This document discusses the management of hypoglycemia and electrolyte imbalances in newborns. It describes the hormonal and metabolic changes that occur after birth that can lead to hypoglycemia if not properly managed. It provides guidelines for monitoring blood glucose levels based on risk factors and algorithms for treating hypoglycemia. The document also discusses electrolyte abnormalities like hypernatremia and hyponatremia that can occur in newborns. It describes the causes and treatment approaches for these conditions. Intravenous fluid management is discussed for preterm infants with considerations for insensible water losses.

1. Management of Hypoglycemia&
Electrolyte Imbalance in newborns
Dr. Sunil Rao
Asistt. Professor
Department of Peadiatrics

2. Hypoglycemia
• Fetal period
• Transitional period

3. Fetal glucose homeostasis
• Fetus gets glucose by facilitated diffusion across placenta.
• GLUT 1 & 3 are present in placenta and fetal membrane
• Factors affecting glucose transport:
(a) Maternal glucose concentration
(b) Materno fetal glucose gradient
(c) Fetal endocrine milieu
(d) Degree of placental metabolism of glucose
Fetal glucose conc. is significantly lower than that of maternal BS.
(20-30%)
• Linear relationship exists between prevailing maternal BS and
fetal BS.

4. After delivery
• Harmones
• Receptors
• Key enzymes

5. Hormonal changes
 Term healthy baby : increases hepatic glucose
production & generates alternate fuels (FFA and
ketone bodies) by suppressing insulin and increasing
secretion of counter regulatory hormones (glucagon,
cortisol, and catecholamine)
 This response is absent in Preterm, SGA, IDM,
smaller of twins, infants of erythroblastosis fetalis.

6. • Confirming a diagnosis of clinically significant
hypoglycemia requires, that one interpret the
blood glucose level within the clinical context.

7. Alteration in hormones & metabolic fuels
following births
Glucagon
Insulin
Glucose
Glycogen
FFA
Catecholamine

8. • Persistent hypoglycemia is associated with
endocrine abnormalities and possible
neurologic sequalae.
• The absence of overt symptom at low glucose
levels does not rule out CNS injury.

9. Outcome
Abnormal neurodevelopmental assessment
• Asymptomatic –6%
• Symptomatic with no seizure-12%
• Symptomatic with seizure-50%
In recurrent & persistent hypoglycemia
• >3days-29%
• >5-7 days-42%

10. Hypoglycemic brain injury
Determinants-
1.clinical presentation
2.severity of hypoglycemia
3.duration of hypoglycemia
4.concomitant disorders
Areas involved-
1.cerebral cortex (parieto-occipital)
2.hippocampus (dentate gyrus)
3.basal ganglia (caudatoputamen)
less involved-cerebellum,brain stem,s.cord

12. Anticipation and Monitoring
 IDM
 SFD
 Preterms
 Rh isoimmunization
 Asphyxia, hypothermia, polycythemia, septicemia
or any sickness
 Any baby on IV fluids or TPN
 Primigravida with cesarean

13. Frequency of monitoring
• IDM – cord bld, 1,2,3,6 hrs, then 6 hrly x 48 hrs
• Preterms/SFD – 1,2,3,6 hrs, then 6 hrly x 72 hrs
• On IV fluids, TPN or other sick babies – 6 hrly
• 2 hours after exchange transfusion

14. Management
 Same management for Asymptomatic and
Symptomatic
 Consider & treat secondary causes
 Minibolus - 200 mg/kg glucose as 2 ml/kg of 10%
dextrose over1 minute.
 Infusion of 10%dextrose @ 6 mg/kg/min (3.6
ml/kg/hour)
 Do not bolus without increasing the infusion rate
 Check blood glucose after 15 minutes
 Use infusion pumps
 If no contraindication, start feeds simultaneously

15. Management Algorithm
Blood glucose (BG) < 40 mg/dl by strip
-------->Evaluate causes
Start IV line
Minibolus –2 ml/kg 10% dextrose IV over 1 min
Start 10% dextrose infusion @ 6 mg/kg/min
EBM/formula feeds if
no contraindication -------->
Check BG after 15 min

16. BG > 40 mg/dl ----->continue
same infusion and monitor
blood glucose
BG < 40 mg/dl
Increase infusion rate by 2 mg/kg/min every 15 min
till euglycemia*. Use 2 IV lines at high infusion rates.
Max: 12-14 mg/kg/min (12.5% dextrose)
Intractable Hypoglycemia
Check insulin : glucose ratio
Central venous line
Hydrocortisone, Glucagon, Diazoxide
*Giving boluses of dextrose without increasing the infusion rate is of no use

18. Step 1: Estimation of concentration of stock solution
6 8 10 12 14 16
40 22 29 36 43 50 58
50 17 23 29 35 40 46
60 14 19 24 29 34 38
70 12 16 21 25 29 33
80 11 14 18 22 25 29
90 10 13 16 19 22 26
100 10 12 14 17 20 23
110 . 10 13 16 18 21
120 . . 12 14 17 19
130 . . 11 13 16 18
140 . . 10 12 14 16
150 . . . 12 13 15
160 . . . 11 13 14
170 . . . 10 12 14
180 . . . . 11 13
Glucose infusion rate (mg/kg/min)

19. Step 2: Preparation of 100ml of stock solution
Concentration of
Stock solution
25%dextrose(ml) 10%dextrose(ml)
10% 0.0 100.0
11% 6.7 93.3
12% 13.3 86.7
13% 20.0 80.0
14% 26.7 73.3
15% 33.3 66.7
16% 40.0 60.0
17% 46.7 53.3
18% 53.3 46.7
19% 60.0 40.0
20% 66.7 33.3
21% 73.3 26.7
22% 80.0 20.0
23% 86.7 13.3
24% 93.3 6.7
25% 100 0
25% dextrose (ml) 50% dextrose (ml)
30% 80 20
35% 60 40
40% 40 60
45% 20 80

20. Tapering of dextrose infusion
When blood glucose has remained normal for
12 hours or if blood glucose exceeds 100
mg/dl, decrease the infusion by 2 mg/kg/min
every 4-6 hours while checking blood glucose.

21. Intractable hypoglycemia
• Uncorrected hypoglycemia despite a glucose
infusion rate of 10-12 mg/kg/min or lasting more
than 5-7 days
• Blood samples for glucose, insulin & C-peptide
levels, other hormones and serum ammonia
• A central line to infuse higher concentration and
higher rate of glucose.
• Glucagon 300 μg/kg IV or SC, or as infusion
• Diazoxide 10-15 mg/kg/day P.O. or IV in 3 or 4
divided doses along with Chlorthiazide ,
Octreotide and Nifedipine

22. Key Messages
Both hypo and hyperglycemia are bad.
Checking BG is the only way to diagnose-
anticipate and monitor.
Titrate glucose infusion rate to maintain
euglycemia

23. Electrolyte Abnormality
• Hypernatremia
• Hyponatremia
• Hyperkalemia
• Hypokalemia

25. Electrolyte Requirements
(meq/kg/d)
Term Preterm
------------------------------------------------------
Days Na K Cl Na K Cl
1 - - - - - -
2- 3. 3 3 3 2 3 2
4 -15 3 3 3 3-5 5 3
-------------------------------------------------------------

26. Na Requirements in PT
mEq/kg/d
upto 5 < 30 wks
4 31-35 wks
3 if stable water balance
Compensate for increasing IWL

27. IV Fluid ml/kg/d :Pre Term
Initial Orders
Day < 1Kgm 1-1.49kg =/>1.5kgm
(7.5% Dx) (10%Dx) (10%Dx)
1 100 90 80
2 * 110 100 90
3 120 110 100
4 125 150 120 110
5 125 150 125-150 125-150
* Add electrolytes. FT : Start with 60

28. I W L

29. IWL - Skin
• Depends on keratinization of skin
• Higher in PT
• Higher in first 3-5days

30. Measurement of IWL
Values in ml/kg/hr & (ml/kg/d)
Wt (Kg) Incubator Radiant Warmer
< 1 3.0 (72) 4.0 (96)
1 – 1.5 2.0 (48) 3.0 (72)
1.5 – 2 1.0 (24) 2.0 (48)

31. Hypernatremia >150 mEq/l in PT
Incidence ? 10 - 40 % , Higher in < 28 wks
Hyperosmolality increases CNS morbidity
Cause :
Insufficient water intake,
Excessive IWL
Excessive sodium intake in VLBW

32. Treatment of Hypernatremia
Correction Rate : 0.5 mEq per hour
Sudden changes in plasma osmolality:
Brain edema, Exacerbation of any ICH.
For shock use N Saline

33. Clinical Example:
• 3 kg Neonate with poor feeding & lactation failure),
weighing 2.1 kgs on d 20 . S.Na is 175 meq/L.
Step 1 Assess water loss :
• Water Deficit = expected lean weight - current weight.
• Baby with poor feeding will loose lean body mass
• 0.5 to 1% mass every day.
• At loss of 0.5%/ d for 20d = 0.5% X 20 d of 3Kg
=3 kg minus 300 gm = 2700 Gms.
• As the baby weighs 2.1 kg at admission,
• Water deficit will be 2700 – 2100 = 600 gms or ml

34. Example
• 2.7 kg baby wt 2.1 kg ,Na 175,
• Fluid deficit 2700 – 2100 = 600 ml
• Free Water Deficit = ( Actual Na – Desired Na/actual Na)
X O.6 X Weight (kg)
• Or = (175 – 145/175) X 0.6 X 2.7 ie 0.277 L.
Calculate Na Deficit (meq) =
• Fluid Deficit (L) – Free water def (L) X 0.6 X actual Na
• = 0.6 – 0.277 x 0.6 x 175 = 33.9meq.
• Calculate final fluid composition

35. Example : final fluid composition
• Goal : correct water deficit 600 ml and Na deficit of
33.9 meq over 3 days.
• (Not more than 10 meq Na/ d). i.e. 200 ml of fluid
deficit and 11.3 meq of Na deficit per day.
• Total fluid for D 1 = Maintenance fluid + deficit (200 ml)
• Maintenance Fluid = insensible losses (30ml/kg) + urine
output
• Total Na on D1 = Maintenance Na(3/kg) + Deficit (11.3
meq)
• Similarly fluid is calculated for next 2 days.

36. Hyponatremia <130 mEq per litre
• More common than hypernatremia in PT.
• Cause : high urinary Na loss -VLBW on diuretic
• SIADH as in asphyxia, RDS, pneumnia
• Renal disease : high urinary Na loss
Therapy options :
Fluid restriction
Sodium chloride.

37. Hyponatremia <130 mEq per litre
• More common than hypernatremia in PT.
• Cause : high urinary Na loss -VLBW on diuretic
• SIADH as in asphyxia, RDS, pneumnia
• Renal disease : high urinary Na loss
Therapy options :
Fluid restriction
Sodium chloride.

38. Hypotonic Hyponatremia
Osm <280 mosm/l
• Hypovolemic
• Euvolemic
• Hypervolemic

39. Hypovolemic Hyponatremia
• Renal losses:
• VLBW on diuretics
• Adrenal insufficiency,
• Proximal RTA,
• Metabolic alkalosis,
• pseudohypoaldost’ism
UNa >20 mEq/1
Treat withSaline
• Extrarenal losses:
• Gastrointestinal
vomiting, Diarrhea,
tubes/fistula
• Sweat
• Third space
UNa <20 mEq/1
Treat with Saline

40. Na Content of Body Fluids meq/l
Sources Na Cl
Stomach 50-80 100-150
Small int / Bile 100-140 90-120
Ileostomy 45 – 135 20-120
Diarrhea 10 - 90 10-110

41. Euvolemic Hyponatremia
• SIADH
• (Asphyxia, ICH, RDS, Pneumonia)
• Water intoxication, IV therapy
• UNa>20 mEq/1
• Water restrict

42. Hypervolemic Hyponatremia
• Edema-forming states
• Congestive hrt failure
• BPD
• UNa<20 mEq/1
• Water restrict
• Renal failure
• Acute
• Chronic
• UNa>40 mEq/1
• Water restrict

43. Therapy of Hyponatremia
• mEq Na required =
(desired Na - present Na) X 0.6 X wt
If seizure, coma, Na<120meq/l, Correct to 125
mEq/l within 4 hrs
• Use 3% NaCl = 513 mEq/L (0.5meq/mL)
Dose:125-Actual XwtX0.6 in 4 Hrs
• Delay in correction may cause death
• Rest of correction : +maintainance over 48 Hrs

44. Example: Fast correction
• S. Na = 115meq/L in a 2 kg baby
• Desired Na = 125meq/L
• Na Deficit = (125-115) X2 Kg X0.6 = 12meq in 4 h.
• Vol of 3% NaCl (0.5meq/mL) = 24 ml in 4 h
• Rest of correction upto 135 meq (=10meq) +
maintainance3/kg in 48 hrs

45. Example:Slow correction
• S. Na = 122meq/L on Day 7 in a 1.5 kg baby
• Desired Na = 135meq/L
• Na Deficit = (135-122)X1.5X0.6 = 11.7meq.
• To be corrected over 48 h.
• Maintenance Na (3meq/kg/day) = 3 X 1.5 X 2 = 9 meq.
• Total Na for 48 h = 11.7 + 9 = 20.7meq.
• Fluid requirement for 48 h = 150 X 1.5 X 2 = 450 ml.
• Hence 21 meq Na in 450 ml of fluids over 48 hours
• i.e. around 5 meq Na in 100 ml OR N/3 solution,

46. Late hyponatremia in PT 1-5wk
• Etiology: Poor Na conservation by kidneys
• Negative Na balance and excess ECF.
• Adding NaCl to the formula
normalizes Na, increases blood volume &
inhibits ADH secretion.

47. Hyperkalemia Diagnosis
• Asymptomatic, ,Brady/tachy rhythm,collapse
• ECG:Incr rate of repolarisation: tall T
• Red conduction :
Atrial - Flat P,Prolonged PR
• Ventricular -wide QRS,slur

48. ECG: Hyper K
Peaked T waves
Flattened P waves, increasing PR (suppression of atrial activity )
QRS widening and slurring. ( conduction delay in ventricular tissue )

49. Hyperkalemia Treatment
Stop exogenous K
• Normalize Conduction:
Ca gluc 1-2ml (100-200 mg)/kg
• Lasix 1mg/kg :renal loss
• Cellular shift of K:
Alkalemia HCO3 ,hyperventilate PH>0.1 : K<0.6
Insulin Bolus = 10% Dx 2ml + 0.5U Insulin /kgWt
Infusion 10% Dx 2-4ml/kg/hr, Insulin10u/dl
• Peritoneal dialysis/ET, Kayexalate 1g/kg in 2ml
NS rectally 4 Hrly

50. Hypokalemia
ECG-conduction defects (prolonged QT, U)

51. ECG changes: Hypo K
Prominent U waves, bifid T waves,
flattened T, QTc prolongation