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Neonatal hypoglycemia
Introduction
• Glucose or dextrose is a vital source of nutrient energy and
is required continuously by the fetus.
• Neonate needs this as either intermittent oral feeds or
continuous IV fluids.
• Hypoglycemia can cause long term neurologic sequelae.
 The important steps in preventing and treating
hypoglycemia are
 to identify neonates at risk of developing hypoglycemia
 to recognize symptoms of hypoglycemia, early feeding and
 to initiate IV fluid therapy, where ever needed.
Neonates at risk of hypoglycemia
o Babies weighing less than 2.0 kg birth weight,
o preterm babies,
o LGA (large for gestational age) babies especially
those weighing more than 3.5 kg,
o infants of diabetic mothers,
o those with delayed cry at birth, any sick neonate
who is not sucking or accepting feeds are all at
risk of developing hypoglycemia.
o The other risk factors for hypoglycemia are RDS,
polycythemia, shock, and hypothermia
Definition of hypoglycemia
• Neonatal hypoglycemia, defined as a plasma
glucose level of less than 30 mg/dL (1.65
mmol/L) in the first 24 hours of life and less
than 45 mg/dL (2.5 mmol/L) thereafter,
• Neonatal hypoglycemia is the most common
metabolic problem in newborns.
Symptoms of hypoglycemia
• The symptoms of hypoglycemia are very nonspecific and
can mimic any illness.
• The common symptoms are:
• Not looking well
• Lethargic,
• Weak cry,
• Poor feeding,
• Temperature instability like hypothermia,
• Poor respiratory effort: shallow breathing, apnea or
cyanosis
• CNS symptoms like: excessive jitteriness, convulsions or
hypotonia.
Factors which increase the risk of
hypoglycemia
• Various factors which increase the risk of
hypoglycemia are hypothermia & cold Stress,
cold environment, wet baby and inadequate
feeding.
Etiology
• The causes of neonatal hypoglycemia include the following:
• Persistent hyperinsulinemic hypoglycemia of infancy (PHHI)
• Limited glycogen stores (eg, prematurity, intrauterine
growth retardation)
• Increased glucose use (eg, hyperthermia, polycythemia,
sepsis, growth hormone deficiency)
• Decreased glycogenolysis, gluconeogenesis, or use of
alternate fuels (eg, inborn errors of metabolism, adrenal
insufficiency)
• Depleted glycogen stores (eg, asphyxia-perinatal stress,
starvation)
hypoglycemia ketotic and nonketotic
Treatment
• To raise the blood sugar value to normal range,
give 200 mg/kg of dextrose i.e. 2 ml /kg of 10%
dextrose as bolus slowly over 3-5 minutes and
start maintenance fluids with a dextrose infusion
rate (DIR) of 6 – 8 mg/kg/min.
• The maximum strength of dextrose that can be
given through a peripheral vein is 12.5%.
• Repeat Dextrostix after 15-30 minutes, if still low,
repeat bolus and increase (DIR) by 1 – 2
mg/kg/min or the maintenance fluids by 10 – 20
ml/kg/day.
• For example in a low birth weight baby on first day of life
give 80ml/kg/ day i.e. 80 x wt of the baby
• e.g. 1.8 kg i.e. 144 ml/day. Divide by 24 to obtain fluid per
hour (144 / 24 = 6 ml/hr).
• Take a measured volume set, fill 1/4th or 6 hrs fluid i.e. 24
ml and deliver at a rate of 6 micro drops/min (number of
drops per minute is equal to rate of fluid/hour).
• The dextrose infusion rate can be calculated by the
following formula:
 Fluid rate (ml/kg/day) x % of Dextrose to be used x 0.007 =
DIR (mg/kg/min).
o e.g. If a baby is on 100 ml/kg/day of 10% dextrose, the DIR
is 7 mg/kg/min. You may also use the reference charts to
calculate the DIR.
How to monitor blood glucose in
hypoglycemia
• In asymptomatic babies measure blood glucose within 2 hrs of
birth, preferably before feeds.
• Frequency & duration depends on clinical features and glucose
value, initial frequency may be 2 hrly, and later 4 hrly and finally 8 -
12 hrly.
• Monitoring is usually done for 72 hrs after birth in at risk newborns
or till glucose levels remain normal for 48 – 72 hrs.
• Symptomatic babies: may require more frequent monitoring.
• Maintain the same DIR till the blood glucose is stable for at least 6 –
8hrs and then decrease the DIR by not greater than 1 – 2
mg/kg/min every 2 hours with adequate monitoring.
Resistant or Persistent Hypoglycemia:
• Resistant or Persistent Hypoglycemia:
• Requirement of a dextrose infusion rate or more than
12 mg/ kg/min suggests resistant hypoglycemia.
• Any hypoglycemia persisting beyond one week despite
adequate management suggests persistent
hypoglycemia.
• One should rule out hyperinsulinemic state or inborn
errors of metabolism.
• Increase the DIR to 12–15 mg/kg/min, keeping in mind
that more than 12.5% dextrose should not be given
through a peripheral vein and a central venous
catheterization is required.
• In resistant or persistent hypoglycemia the
following drugs should be considered: –
• Hydrocortisone: 10 mg/kg/day in two divided
doses intravenously
• Glucagon: 100 – 300 ug/kg/dose IM to a
maximum of 3 doses in babies with adequate
glycogen stores
• Diazoxide: 2 – 5 mg/kg/dose every 8 hrly orally
• Octreotide : Synthetic somatostatin in a dose of
2–10 ug/kg/day subcutaneously q 8 -12 hourly
• Babies with persistent or resistant hypoglycemia
should be REFERRED to a specialize center for
farther investigations
THANKS FOR YOUR
Attention

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Neonatal hypoglycemia

  • 2. Introduction • Glucose or dextrose is a vital source of nutrient energy and is required continuously by the fetus. • Neonate needs this as either intermittent oral feeds or continuous IV fluids. • Hypoglycemia can cause long term neurologic sequelae.  The important steps in preventing and treating hypoglycemia are  to identify neonates at risk of developing hypoglycemia  to recognize symptoms of hypoglycemia, early feeding and  to initiate IV fluid therapy, where ever needed.
  • 3. Neonates at risk of hypoglycemia o Babies weighing less than 2.0 kg birth weight, o preterm babies, o LGA (large for gestational age) babies especially those weighing more than 3.5 kg, o infants of diabetic mothers, o those with delayed cry at birth, any sick neonate who is not sucking or accepting feeds are all at risk of developing hypoglycemia. o The other risk factors for hypoglycemia are RDS, polycythemia, shock, and hypothermia
  • 4. Definition of hypoglycemia • Neonatal hypoglycemia, defined as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter, • Neonatal hypoglycemia is the most common metabolic problem in newborns.
  • 5. Symptoms of hypoglycemia • The symptoms of hypoglycemia are very nonspecific and can mimic any illness. • The common symptoms are: • Not looking well • Lethargic, • Weak cry, • Poor feeding, • Temperature instability like hypothermia, • Poor respiratory effort: shallow breathing, apnea or cyanosis • CNS symptoms like: excessive jitteriness, convulsions or hypotonia.
  • 6. Factors which increase the risk of hypoglycemia • Various factors which increase the risk of hypoglycemia are hypothermia & cold Stress, cold environment, wet baby and inadequate feeding.
  • 7. Etiology • The causes of neonatal hypoglycemia include the following: • Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) • Limited glycogen stores (eg, prematurity, intrauterine growth retardation) • Increased glucose use (eg, hyperthermia, polycythemia, sepsis, growth hormone deficiency) • Decreased glycogenolysis, gluconeogenesis, or use of alternate fuels (eg, inborn errors of metabolism, adrenal insufficiency) • Depleted glycogen stores (eg, asphyxia-perinatal stress, starvation)
  • 9. Treatment • To raise the blood sugar value to normal range, give 200 mg/kg of dextrose i.e. 2 ml /kg of 10% dextrose as bolus slowly over 3-5 minutes and start maintenance fluids with a dextrose infusion rate (DIR) of 6 – 8 mg/kg/min. • The maximum strength of dextrose that can be given through a peripheral vein is 12.5%. • Repeat Dextrostix after 15-30 minutes, if still low, repeat bolus and increase (DIR) by 1 – 2 mg/kg/min or the maintenance fluids by 10 – 20 ml/kg/day.
  • 10. • For example in a low birth weight baby on first day of life give 80ml/kg/ day i.e. 80 x wt of the baby • e.g. 1.8 kg i.e. 144 ml/day. Divide by 24 to obtain fluid per hour (144 / 24 = 6 ml/hr). • Take a measured volume set, fill 1/4th or 6 hrs fluid i.e. 24 ml and deliver at a rate of 6 micro drops/min (number of drops per minute is equal to rate of fluid/hour). • The dextrose infusion rate can be calculated by the following formula:  Fluid rate (ml/kg/day) x % of Dextrose to be used x 0.007 = DIR (mg/kg/min). o e.g. If a baby is on 100 ml/kg/day of 10% dextrose, the DIR is 7 mg/kg/min. You may also use the reference charts to calculate the DIR.
  • 11. How to monitor blood glucose in hypoglycemia • In asymptomatic babies measure blood glucose within 2 hrs of birth, preferably before feeds. • Frequency & duration depends on clinical features and glucose value, initial frequency may be 2 hrly, and later 4 hrly and finally 8 - 12 hrly. • Monitoring is usually done for 72 hrs after birth in at risk newborns or till glucose levels remain normal for 48 – 72 hrs. • Symptomatic babies: may require more frequent monitoring. • Maintain the same DIR till the blood glucose is stable for at least 6 – 8hrs and then decrease the DIR by not greater than 1 – 2 mg/kg/min every 2 hours with adequate monitoring.
  • 12. Resistant or Persistent Hypoglycemia: • Resistant or Persistent Hypoglycemia: • Requirement of a dextrose infusion rate or more than 12 mg/ kg/min suggests resistant hypoglycemia. • Any hypoglycemia persisting beyond one week despite adequate management suggests persistent hypoglycemia. • One should rule out hyperinsulinemic state or inborn errors of metabolism. • Increase the DIR to 12–15 mg/kg/min, keeping in mind that more than 12.5% dextrose should not be given through a peripheral vein and a central venous catheterization is required.
  • 13. • In resistant or persistent hypoglycemia the following drugs should be considered: – • Hydrocortisone: 10 mg/kg/day in two divided doses intravenously • Glucagon: 100 – 300 ug/kg/dose IM to a maximum of 3 doses in babies with adequate glycogen stores • Diazoxide: 2 – 5 mg/kg/dose every 8 hrly orally • Octreotide : Synthetic somatostatin in a dose of 2–10 ug/kg/day subcutaneously q 8 -12 hourly • Babies with persistent or resistant hypoglycemia should be REFERRED to a specialize center for farther investigations