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Neonatal hypoglycaemia

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Neonatal hypoglycaemia

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Neonatal hypoglycaemia

  1. 1. Department of Paediatrics
  2. 2.  Thaahira,19 year old booked primi  Came at ₄₀ weeks gestation  No history of gestational diabetes or PIH  All three trimesters - uneventful.
  3. 3.  Date of birth: ₅⁄₉⁄₁₃ at 8.15 p.m  FTNVD/40 weeks/ male baby  Birth weight: ₂.₀₇₄kg /Cried soon after birth/ SMALL FOR DATE.
  4. 4. NEONATAL HYPOGLYCEMIA -<40mg/dl irrespective of gestational age and weight
  5. 5.  GRBS at 10.00 a.m, 6/9/13 (14 hrs of life ) was 40mg/dl.  Baby was asymptomatic.(ASYMPTOMATIC HYPOGLYCAEMIA)  No sufficient breast milk available , advised formula feed .
  6. 6.  Baby not tolerating formula feeds , shifted to NICU by 11·45 a.m 6/9/13 (at 16 hrs of life).  Baby was cannulated at 12·00pm on left arm (Cannula I) , 6 ml of 10% dextrose given as bolus.  Advice: 1. half hrly monitoring of GRBS till sugars are stable 2. Formula feed/Expressed Breast milk (EBM) 10ml fourth hourly 3. IVF -10% Dextrose ,5 drops/minute at a glucose infusion rate of 4mg/kg/minute.  Sugar after starting dextrose infusion :108 mg/dl
  7. 7.  Baby’s I.V cannula went out by 4 am on 7/9/13 (32 hours of life).  I.V cannula staying time for the first cannula - 16 hours ,  recannulated on left leg (Cannula II)  Baby not tolerating oral feeds even now.  1 . Domstal drops two drops sixth hourly  2.. Inj.calcium gluconate 2ml in alternate 6 hrly fluids.
  8. 8. second day of life(7/9/13)  Around 5.00 pm ( 45 hours of life) baby was having jitteriness .We checked GRBS.  The Glucometer readings were erratic and unreliable First glucometer - First reading - 455 Second reading – 490 Second glucometer – 390 Third glucometer - - 33 Simultaneous lab glucose value – 20mg/dl
  9. 9.  Dr. Karthikeyan’s advice over phone 1.Inj.Dextrose 10% 6ml IV bolus stat 2.Inj.Hydrocortisone 25mg IV stat and 10mg TDS 3. IVF-10ml 25% Dextrose + 28ml 10% Dextrose + 2ml Calcium Gluconate at an infusion rate of 6.7ml/hr GLUCOSE INFUSION RATE was 8mg/kg/minute 4.Inj.Emeset 0.3ml IV TDS 5.Expressed Breast milk(EBM) two hourly 6∙Feeding through NGT if vomiting persists 7.Hourly monitoring of GRBS
  10. 10.  IV cannula went out for the second time at 5.45pm, 7/9/13 (45 hours of life)  I .V cannula staying time for second cannula - 13.45hrs .  By 6.00 p.m recannulated on right leg (cannula III) , stat medications given.  7.00pm, 7/9/13( 47 hours of life) lab glucose value was 76mg/dl  10∙00pm, 7/9/13 (50 hours ) , GRBS was 51mg/dl advice: increase the IV infusion rate to 8ml/hr  Baby tolerating EBM 10 ml 2 hrly  Thereafter GRBS was maintained above 70mg/dl
  11. 11.  Third day of life (8/9/13, Sunday)  By 8/9/13, 12.45pm IV cannula was out for the third time.  I.V cannula staying time for the third cannula - 18.45 hours.  Baby recannulated on left arm (Cannula IV)  4.00pm GRBS - 145mg/dl ,IV infusion rate was reduced to 4ml/hr  Baby tolerated 15ml of EBM two hrly .  By 8.00pm IV infusion rate reduced to 2ml/hr and by 2.00am to 1ml/hr 
  12. 12.  Fourth day of life(9/9/13)  At 6.00am IV cannula went out for the fourth time.  I.V cannula staying time for the fourth cannula- 17 hours.  No peripheral veins available for further cannulation!!!!.  Fortunately baby’s blood sugar was maintained without I.V infusion of dextrose
  13. 13. Fourth day Advice : 1. four hourly monitoring of GRBS 2. Continue EBM two hourly 3. Syr.calcimax 0.5ml each feeds
  14. 14.  Fifth day of life (10/9/13)  Baby was put to mother’s breast , failed to suck well due to nipple retraction .  nipples’ retraction was corrected by continuous efforts of syringing. Baby started sucking well.  After 24hours of successful breastfeeding , baby shifted to mother’s side on the sixth day (11/9/13) of life .  Baby discharged on the seventh day (12/9/13) of life in good condition on direct breast feeds.
  15. 15. NEONATAL HYPOGLYCEMIA -<40mg/dl irrespective of gestational age and weight
  16. 16.  Group I – Substrate deficiency (Reduced stores)  1·Prematurity  2.Small for date babies  3.Infant of PIH mother  4.VLBW (Very Low Birth Weight babies)  Group II – Hyperinsulinaemia  A. Transient  1.Infant of diabetic mother  2.leucine sensitivity  B.Permanent  Nesidioblastosis (Insulinomas)
  17. 17.  Group III – Endocrine causes 1 ·Growth hormone deficiency 2. Cortisol deficiency (congenital adrenal hyperplasia ) 3 Addison’s disease 4 Hypothyroidism  Group IV- Metabolic causes  1.Glucose phosphatase deficiency  2. Disorders of fructose metabolism  3. Short chain and medium chain Acyl Co A dehydrogenase deficiencies  4. Galactosemia
  18. 18.  1.SYMPTOMATIC Symptoms like 1. lethargy 2. Jitteriness 3. apnoea 4. Cyanosis 5. respiratory distress 6. seizures  2.ASYMPTOMATIC
  19. 19.  50% risk of neurological damage with the symptomatic hypoglycemia  In our case hypoglycemia is probably due to substrate deficiency (SFD)  Maximum Glucose Infusion Rate in our case - 9 mg/kg/minute  GIR >12mg/kg/minute – suspect Hyperinsulinism
  20. 20. 1. Lack of facilities- Infusion pump - which is vital in managing hypoglycemic patients to give a steady infusion of glucose  Iatrogenic hyperinsulinism can happen if infusion is not even  Multi channel monitor with neonatal BP measurement is NA
  21. 21. 2.Nursing care  I.V lines are precious in neonates  Average cannula staying time should be 48-72 Hrs  In our case 4 cannulas were needed within 48 hrs  Nursing care suboptimal
  22. 22.  3.Unreliability of Glucometers in management  Glucometer values will be normally 10mg/dl >lab values  Our glucometers showed high glucose levels when the baby was hypoglycemic
  23. 23.  4.Trained residents experienced in Neonatal care  Glucose infusion >12.5% dextrose should be given through central veins  Persons experienced in umbilical Venous catheterization or other central lines should be available.

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