): 30th Annual report. Available at: https://aapcc.s3.amazonaws.com/pdfs/annual_reports/ 2012_NPDS_Annual_Report.pdf. Accessed April 2014. 6. Palano GM, Pratico AD, Pratico ER, et al. [Accidental ethyl alcohol intoxication in a 30-day-old infant. Clinical findings and neurological follow-up]. Minerva Pediatr 2007;59:275–9. 7. Chikwava K, Lower DR, Frangiskakis SH, Sepulveda JL, Virji MA, Rao KN. Acute ethanol intoxication in a 7-month-old infant. Pediatr Dev Pathol 2004;7:400–2. 8. Tovey C, Rana PS, Anderson DJ. Alcohol intoxication in a toddler. J Accid Emerg Med 1998;15:69–70. 9. Moss MH. Alcohol-induced hypoglycemia and coma caused by alcohol sponging. Pediatrics 1970;46:445–7. 10. Autret E, Sanyas P, Chantepie A, Gold F, Laugier J. [Poisoning by externally-administered ethanol in an infant]. Arch Fr Pediatr 1982; 39:823–4. 11. Dalt LD, Dall’Amico R, Laverda AM, Chemollo C, Chiandetti L. Percutaneous ethyl alcohol intoxication in a one-month-old infant. Pediatr Emerg Care 1991;7:343–4. 12. Simon HK, Cox JM, Sucov A, Linakis JG. Serum ethanol clearance in intoxicated children and adolescents presenting to the ED. Acad Emerg Med 1994;1:520–4. 13. Madison LL. Ethanol-induced hypoglycemia. Adv Metab Disord 1968;3:85–109. 14. Cummins LH. Hypoglycemia and convulsions in children following alcohol ingestion. J Pediatr 1961;58:23–6. 15. Sporer KA, Ernst AA, Conte R, Nick TG. The incidence of ethanolinduced hypoglycemia. Am J Emerg Med 1992;10:403–5. 16. Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001;24:1888–93. 17. Huang Z, Sjo¨holm A. Ethanol acutely stimulates islet blood flow, amplifies insulin secretion, and induces hypoglycemia via NO and vagally mediated mechanisms. Endocrinology 2008;149:232–6.
http://dx.doi.org/10.1016/j.jemermed.2014.06.032
Clinical Communications: Pediatrics ACCIDENTAL ACUTE ALCOHOL INTOXICATION IN INFANTS: REVIEW AND CASE REPORT Gabriella Minera, DO* and Evan Robinson, BS† *Arrowhead Regional Medical Center, Colton, California and †Western University of Health Sciences, Pomona, California Reprint Address: Evan Robinson, BS, Western University of Health Sciences, Pomona, CA
, Abstract—Background: Acute alcohol intoxication in children younger than 18 months old is both rarely documented and rarely fatal. Previous case reports suggest hypoglycemia and faster than normal rates of alcohol elimination found in children with acute alcohol intoxication compared with adults, but data are lacking. Case Report: A 2-monthold infant presented with a decreased mental status after accidental ingestion of alcohol. He was diagnosed with acute alcohol intoxication, with a blood alcohol level of 330 mg/dL and was hyperglycemic (167 mg/dL). Alcohol elimination rate was calculated to be 21.6 mg/dL/h, similar to that in adults. To our knowledge, this case is the second youngest documented patient with accidental alcohol intoxication via ingestion in the United States. We present a rare case report of acute alcohol intoxication in an infant and a review of the literature. Why Should an Emergency Physician Be Aware of This?: Although rare in the literature, poison control data suggests that alcohol poisoning in very young children is not rare. Emergency physicians should be prepared for the management of infants with alcohol poisoning. This case report and review brings attention to this subject and briefly discusses ethanol metabolism in infants. Ó 2014 Elsevier Inc.
Prevention records for infant deaths due to accidental alcohol poisoning found only one reported death from 1995 to 2007 (representing available online infant death records) (1 4). However, in 2012 alone, 1349 ethanol exposures to children 5 years old and younger were reported to the American Association of Poison Control Centers (5). A literature search was performed, excluding cases involving children older than 18 months, which limited results to seven. One of these was iatrogenic, bringing the tally to six accidental cases of infants (18 months or younger). We report a case of a 9-week-old boy with accidental alcohol intoxication and review the current literature. CASE REPORT A 9-week-old male was brought into our emergency department by his mother after he began acting strangely and she noticed that he smelled of alcohol. He was delivered by cesarean section at 36 weeks, with a medical history of a patent ductus arteriosus and umbilical hernia. The mother admitted that the night before she had gone to a party and taken home some vodka in a water bottle. The next morning, the infant’s grandmother accidentally used approximately 90 mL of the vodka to prepare the patient’s baby formula (Enfamil), mistaking it for water. On examination, he appeared dazed but tracked eyes appropriately. His heart rate was 160 beats/min, respirations were 22 breaths/min, temperature was 97.7 F, oxygen saturation was 99% on room air, and weight 9.5 kg.
, Keywords—acute alcohol intoxication; infant alcohol poisoning; accidental alcohol poisoning
INTRODUCTION Reports in the scientific literature of accidental alcohol intoxication in an infant are rare, and deaths are exceedingly so. Results of Centers for Disease Control and
RECEIVED: 8 October 2013; FINAL SUBMISSION RECEIVED: 8 April 2014; ACCEPTED: 30 June 2014 524
Accidental Acute Alcohol Intoxication
A complete blood panel, toxicology screen, basic chemistry panel, and fingerstick glucose were obtained. The patient was started on normal saline 0.9% at 90 cc/h and then switched at the recommendation of poison control to dextrose 5% and normal saline solution (D5NS) at 90 cc/h, 50 min after presentation. Serum blood alcohol was found to be 330 mg/dL. Three hours later, it was 0.27 mg/dL, and at 24 h was < 0.01 mg/dL. Fingerstick glucose was 167 mg/dL at admission, 160 mg/dL 1 h later, and 98 mg/dL (serum) 3 h later (Figure 1). Potassium was elevated at 6.5 mEq/L, and 5.1 mEq/L 3 h later. Chloride was 111 mEq/dL, bicarbonate was 18 mmol/dL, blood urea nitrogen was 5 mmol/dL, creatinine was 0.3 mg/dL, phosphate was 6.8 mg/dL, and aspartate transaminase was 43 IU/L. One hour after admission, the infant was reported to be ‘‘more fussy and appropriate,’’ and appeared ‘‘happy’’ interacting with his mother. The patient continued to be in no distress and was transferred to the pediatrics unit for observation. The i.v. fluids were discontinued and the patient was discharged home to the mother’s care approximately 24 h after initial presentation. Follow-up occurred 4 days later without incident. DISCUSSION Case reports of acute alcohol intoxication in an infant are lacking in the literature. Two cases were due to unintentional mixing of alcohol with baby formula. In Italy, a case was reported where white wine was mixed in a 1-month-old’s formula. He had a blood alcohol level (BAC) of 75 mg/dL on admission, with symptoms of decreased level of consciousness, tremors, and lowgrade fever. The patient was developmentally normal at 1-year follow-up (6). In the United States, a case was reported where vodka was mixed in a 7-month-old’s formula. He had a BAC of 183 mg/dL on admission, appeared in no apparent
Figure 1. Measured serum glucose concentration (ACCUChek and laboratory) over time. Concentration decreased at approximately 13.8 mg/dL/h.
525
distress, but was described as tachycardic, tachypneic, and mildly hypotensive (7). One case was due to accidental ingestion of medication containing ethanol. In Britain, an 18-month-old female was brought to the emergency department after drinking approximately 200 mL paracetamol elixir that contained 10% by volume of 96% ethanol. The authors used an algorithm to estimate the BAC to be 187 mg/dL. On examination, she had a Glasgow Coma Scale score of 3 and was hypotensive. She recovered within 24 h (8). Three cases involved ethanol poisoning via absorption. A 6-month-old male was brought to the emergency department after his family reportedly gave him a sponge bath for 13 h using 750 mL of 70% ethanol on his trunk and extremities. They stated they were following their primary care provider’s instructions after a diagnosis of otitis media the previous day. On arrival, the infant was comatose and in critical condition, hypothermic (94.2 F), tachycardic, and tachypneic. The BAC was 220 mg/dL and blood glucose was 22 mg/dL. He recovered by 24 h (9). A 15-day-old infant was discovered to have a BAC of 440 mg/dL at a French hospital after the parents attempted to ‘‘sterilize’’ his umbilical cord by applying ethanol-soaked dressings. After several hours, the infant recovered with symptomatic treatment only, including i.v. dextrose and intubation with subsequent extubation at 48 h. This study reported an elimination rate of 20 mg/dL/h and a half-life of 17 h. Of note, this patient did have a history significant for a prior anoxic brain injury secondary to two apneic episodes at 13 days of life (10). A 1-month-old female was transferred to an Italian pediatrics department for suspected meningoencephalitis due to unexplained lethargy and was later found to have a BAC of 362 mg/dL. The parents reported using ethanol (95% by volume) soaked gauze to promote umbilical cord detachment (found to be necrotic with hyperemia in contiguous skin). On examination, she was lethargic/ hypotonia, tachycardic, tachypneic, and mildly hypotensive. At 18 h, her BAC was 31 mg/dL, and she was generally improved and being nursed by her mother (11). Previous cases have attempted to identify the elimination rate of ethanol in young children. In our patient, using the two data points for BAC, an elimination rate of 21.6 mg/dL/h (Figure 2) can be extrapolated, close to the rate seen in older children, adolescents, and adults. This supports a previous retrospective study by Simon et al. performed in 1994 (12). This conflicts with a case that described an elimination rate of 49.7 mg/dL/h in a 7-month-old. It is possible that the pharmacokinetic profile in this patient was more primarily first order due to the lower BAC compared with our patient. Both studies are limited by the number of data points, so it is difficult to
526
G. Minera and E. Robinson
on glucose metabolism appear variable and should be monitored frequently. An infant with unexplained decrease in level of consciousness should have ethanol intoxication considered as a possible diagnosis and a BAC ordered. Intravenous D5NS is the recommended fluid in infants with acute ethanol intoxication. In summary, we report a case of acute alcohol intoxication in a 2-month-old infant with no significant adverse outcomes. REFERENCES Figure 2. Alcohol elimination over time. Solid line represents blood samples acquired over an approximately 24-h period. The dashed line is fitted to the first two data points, as blood alcohol concentration (BAC) had likely reached zero before the last collection.
draw concrete conclusions about the normal ethanol metabolism of infants at this time. The effect of ethanol ingestion on glucose levels has been studied by Madison and Cummins, demonstrating hypoglycemia after alcohol ingestion (13,14). However, a more recent prospective study of 378 patients demonstrated no difference in rates of hypoglycemia between acutely intoxicated patients and controls (15). Interestingly, it did find rates of hyperglycemia in intoxicated patients were about half that of the control group. The observation of hypoglycemia after ethanol ingestion could be due to inhibition of gluconeogenesis, as has been observed in diabetic patients with ethanol ingestion (16). Additionally, it could be the result of ethanol redirecting microcirculation in the pancreas, leading to increased insulin release (17). Our patient was initially hyperglycemic (167 mg/dL) and became normoglycemic within 3 h. This might suggest that the effect of alcohol on glucose regulation is not predictable in infants, and the acutely intoxicated infant requires frequent glucose monitoring. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Acute alcohol intoxication in an infant appears to be highly under-reported in scientific journals, considering the number of cases in children younger than 6 years old reported to poison control. In 2012 alone, there were 1349 reports to poison control for ethanol exposure in children 5 years old and younger (5). In infants, the rates of alcohol elimination and the effect of alcohol
1. National Center for Health Statistics. Linked birth/infant death records 2007. Hyattsville, MD: National Center for Health Statistics; 2007. 2. National Center for Health Statistics. Linked birth/infant death records 2003 2006. Hyattsville, MD: National Center for Health Statistics; 2006. 3. National Center for Health Statistics. Linked birth/infant death records 1999 2002. Hyattsville, MD: National Center for Health Statistics; 2002. 4. National Center for Health Statistics. Linked birth/infant death records 1995 1998. Hyattsville, MD: National Center for Health Statistics; 1998. 5. Mowry JB, Spyker DA, Cantilena LR, Bailey JE, Ford M. 2012 Annual report of the American Association of Poison Control Centers ’ National Poison Data System (NPDS): 30th Annual report. Available at: https://aapcc.s3.amazonaws.com/pdfs/annual_reports/ 2012_NPDS_Annual_Report.pdf. Accessed April 2014. 6. Palano GM, Pratico AD, Pratico ER, et al. [Accidental ethyl alcohol intoxication in a 30-day-old infant. Clinical findings and neurological follow-up]. Minerva Pediatr 2007;59:275–9. 7. Chikwava K, Lower DR, Frangiskakis SH, Sepulveda JL, Virji MA, Rao KN. Acute ethanol intoxication in a 7-month-old infant. Pediatr Dev Pathol 2004;7:400–2. 8. Tovey C, Rana PS, Anderson DJ. Alcohol intoxication in a toddler. J Accid Emerg Med 1998;15:69–70. 9. Moss MH. Alcohol-induced hypoglycemia and coma caused by alcohol sponging. Pediatrics 1970;46:445–7. 10. Autret E, Sanyas P, Chantepie A, Gold F, Laugier J. [Poisoning by externally-administered ethanol in an infant]. Arch Fr Pediatr 1982; 39:823–4. 11. Dalt LD, Dall’Amico R, Laverda AM, Chemollo C, Chiandetti L. Percutaneous ethyl alcohol intoxication in a one-month-old infant. Pediatr Emerg Care 1991;7:343–4. 12. Simon HK, Cox JM, Sucov A, Linakis JG. Serum ethanol clearance in intoxicated children and adolescents presenting to the ED. Acad Emerg Med 1994;1:520–4. 13. Madison LL. Ethanol-induced hypoglycemia. Adv Metab Disord 1968;3:85–109. 14. Cummins LH. Hypoglycemia and convulsions in children following alcohol ingestion. J Pediatr 1961;58:23–6. 15. Sporer KA, Ernst AA, Conte R, Nick TG. The incidence of ethanolinduced hypoglycemia. Am J Emerg Med 1992;10:403–5. 16. Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001;24:1888–93. 17. Huang Z, Sjo¨holm A. Ethanol acutely stimulates islet blood flow, amplifies insulin secretion, and induces hypoglycemia via NO and vagally mediated mechanisms. Endocrinology 2008;149:232–6.
