Neonatal hypoglycemia
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Neonatal hypoglycemia

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Neonatal hypoglycemia Neonatal hypoglycemia Presentation Transcript

  • 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 •Sepsis •Increased work of breathing •Perinatal asphyxia 4. Other endocrine abnormalities: •Pan-hypopituitarism •Adrenal insufficiency •Hypothyroidism 5. Miscellaneous conditions: •Polycythemia •CNS abnormalities •Congenital heart disease
  • 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 Tachypnoea Cyanosis Apnoea Seizures Cardiac arrest Irritability Hypotonia Lethargy High-pitched cry Hypothermia Poor sucking Sweating pallor
  •  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!