Download - Hypoglycemia in newborns
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HYPOGLYCEMIA IN NEWBORN
HYPOGLYCEMIA IN NEWBORN
AMRUTHA RAMAKRISHNAN
1ST YR MSc NSG
AMRUTHA RAMAKRISHNAN
1ST YR MSc NSG
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B Glucose levels in NBBB Glucose levels in NBB
• At birth – 60 – 70% (2/3) of mother’s B glucose level
• In first 24 hrs – Falls• Next 24 hrs – Transient
rise• 3 – 4 days of age –
Dangerously low levels• Thereafter – Stability
achieved1
10
432Days of life
20
30
40
50
60
70
80
B G
luco
se (
mg%
)
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Hypoglycemia in Newborn?Hypoglycemia in Newborn?
• Serum glucose <40 mg%
• In preterm infants, repeated blood glucose levels below 50 mg/dL may be associated with neurodevelopmental delay.
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• Definition• The operational threshold for
hypoglycemia is defined as that concentration of plasma or whole blood glucose at which clinicians should consider intervention, based on the evidence currently available in literature.
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High risk High riskLBW Preterm infants (SGA) (IDM) (LGA) Rh-hemolytic disease
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High riskHigh risk
• therapy with terbutaline propranolol lebatolol and oral hypoglycemic agents
• IUGR.• sick neonate• Infants on TPN
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ETIOLOGYETIOLOGY
• increased utilization of glucose (Hyperinsulinism)
• decreased production or stores
• increased utilization &/ decreased production / other causes
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HyperinsulinismHyperinsulinism
Diabetic mothers
Maternal tocolytic therapy
Maternal chlorpropamide therapy
Beckwith- weidmann syndrome
Abrupt cessation of high glucose infusions
exchange transfusion of blood containing high
glucose concentration
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Beckwith-Weidmann syndromeBeckwith-Weidmann syndrome
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Decreased production or storesDecreased production or stores
Preterm (SGA & LGA)
IUGR (Preterm & post term)
Inadequate calorie intake
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increased utilization &/ decreased production / other
causes
increased utilization &/ decreased production / other
causes Perinatal stress
Defects in CHO metabolism
Endocrine deficiency
Polycythemia
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Time schedule for screeningTime schedule for screening
• IDMs
• asymptomatic hypoglycemia very early viz. 1 to 2 hours and rarely beyond 12 hours
• preterm and SGA may be at risk up to 36 h (range 0.8 to 34.2 h)
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Symptomatology of infants
Time schedule for screening
At risk neonates 2, 6, 12, 24, 48, and 72 hrs
Sick infantsSepsis, asphyxia, shock inthe active phase of illness
Every 6-8 hrs
Stable VLBW infants onparenteral nutrition
Initial 72 h: every 6 to 8 hrs;after 72 hrs in stable babies: once a day
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When should be screening is stopped
When should be screening is stopped
INFANTS TIME
At risk End of 72 hrs
infant on IV fluids Has two consecutive values >50 mg/dL on total oral feeds afterstopping of the IV fluids.
Infant whose blood sugar normalized on oral feed
Consider at risk and monitor for 48 hours
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Method of Glucose estimationMethod of Glucose estimation
• Bed side reagent strips (Glucose oxidase):
• Laboratory diagnosis
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Clinical signs associated with hypoglycemia
Clinical signs associated with hypoglycemia
•Asymptomatic
•Symptomatic
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SymptomaticSymptomatic
• stupor,• jitteriness,• tremors, • apathy, • episodes of cyanosis, • convulsions, • intermittent apneic spells • tachypnea, weak• .
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SymptomaticSymptomatic
• and high pitched cry,• limpness and lethargy, • difficulty in feeding, • eye rolling• sweating, • sudden pallor,• hypothermia and • cardiac arrest
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Management of asymptomatic hypoglycemia
Management of asymptomatic hypoglycemia
• Blood sugar 20-40 mg/dL
asymptomatic hypoglycemia
• Trial of oral feeds (expressed breast milk or formula) and
• Repeat blood test after 1 hour.• If repeat blood sugar is more than 50• mg/dL, two hourly feeds is ensured
with 6 hourly monitoring for 48 hrs• If repeat blood sugar is <40 mg/dL, IV
Dextrose is started and• further management is as for
symptomatic hypoglycemia
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ASYMPTOMATICASYMPTOMATIC
• Blood sugar levels <20 mg/dL
asymptomatic
hypoglycemia
• IV Dextrose is started at 6 mg/kg/min of glucose;
• Further management is as for symptomatic hypoglycemia
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symptomatic hypoglycemiasymptomatic hypoglycemia
• including seizures, a bolus of 2 mL/kg of 10% dextrose (200mg/kg)
• Immediately after the bolus, a glucose infusion at an initial rate of 6-8 mg/kg/min should be started.
• Check blood sugar after 30 to 60 min and then every 6 hour until blood sugar is >50 mg/dL.
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symptomatic hypoglycemiasymptomatic hypoglycemia
• Repeat subsequent hypoglycemic episodes may be treated by increasing the glucose infusion rate by 2 mg/kg/min until a maximum of 12 mg/kg/min.
• After 24 hours of IV glucose therapy, once two or more consecutive blood glucose values are >50 mg/dL, the infusion can be tapered off
• the rate of 2 mg/kg/min every 6 hours with BGL monitoring.
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symptomatic hypoglycemiasymptomatic hypoglycemia
• oral feeds.• 4 mg/kg/min of glucose infusion is
reached• and oral intake is adequate and the blood
sugar values are consistently >50 mg/dL, the infusion can be stopped without further tapering.
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Recurrent / resistant hypoglycemia
Recurrent / resistant hypoglycemia
• when there is a failure to maintain normal blood sugar levels despite a glucose infusion of 12 mg/kg/min or when stabilization is not achieved by 7 days of therapy. High levels of glucose infusion may be needed in the infants to achieve euglycemia
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TreatmentTreatment
• Hydrocortisone 5 mg/kg/day IV or PO in two divided doses for 24 to 48 hrs
• Diazoxide 10-25 mg/kg/day in three divided doses PO.
• Glucagon 100 mg/kg subcutaneous or intramuscular (max 300 mg)
• Octreotide (synthetic somatostatin in dose of 2-10 μg/kg/day subcutaneously two to three times a day.
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PreventionPrevention
• Early feeding - as soon as the infant is ready, preferably within 1 hour of birth.
• What feed? – Breastmilk (colostrum) Not dextrose-water.
• Assess risk factors and symptoms. Assess for presence of the following risk factors and symptoms
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PreventionPrevention