HYPOGLYCEMIA A COMMON CASE SCENARIO IN NEW BORN .SLIDE DEALING WITH ALL ASPECT OF HYPOGLYCEMIA.

1. HYPOGLYCEMIA
DR MAHTAB
MBBS,DCH,DNB
HIMSR, NEW DELHI

2. DEFINITION
 NO UNIVERSAL DEFINITION FOR HYPOGLYCEMIA
 BGL < 40MG/DL (PLASMA GLUCOSE LEVEL <45MG/DL)
 WHO DEFINES BGL <45MG/DL (2.2MMOL/l)

3.  GLUCOSE PROVIDE THE FETUS 60-70% OF ITS ENERGY NEEDS.
 ALMOST DERIVE FROM MATERNAL CIRCULATION
 FETAL GLUCOSE LEVEL IS 2/3 OF MATERNAL LEVEL
 DURING NORMAL TRANSITION BGL FALL TO LOW POINT 1-2 HR OF LIFE
 AND THAN INCREASE AND STABLIZE AT MEAN LEVEL OF 65-70MG/DL BY AGE OF
3-4 HOURS

4. INCIDENCE
 ESTIMATED TO OCCUR UPTO 16% IN LGA AND 15% IN SGA INFANT

5. ETIOLOGY
 1. HYPERINSULINEMIC HYPOGLYCEMIA;MAJOR CAUSE OF PERSISTENT RECURRENT
HYPOGLYCEMIA MOST COMMON EG IS IDM
CONGENITAL DEFECT MUTATION IN GENE ENCODING PANCREATIC BETA CELLS ATP SENSATIVE
POTASSIUM CHANNEL SUCH AS ABCC8
SECONDARY TO OTHER CONDITION
1. BIRTH ASPHYXIA
2. BECKWITH-WIEDMAN SYNDROME
3. CONGENITAL DISORDER OF GLYCOSYLATION AND OTHER METABOLIC CONDITION
4. ERYTHROBLASTOSIS
5. ABRUPT CESSATION OF HIGH GLUCOSE INFUSION
6. INSULIN PRODUCING TUMOUR

6. 2 LGA
3. DECREASED PRODUCTION/STORE
PREMATURITY
IUGR
INADEQUATE CALORIC INTAKE
DELAYED ONSET OF FEEDING
4. INCREASED UTILIZATION/OR DECREASED PRODUCTION
PERINATAL STRESS :SEPSIS,SHOCK,ASPHYXIA,HYPOTHERMIA,RESPIRATORY
DISTRESS,POST RESUSCITATION
5. DEFECT IN CARBOHYDRATE METABOLISM ;GLYCOGEN STORAGE DISEASE,FRUCTOSE
INTOLERANCE,GALACTOSEMIA
6. ENDOCRINE DEFICIENCY: ADRENAL INSUFFICIENCY,HYPOTHALAMIC
DEFICIENCY,CONGENITAL HYPOPITUITARISM,GLUCAGON DEFICIENCY,EPINEPHNRINE
DEFICIENCY

7.  DEFECT IN AMINO ACID METABOLISM:MSUD,PROPIONIC ACIDEMIA,METHYLMALONIC
ACIDEMIA,TYROSINEMIA
 POLYCYTHEMIA
 MATERNAL THERAPY WITH BETA BLOCKERS EG LABETALOL OR PROPANALOL

8. SCREENING OF HYPOGLYCEMIA
 INDICATION OF ROUTINE BLOOD GLUCOSE SCREENING
 SGA <10TH PERCENTILE
 LGA>90TH PERCENTILE
 INFANT <35WEEK /<2OOGM
 IDM
 INFANT WITH RH-HEMOLYTIC DISEASE
 INFANT BORN TO MOTHER RECEIVING THERAPY TERBUTALINE/PROPANOLOL/LEBATOLOL/ORAL
HYPOGLYCEMIC AGENTS
 MORPHOLOGICAL IUGR
 ANY SICK INFANT EG PERINATAL ASPHYXIA,POLYCYTHEMIA,SEPSIS,SHOCK,DURING ILLNESS
 INFANT ON PARENTERAL NUTRITION

9. SCHEDULE OF BLOOD SUGAR MONITORING
 AT RISK INFANT 2,6,12,24,48,72 HR OF LIFE
 SICK INFANT DURING ILLNESS EVERY 6-8 HR
 STABLE VLBWINFANTS ON PARENTERAL NUTRITION …….INITIAL 72HR EVERY 6-8
HR AFTER 72 HR ONCE A DAYS

10.  INFANT WHOM SCREENING IS NOT REQUIRED
TERM HEALTHY BREASTFEED AGAINFANT
HOWEVER TERM INFANTS WITH POOR FEEDING ,PRESENCE OF INADEQUATE
LACTATION OR PRESENCE OF COLD STRESS CONSIDER FOR SCREENING

11. METHOD OF BLOOD GLUCOSE LEVEL
ESTIMATION
 REAGENT STRIP (GLUCOSE OXIDASE METHOD) WIDELY USED,BUT UNRELIABLE
ESPECIALLY AT LEVEL WHERE THERAPEUTIC INTERVENTION IS REQUIRED SUCH AS 40-
50MG/DL (HIGH FLASE POSITIVE FOR HYPOGLYCEMIA)
 GOOD FOR SCREENING PURPOSE BUT LOW VALUE CONFIRMED BY PROPER
LABORATORY ANALYSIS
 THERE IS VARIATION BETWEEN CAPILLARY AND VENOUS BLOOD,BLOOD AND
PLASMA AND IMMEDIATE AND STORED BLOOD
WHOLE BLOOD SUGAR VALUE IS 10-15% LESS THAN PLASMA VALUE,BGL CAN FALL BY
14-18MG/DL PER HOUR IN WAIT SAMPLE
 ANY ABNORMAL BGL BY THIS TECHNIQUE MUST BE CONFIRMED BY STANDARD
LABORATORY METHOD

13.  LABORATORY METHOD MOST ACCURATE METHOD
GLUCOSE CAN MEASURED BY EITHER THE GLUCOSE OXIDASE (CALORIMETRIC
)METHOD OR BY GLUCOSE ELECTRODE METHOD

14. C/F A/W HYPOGLYCEMIA
 ASYMPTOMATIC; LOW BGL MAY NOT MANIFEST CLINICALLY
 SYMPTOMATIC; CLINICAL SIGN IS VARIABLE INCLUDE
STUPOR,JITTERINESS,TREMER,APATHY,EPISODE OF
CYANOSIS,CONVULSION,INTERMITTENT APNEIC SPELL OR TACHYPNEA,WEAK
AND HIGH PITCHED CRY,LIMPNESS AND LETHARGY,DIFFICULTY IN FEEDING
,EPISODE OF SWEATING,SUDDEN PALLOR,HYPOTHERMIA RARELY CARDIAC
ARREST HAVE ALSO BEEN REPORTED

15. MANAGEMENT
 ASYMPTOMATIC;
BGL 20-40MG/DL TRIAL OF ORAL FEED AND REPEAT GLUCOSE AFTER 1 HR
 IF REPEAT BGL >40MG/DL 2HRLY FEED ARE ENSURED WITH 6 HOURLY
MONITORING OF BGL FOR 48 HR TARGET VALUE IS 50-120MG/DL
 IF REPEAT BGL <40MG/DL IV DEXTROSE IS STARTED
 BGL <20mg/dl iv dextrose 6mg/kg/min
 ORAL FEED ; DIRECT BF,EBM,IF NOT AVALIEBLE FORMULA FEED,SOME RCT ON SGA
AGA USE SUCROSE FORTIFIED MILK 5GM SUGAR PER 100ML MILK

16.  MANAGEMENT OF SYMPTOMATIC HYPOGLYCEMIA
 A BOLUS 2ML/KG OF 10% DEXTROSE THIS F/B 6-8MG/KG/MINBGL SHOULD BE
CHECKED AFTER 30-60MIN AND THEN EVERY 6 HOUR UNTIL BLOOD SUGAR IS
>50MG/DL
 IF BGL <40MG/DL DESPITE BOLUS AND GIR INFUSION RATE IS INCREASED IN
STEPS OF 2MG/KG/MIN UNTIL A MAX 12MG/KG/MIN
 AFTER 24 HR OF IV GLUCOSE THERAPY ONCE TWO OR MORE CONSECUTIVE
BGLS ARE >50MG/DL INFUSION RATE IS TAPER 2MG/KG/MIN EVERY 6 HRLY
ACCOMPANIED INCREASED IN ORAL FEED ONCE RATE IS 4MG/KG/MIN ,ORAL
INTAKE ADEQUATE AND BG CONSISTENTLY >50MG/DL THE INFUSION CAN BE
STOPPED
 AVOID USING MORE THAN 12.5%D INFUSION THROUGH PERIPHERAL VEIN DUE
TO RISK OF THROMBOPHLEBITIS

17. MANAGEMENT OF HYPOGLYCEMIA

18.  THERE IS NO SINGLE VALUE BELOW WHICH BRAIN INJURY DEFINITELY OCCUR
 BGL <4OMG/DL AT ANY TIME IN NEW BORN REQUIRE FOLLOWUP GLUCOSE
MEASUREMENT TO DOCUMENT NORMAL VALUE
 OUR GOAL TO MAINTAINGLUCOSE VALUE ABOVE 45MG/DL IN THE FIRST DAY
,AND MORE THAN 50MG/DL THEREAFTER
 WITHININ THE FIRST HOUR OF LIFE NORMAL ASYMPTOMATIC BABIES MAY HAVE
TRANSIENT GLUCOSE LEVEL IN 30s THAT WILL INCREASE SPONTANEOUSLY OR
IN RESPONSE TO FEEDING

19. RECURRENT /RESISTENT HYPOGLYCEMIA
 IF FAIL TO MAINTAIN NORMAL BGL DESPITE A GIR 12MG/KG/MIN OR REQUIRED IV GLUCOSE
FOR GREATER THAN 7 DAYS
 IMPORTANT CAUSE OF RESISTANT HYPOGLYCEMIA;
CONGENITAL HYPOPITUITARISM
ADREANAL INSUFFICIENCY
HYPERINSULINEMIC STATES
GALACTOSEMIA
GLYCOGEN STORAGE DISEASE
MSUD
FATTY ACID OXIDATION DISORDER
MITOCHONDRIAL DISORDER

20.  BESIDE INCREASING GIR FOR RESISTENT HYPOGLYCEMIA CERTAIN DRUGS MAY BE TRIED BEFORE
DRUG TAKE THESE SAMPLE TO INVESTIGATE THE CAUSE
SERUM INSULIN LEVEL
SERUM CORTISOL LEVEL
GROWTH HORMONE LEVEL
BLOOD AMMONIA
BLOOD LACTATE LEVEL
URINE KETONE AND REDUCING SUBSTANCES
URINE AND SUGAR AMINOACIDOGRAM
FREE FATTY ACID LEVEL
GALACTOSE 1 PHOSPHATE URIDYL TRANSFERASE LEVELS

21.  DRUGS;
1.HYDROCORTISONE 5MG/KG/DAY IV OR PO IN TWO DIVIDED DOSE FOR 24-48 HRS.
2. DIAZOXIDE 10-25MG/KG/DAY IN THREE DIVIDED DOSES (REDUCE SECRETION OF INSULIN)
THEREFORE USEFUL IN STATE OF UNREGULATED INSULIN SECRETION LIKE INSULINOMA
3. GLUCAGON 100MICROG/KG SC/IM MAX 300MICROG UPTO 3 DOSES. GLUCAGON ACT BY
MOBILIZING HEPATIC GLUCOSE STORES,ENHANCE GLUCONEOGENESIS AND PROMOTE
KETOGENESIS
4. OCTREOTIDE SYNTHETIC SOMATOSTATIN 2-10MICROG/KG/DAY SC 2-3BTIMES A DAY.
*DON’T USE DIAZOXIDE AND GLUCAGON IN SGA

22.  USEFUL FORMULA:
 GIR = % OF DEXTROSE BEING TRANSFUSED ×RATE(ML/HR)
BODY WT (KG)× 6
 INFUSION RATE MG/KG/MIN= IV RATE (ML/KG/DAY) × % DEXTROSE
144
INFUSION RATE = FLUID RATE (ML/KG/DAY)×0.007×% OF DEXTROSE INFUSED

23. FOLLOW UP AND OUTCOME
OUTCOME DETERMINED BY FACTOR LIKE DURATION,DEGREE OF
HYPOGLYCEMIA,RATE AF CEREBRAL BLOOD FLOW,CEREBRAL UTILISATION OF
GLUCOSE AND ALSO CO-MORBIDITIES
 INFANT IS ASSESSED AT ONE MONTH FOR VISION AND HEARING
 AT 3,6,9,12,18 MONTH FOR GROWTH, NEURODEVELOPMENTAL ,VISION AND
HEARING LOSS
 MRI AT 4-6 WEEK PROVIDE A GOOD ESTIMATION OF HYPOGLYCEMIC INJURY

24. THANK YOU HIMSR
SOURCE:NELSON
CLOHARTY
AIIMS PROTOCOL IN PEDIATRICS