Dr.Salika Jayasundara (MO/SCBU)General Hospital – Kegalle

Sri Lanka

References

Medscape references neonatal hypoglycemia

Author: Hilarie Cranmer, MD, MPH, FACEP

Updated: Sep 15, 2011

AAP Guidelines for Neonatal Hypoglycemia(2011)

Neonatal hypoglycaemia and blood glucose level monitoring

Queensland Maternity and Neonatal Clinical Guidelines (February 2012 )

The definition of clinically significant hypoglycemia remains one of the most confused issues in neonatology.

 Blood glucose level ( AAP guidelines 2011)

< 30 mg/dL (1.65 mmol/L) in the first 24 hrs of life < 40 mg/dL (2.2 mmol/L) after 24 hrs

severe hypoglycemia is: < 24mg/dl (1.4 mmol/L )

Hypoglycemia is the most common metabolic problem in neonates

Overall Incidence = 1- 5/1000 live births Normal newborns – 10% if feeding is

delayed for 3-6 hours after birth At-Risk Infants – 30%

LGA – 8% Preterm – 15% SGA – 15% IDM – 20%

Glucose is the primary fuel for the brain.

The brain needs a steady supply of glucose to function normally.

Glucose is the fetus’s only source of carbohydrate.

Cerebral glucose utilization accounts for 90% of the neonate’s glucose consumption

Fetal plasma glucose is 60 – 80% of the maternal glucose level.

The fetus stores glucose in the form of glycogen (liver, heart, lung, and skeletal muscle).

Most of the glycogen is made and stored in the last month of the 3rd trimester.

The fetus has limited ability to convert glycogen to glucose and must rely upon placental transfer of glucose to meet energy needs.

When the infant is born, the cord is cut and so is the major supply of glucose!

serum glucose levels decline after birth until age 1-3 hours, then they spontaneously increase.

Liver glycogen stores become rapidly depleted within hours of birth, and gluconeogenesis, primarily from alanine, can account for 10% of glucose turnover in the newborn infant by several hours of age.

Certain groups of babies may be unable to make the appropriate metabolic adaptations to extra uterine life and are considered ‘at risk’ of severe and/or persistent hypoglycaemia.

< 37 weeks gestation Infant of a diabetic mother Small for gestational age Large for gestational age Stressed/ill neonates Exposure to certain medications

Treatment of preterm labor Treatment of hypertension Treatment of type 2 diabetes Benzothiazide diuretics Tricyclic antidepressants in the 3rd

trimester

1. Decreased substrate availability: •IUGR •Glycogen storage disease •Inborn errors (e.g., fructose intolerance) • Prematurity •Prolonged fasting without IV glucose

2. Hyperinsulinemia: •Infant of diabetic mother •Islet cell

hyperplasia •Erythroblastosis fetalis •Exchange

transfusion •Beckwith-Wiedemann Syndrome •Maternal drugs (( Terbutaline, Propanolol,

Chlorpromazine and benzothiazides ) •Abrupt cessation of IV glucose

3. Increased glucose utilization:•Hypothermia •Increased work of

breathing•Sepsis •Perinatal asphyxia

4. Other endocrine abnormalities:•Pan-hypopituitarism •Hypothyroidism•Adrenal insufficiency

5. Miscellaneous conditions:•Polycythemia •Congenital heart

disease•CNS abnormalities

Summary

Limited Glycogen Stores Hyperinsulinism Diminished Glucose Production Limited Glucose Delivery

The clinical signs of hypoglycemia are neither sensitive nor specific.

Any baby that is unwell or who has signs that cannot be readily explained should have their BGL checked.

Babies with signs specific for hypoglycemia require urgent pediatric review and management with IV therapy.

Jitteriness Poor sucking Tachypnoea Sweating Cyanosis pallor Apnoea Seizures Cardiac arrest Irritability Hypotonia Lethargy High-pitched cry Hypothermia

It is not necessary to screen asymptomatic , appropriately grown term babies that do not have risk factors.

Babies should have BGL screens if: they have any risk factors (one or more) they are unwell they have any unexplained abnormal

signs that may be due to hypoglycaemia

Well babies with risk factors controversial

initially at 1, 2, and 4 hours of age Then every 4 to 6 hours or pre second feed (within 3 hours of birth) then check pre-feeds Unwell babies with/without clinical signs immediately, repeat BGL checks regularly

( 6hrly) Confirm any glucometer BGL less than 2.0

mmol/L by blood gas machine or laboratory analysis.

However do not wait for this confirmation before starting appropriate treatment

IV glucose bolus 10% dextrose 2 – 3 ml/kg

Followed by iv infusion 10% dextrose 5 -8 mg/kg/min (60-100ml/kg/day) B/O diabetic mother 8-10mg/kg/minRecheck level in 30-60mints & monitor every 2-4 hrly For persistent hypoglycemia

increase rate stepwise up to 10-15mg/kg/min

Maximal concentration of glucose in peripheral IV is D12.5.

>12.5%, insert central venous catheter

Weaning IV dextrose infusion start when BGL is stable for 12-24 hrs

To calculate rate of glucose administration

% glucose x mL/kg/d = glucose infusion rate 144 (mg/kg/min)

or % glucose x mL/h = glucose infusion rate 6 x body weight (kg) (mg/kg/min)

Consider pharmacological intervention for severe, persistent or recurrent hypoglycaemia Glucagon 200 microgram/kg IV/IM stat 10-50 microgram/kg/hr infusion

Hydrocortisone 1 mg/kg/dose IV 6 hourly Diazoxide , Octreotide , Hydrochlorothiazide

need further Ix to find the cause Ex:- Insulin (±C-peptide) , Cortisol , Ketones GH , Adrenocorticotrophic hormone serum amino acid

profile ,ammonia , free fatty acids,MRI ,urine analysis

Selective Neuronal necrosis in multiple brain regions including the superficial cortex, dentate gyrus,hippocampus and caudate and putamen

In preterm infants predisposes to IVH Impaired cognitive and motor function Imaging studies in term infants and

selected preterm infants

Maintain temperature with skin to skin contact at delivery room

Early and frequent feedings Increase awareness of conditions

that predispose an infant to hypoglycemia

Early screening of at-risk infants

The clinical signs of hypoglycemia are neither sensitive nor specific

Any baby that is unwell or who has signs that cannot be readily explained should have their BGL checked.

NEVER give a bolus of dextrose without also increasing the background rate or concentration of IV dextrose infusion.

Hypoglycaemia is treatable condition

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