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/min
Recheck 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

THANK YOU!