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Neonatal hypoglycaemia
1. Neonatal
Hypoglycaemia
Dr Varsha Atul Shah
Dept of Neonatal and Developmental Medicine
Singapore General Hospital
2. Extremes of
Birth Weight
Neonatal
Hypoglycaemia
Prematurity
3. Definition
β’ Controversial
β’ Operational threshold
β Pragmatic approach
β i.e. blood glucose level at which clinical
intervention should be considered
β Indication for action but not diagnostic of
disease
β Symptomatic: < 45mg/dl (2.5mmol/L)
β Asymptomatic & at-risk: < 36mg/dl (2.0mmol/L)
5. β’ Term breastfed infants
β Can utilise ketones as source of energy in
absence of glucose during transient starvation
β May tolerate low glucose levels better
6. Clinical Features
β’ Non specific
β Apathy, lethargy, irritability
β Hypotonia, limpness
β Sweating, tremors, jitteriness, abnormal cry
(weak / high pitched)
β Hypothermia
β Poor feeding, vomiting
β Apnoea, irregular respiration, respiratory
distress, cyanosis
β Tachycardia, CCF
β Seizures, coma
β’ Asymptomatic
13. Management
β’ Prevention
β Antenatal & intrapartum care
β’ e.g. control of maternal diabetes, causes of
prematurity & IUGR
β Avoid environmental stress e.g. cold
β Early feeding / IV dextrose infusion
14. β’ Anticipation
β Screening
1. At-risk babies
a. Maternal
e.g. drugs, intrapartum glucose, diabetes, etc
b. Neonatal
e.g. asphyxia / perinatal stress, premature, SGA / LGA, low
birth weight, sepsis, shock, polycythaemia, etc
2. Those with symptoms
Non specific; high index of suspicion
15. β’ Diagnosis
β Screening using glucose reagent strips
β’ Within 2 - 3 hrs after birth & before feeding
(2 - 4 hrly) for 24 - 48 hrs & whenever
symptomatic
β Confirmatory laboratory diagnosis important
β’ Do not delay treatment while waiting for result
β’ Analysed promptly to avoid falsely low value due
to glycolysis
16. β’ Treatment
β Aim to maintain plasma glucose > 45mg/dl
(2.5mmol/L)
β IV dextrose
β’ Mini bolus Dex 10% (2ml/kg) followed by infusion
β’ Central line required for high dextrose
concentrations (> Dex 10%)
β’ Continued close plasma glucose monitoring to
titrate infusion
β’ Avoid abruptly decreasing dextrose infusion
(rebound hypoglycaemia)
18. β’ Most hypoglycaemia resolve in 2 - 3 dys
β’ Persistent / recurrent hypoglycaemia for >
1 week may require evaluation for other
causes
β e.g. insulin, cortisol, other endocrine &
insulin
IEM studies during period of
hypoglycaemia
β’ During a period of hypoglycaemia, a normal
infantβs blood insulin level should be low or
absent. If it is very high suggests
hyperinsulinism. It inhibits braeking down of
glyconen
19. Significance of Hypoglycaemia
β’ Neuronal cell injury, cerebral damage, long
term neurologic sequelae
β’ No single value below which or duration
beyond which brain injury definitely occurs
β’ ? Vulnerability of brain of infants of
different gestational ages
β’ Prevention, prompt treatment important
21. T2 weighted axial MRI at 10 months of age
Boy with isolated hypoglycaemia:
shows parenchymal loss posteriorly with
computed tomography at 6 days of
high signal in the white matter of the
age shows cortical and white matter
parietal and occipital lobes (arrows). Note
low density that is most severe in
thin and atrophic gyri (arrowhead)
the parietal and occipital lobes
Traill, Arch Dis Child 1998
22. Boy with a variant of glycogen T2 weighted axial magnetic resonance image
storage disease type 2b. Computed
at 7 years of age shows marked atrophy in
tomogram at 6 days of age shows low
the parietal and occipital cortex and
density in the cortex and white
underlying cerebral white matter
matter of the parietal and occipital
lobes Traill, Arch Dis Child 1998
23. Outcome
β’ Varied
β’ Some have no long term sequelae
β’ Symptomatic / severe / persistent
hypoglycaemia
β Abnormal neurointellectual development
Polycythaemia: ο glucose utilisation by ο red cell mass Exchange transfusion: With blood that has a low glucose level with a glucose infusion or reactive hypoglycaemia following exchange with hyperglycaemic blood Congenital heart disease Maternal propranolol: 1. Prevention of sympathetic stimulation of glycogenolysis 2. Prevention of recovery from insulin-induced decreases in free FAs & glycerol 3. Inhibition of epinephrine-induced increases in free FAs & lactate after excercise
Screening using glucose reagent strips - unproven reliability bcos: 1. Reagent strips measure whole blood glucose, which is 15% lower than plasma levels 2. False positive / false negative Glucose level can fall 18mg/dl per hour in blood sample that awaits analysis