This document discusses hypoglycemia in neonates. It defines neonatal hypoglycemia as a plasma glucose level below 30 mg/dL in the first 24 hours of life or below 45 mg/dL thereafter. It identifies factors that increase hypoglycemia risk, such as low birth weight, prematurity, and maternal diabetes. Symptoms are nonspecific but include poor feeding, temperature instability, and central nervous system issues. Treatment involves glucose boluses and maintenance with intravenous dextrose infusions. Resistant or persistent hypoglycemia may require higher infusion rates, hydrocortisone, glucagon, or other drugs. Careful glucose monitoring is important to prevent neurological complications.

1. Hypogylcemia
• presented by :-
• Rahul Mahato
• 4th year bsc Nursing

2. Introduction
• Glucose or dextrose is a vital source of nutrient energy and is required
continuously by the fetus.
• Neonate needs this as either intermittent oral feeds or continuous IV fluids.
• Hypoglycemia can cause long term neurologic sequelae.
• The important steps in preventing and treating hypoglycemia are
• to identify neonates at risk of developing hypoglycemia
• to recognize symptoms of hypoglycemia, early feeding and
• to initiate IV fluid therapy, where ever needed.

3. Definition of hypoglycemia
• Neonatal hypoglycemia, defined as a plasma glucose level of less than 30
mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5
mmol/L) thereafter,
• Neonatal hypoglycemia is the most common metabolic problem in
newborns.

4. Symptoms of hypoglycemia
• The symptoms of hypoglycemia are very nonspecific
• The common symptoms are:
• Not looking well
• Lethargic
• Weak cry
• Poor feeding
• Temperature instability like hypothermia
• Poor respiratory effort: shallow breathing, apnea orcyanosis
• CNS symptoms like: excessive jitteriness, convulsions or hypotonia

5. Factors which increase the risk of hypoglycemia
• Various factors which increase the risk of hypoglycemia are hypothermia &
cold Stress, cold environment, wet baby and inadequate feeding.

6. Neonates at risk of hypoglycemia
• Babies weighing less than 2.0 kg birth weight
• preterm babies
• LGA (large for gestational age) babies especially those weighing more than
3.5 kg
• infants of diabetic mothers
• those with delayed cry at birth, any sick neonate who is not sucking or
accepting feeds are all at risk of developing hypoglycemia
• The other risk factors for hypoglycemia are RDS, polycythemia, shock, and
hypothermia

7. Etiology
• The causes of neonatal hypoglycemia include the following:
• Persistent hyperinsulinemic hypoglycemia of infancy (PHHI)
• Limited glycogen stores (eg, prematurity, intrauterine growth retardation)
• Increased glucose use (eg, hyperthermia, polycythemia, sepsis, growth
hormone deficiency)
• Decreased glycogenolysis, gluconeogenesis, or use of alternate fuels (eg,
inborn errors of metabolism, adrenal insufficiency)
• Depleted glycogen stores (eg, asphyxia-perinatal stress, starvation)

8. hypoglycemia ketotic and nonketotic
Ketotic hypoglycemia
1. Metabolic disorders
Non-Ketotic hypoglycemia
Organic acidurias
Inbom errors of glycogenolysis
Inbom errors of gluconeogenesis
2. Cortisol deficiency
3. Growth hormone deficiency
4. Starvation
Non-Ketotic hypoglycemia
1.Metabolic disorders
Disorders of beta Oxidation of fatty
acids
2. insulinoma

9. Treatment
• To raise the blood sugar value to normal range, give 200 mg/kg of dextrose
i.e. 2 ml/kg of 10% dextrose as bolus slowly over 3-5 minutes and start
maintenance fluids with a dextrose infusion rate (DIR) of 6-8 mg/kg/min.
• The maximum strength of dextrose that can be given through a peripheral
vein is 12.5%.
• Repeat Dextrostix after 15-30 minutes, if still low, repeat bolus and increase
(DIR) by 1-2 mg/kg/min or the maintenance fluids by 10-20 ml/kg/day.
• For example in a low birth weight baby on first day of life give 80ml/kg/day
i.e. 80 x wt of the baby
• e.g. 1.8 kg i.e. 144 ml/day. Divide by 24 to obtain fluid per hour (144/24 = 6
ml/hr)

10. • Take a measured volume set, fill 1/4th or 6 hrs fluid i.e. 24 ml and deliver at a
rate of 6 micro drops/min (number of drops per minute is equal to rate of
fluid/hour)
• The dextrose infusion rate can be calculated by the following formula:
• Fluid rate (ml/kg/day) x % of Dextrose to be used x 0.007 = DIR (mg/kg/min)
• e.g. If a baby is on 100 ml/kg/day of 10% dextrose, the DIR is 7 mg/kg/min.
You may also use the reference charts to calculate the DIR.

11. How to monitor blood glucose in hypoglycemia
• In asymptomatic babies measure blood glucose within 2 hrs of birth,
preferably before feeds.
• Frequency & duration depends on clinical features and glucose value, initial
frequency may be 2 hrly, and later 4 hrly and finally 8 - 12 hrly.
• Monitoring is usually done for 72 hrs after birth in at risk newborns or till
glucose levels remain normal for 48-72 hrs.
• Symptomatic babies: may require more frequent monitoring.
• Maintain the same DIR till the blood glucose is stable for at least 6- 8hrs and
then decrease the DIR by not greater than 1-2 mg/kg/min every 2 hours with
adequate monitoring

12. Resistant and Persistent Hypoglycemia
• Resistant or Persistent Hypoglycemia:
• Requirement of a dextrose infusion rate or more than 12 mg/kg/min
suggests resistant hypoglycemia.
• Any hypoglycemia persisting beyond one week despite adequate
management suggests persistent hypoglycemia.
• One should rule out hyperinsulinemic state or inborn errors of metabolism.
• Increase the DIR to 12-15 mg/kg/min, keeping in mind that more than 12.5%
dextrose should not be given through a peripheral vein and a central venous
catheterization is required.
• In resistant or persistent hypoglycemia the following drugs should be
considered:-
• Hydrocortisone: 10 mg/kg/day in two divided doses intravenously

13. • Glucagon: 100-300 ug/kg/dose IM to a maximum of 3 doses in babies with
adequate glycogen stores
• Diazoxide: 2-5 mg/kg/dose every 8 hrly orally
• Octreotide: Synthetic somatostatin in a dose of 2-10 ug/kg/day
subcutaneously q 8-12 hourly
• Babies with persistent or resistant hypoglycemia should be REFERRED to a
specialize center for farther investigations

14. Conclusion
• Awareness of risk factors that predispose infants to hypoglycemia allows for
screening of those at risk.
• If detected hypoglycemia can be treated promptly, thereby preventing the
development of severe or symptomatic hypoglycemia, which is associated
with adverse outcome.
• Asymptomatic hypoglycaemia: It is likely that hypoglycemia contributes to
abnormal neurodevelopmental outcome in infants with other risk factors for
brain injury, such as prematurity

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