approach to Neonatal hypoglycaemia

1. Neonatal Hypoglycemia

2. Outline
• Definition
• Etiology
• Signs and Symptoms
• Management
• Complications

3. Neonatal hypoglycemia
• Most common metabolic abnormality in neonates
• Defined as a Blood glucose level of
• <30 mg/dl ( 1.65mmol/l) in the first 24 hrs of life
• <40 mg/dl ( 2.6mmol/L) after first 24 hours.
• Severe hypoglycemia: <24mg/dl (1.4mmol/l)
Whipple’s Triad
• Low glucose level should be documented
• Signs and Symptoms of hypoglycemia
• Resolution of signs and symptoms on restoration of blood glucose

4. Etiology
1. Decreased Production of glucose/ low glycogen stores
• Prematurity
• IUGR
• Defects in carbohydrate metabolism, Glycogen storage diseases
• Inadequate calorie intake
• Delayed onset of feeding
2. Hyperinsulinemia
• Infant of a diabetic mother
• Maternal drugs(Terbutaline, propranolol, chlorpromazine,
benzothiazides
• Islet cell hyperplasia
• Erythroblastosis fetalis
• Beckwith Wiedenmann Syndrome

5. Beckwith-Wiedemann syndrome.
• Diffuse pancreatic islet cell hyperplasia, causing hypoglycemia
secondary to hyperinsulinemia.
• EMG triad: exophtalmos-macroglosia- gigantism, microcephaly,
visceromegaly, earlobe pits or creases, facial nevus flammeus,
renal abnormalities and hemihypertrophy (unilateral
overgrowth).
• associated with tumors- Wilms, hepatoblastoma, adrenal
carcinoma, rhabdomyosarcoma.

6. Etiology cont’d
3. Increased Utilization of glucose
• Sepsis, shock, asphyxia, respiratory distress, hypothermia, post resuscitation.
4. Other Endocrine abnormalities
• Pan Hypopituitarism
• Adrenal insufficiency
• Hypothyroidism
• Growth hormone deficiency
5. Others
• Polycythemia, congenital heart defects, CNS abnormalities, inborn metabolic
diseases.

7. High risk group
High risk groups that need screening for hypoglycemia in the first hour
of life include the following.
• SGA, LGA
• Prematurity
• Infants born to insulin depended mothers
• Birth asphyxia/perinatal distress, low apgars

8. Signs and Symptoms
• Jitteriness and/ or tremors
• Hypotonia
• Change in level of consciousness: (Irritability, lethargy, stupor, coma)
• Seizures
• Tachypnoea, Apnoea, cyanosis
• Weak or high pitched cry
• Hypothermia
• Poor sucking/poor feeding
• Sweating
• Palour

9. Management
• Resuscitate if need be
• Keep the baby warm
• Obtain IV access
• Collect blood for basic investigations: FBC, U&E, CRP,ESR, Blood culture.
• Start 10% Dextrose infusion 60-65mls/kg/day at a rate of 5-8
mg/kg/min.
• Glucose infusion rate(mg/kg/min)= (% glucose x ml/kg/day)/144.
• If Blood glucose control is not achieved, glucagon at 0.1mg/kg per
dose may be given repeatedly 6 to 12hrly IMI.
• Blood glucose should be monitored hourly and small volume of milk
feeds (breastmilk) should be commenced as soon as possible
• When the patient is asymptomatic and the blood glucose level has
stabilized, dextrose infusion is decreased slowly while milk feeds are
slowly increased.

10. Glucose infusion tapering.
• When blood glucose level > 60 mg/dl decrease infusion rate by 2
mg/kg/min every 12 hrs, until glucose infusion rate comes down to 6
mg/kg/min.
• Introduce oral feeds when glucose infusion is being tapered
depending on infant condition (blood glucose level stable for 3-6
hours).
• Stop iv glucose infusion when blood glucose values stable (50 to 70
mg/dl) for 2-3 days at infusion of 4 mg/kg/min.

11. Management Cont’d
• Consider pharmacological intervention for severe, persistent or recurrent
hypoglycemia.
• Glucagon
• Hydrocortisone 1mg/kg/dose IV 6hrly
• Diazoxide, Octreotide, Hydrochlorothiazide.
• Further Investigations
• Insulin (c peptide), cortisol, ketones, GH, ACTH, Thyroid function tests, serum
amino acid profile, urinalysis, screening for inborn metabolic errors.

12. Diazoxide:
• used for the treatment of hypoglycemia due to
hyperinsulinism- decreases insulin secretion and increases
epinephrine release, which results in an increase in hepatic
glucose production and a decrease in peripheral utilization of
glucose.
• The usual effective dose in newborn is 5 to 20 mg/kg/day,
administered orally in an 8- to 12-hour dose.

13. Octreotide:
• somatostatin analogue, suppresses the secretion of both insulin and
glucagon.
• used in the short-term treatment of a variety of hyperfunctioning
endocrine tumors, such as insulinomas, glucagonomas, GH-secreting
adenomasand nesidoblastosis (hyperinsulinemic hypoglycemia).

14. Long term sequelae of neonatal hypoglycemia
• Recurrent seizure activity
• Mental retardation
• Developmental delay
• Personality disorders

15. Prevention
• Maintain temperature control with skin to skin contact in the delivery
room
• Early and frequent feeding
• Increase awareness of conditions that predispose an infant to
hypoglycemia
• Early screening of high risk infants

16. References
• Behrman, R. E. (et el) Nelson Essentials of Pediatrics (6th ed). Saunders
Elsevier.,Philadelphia, 2011.
• Clayden, G. , Lissauer, T. Illustrated Textbook of Paediatrics (4th ed).
Mosby Elsevier, China, 2012.
• Wittenberg D. F. , Coovadia’s paediatrics & Child health (6th ed).
Oxford University press, South Africa, 2009.
• Medscape: Neonatal hypoglycemia