this ppt contains some easy formula to calculate GIR, how to increase GIR by 1, tables for fluid and treatment,

1. Treatment of Neonatal
Hypoglycemia
DR MANDAR HAVAL
DCH.DNB.
FELLOW IN NEONATOLOGY (NNF)

2. • NEONATAL HYPOGLYCEMIA IS A METABOLIC
DISORDER AND OPERATIONAL THRESHOLD
VALUE OF BLOOD GLUCOSE <40MG/DL
(PLASMA GLUCOSE < 45MG/DL) SHOULD BE
USED TO GUIDE MANAGEMENT
What should be the operational
threshold for management of neonatal
hypoglycemia

3. Why should hypoglycemia in new born
should manage aggressively
• Glucose is a predominant fuel of a neonatal
brain
• Low blood glucose in new born period in
isolation as well as associated with other
morbidities predispose to long term
neurological output

4. Which neonate should be screen for
hypoglycemia
• All at risk neonate and sick infant should be
screen
• Eg
1. preterm infants /Small for gestation / Large for
gestation
2. Infant of diabetic mother
3. Post exchange blood transfusion
4. On intravenous fluid and parenteral nutrition
5. Mother on Beta blocker, OHA, intrapartam
dextrose infusion

5. Schedule of blood glucose monitoring
Category of infants Time schedule
1 At risk neonates (SN 1-8 in Table 1) 2, 6, 12, 24, 48, and 72 hrs
2 Sick infants (Infants with sepsis, asphyxia,
shock during active phase of illness.
Once the underlying condition is under control,
frequency of screening can be reduced or omitted) Every 6-8 hrs
(individualize as needed)
3 Stable VLBW infants on parenteral nutrition Initial 72 h: every 6 to 8 hrs
After 72 hr: once a day
Infants exhibiting signs compatible with hypoglycemia at any time also need to be
investigated.

6. How should blood glucose be tested
in neonate
• Glucose reagent strip are use to screen for
hypoglycemia.
• If values are low , a blood sample should be
sent to a lab for confirmation by glucose
oxidase or glucose electrode method
• Treatment should be commenced on the
basis of screening test and should not be
delayed till lab results

7. Neonate with asymptomatic
hypoglycemia management
Healthy asymptomatic hypoglycemic
neonate
Measured breast milk or formula feed* by
spoon or gavage
Check blood glucose after 30 – 60 min
later
If BSL>45 , 2-3 hr feed is ensure with 4-6hr
monitoring for blood glucose upto 48hr

8. IV Glucose infusion should be started
in babies with asymptomatic
hypoglycemia
• BSL< 25mg/dl
• BSL< 40mg/dl despite of one attempt of
feeding breast milk
• Enteral feeding is contraindicated
• Baby became symptomatic

10. How to mix various solution for
creating a desired concentration of
glucose in IV infusate
• 100ml of fluid of desired dextrose
concentration by using 5% and 25% dextrose
is as follows
• 5X – 25 = Y (X- required percentage of
dextrose , Y – amount of 25%D to be made up
with 5% D to make a total of 100ml)

11. Eg. To prepare 100ml 0f 25% D
• Formula – 5X – 25 =Y ( X – 12.5)
5 * 12.5 – 25 = 37.5 (Y)
• Thus 37.5ml of 25%D is to be added in 62.5ml
(100-37.5) of 5%D to get 100ml of 12.5% D

12. Calculation of GIR
1. GIR = %D being infused X rate of infusion
Body Wt X 6
2. GIR = Rate of IV fluids (ml/kg/day) X % of
dextrose infused
144

13. • 3. GIR = Rate of IV fluid (ml/kg/day) X % of
dextrose infused X 0.007

14. Note -
• 10%D – 100mg/ml
• 5% D – 50mg/ml
• 7.5% D – 75mg/ml
• 12.5% D – 125mg/ml

15. Simple method to calculate GIR
• Desired fluid intake (ml/kg/day) eg-80ml/kg/day
• Convert it into ml/kg/min by dividing the figure
by 1440 ( 24hr – 1440min)
i.e 80/1440 = 0.055
• If 10% D is used then multiply the above fig by
100 (as 10% D has 100mg)
i.e 0.055 X 100= 5.5mg/kg/min

16. How to increase GIR by 1mg/kg/min
• Add 2ml/kg of 25% D to the volume of the
fluid infused over 8 hr .
• Explanation –
i) 25% D has 250mg/ml of D(2ml = 500mg)
ii) 8hr period has 8 X 60min = 480 min
iii) so 2ml/kg of 25%D over 8 hr will increase
the GIR by 500/480 = 1mg/kg/min(roughly)

17. Daily
fluid volume
(mL/kg/d) Glucose infusion rate (GIR)
6 mg/kg/min 8 mg/kg/min 10 mg/kg/min
D10 D25 D10 D25 D10 D25
• 60 42 18 24 36 5 55
• 75 68 7 49 26 30 45
• 90 90 - 74 16 55 35
• 105 85* - 99 6 80 25
• 120 100* - 120 - 97 18
Achieving appropriate glucose infusion rate at different daily
fluid intakes

18. How to covert mg/dl to mmol/L
• To convert mmol/L to mg/dl multiply by 18
1mmol = 1 X (18) mg/dl
• Similarly divide by 18 if converting into mg/dl
from mmol/L

19. How to calculate GIR in an infant on
oral feed along with simultaneously
intravenous infusion of glucose
• GIR =
IV rate (ml/hr) X Dextrose conc (g/dl) X
0.0167/wt(kg)
Feed rate(ml/hr) X Dextrose conc*(gm/dl) X
0.0167/wt(kg)
•Amount of dextrose in milk: breast milk 7.1gm/dl, Term formula 7.1gm/dl
preterm formula 8.5gm/dl

21. How should be refractory and prolong
hypoglycemia be evaluated
• GIR requiring more than 12mg/kg/min for
more than 24 hr
OR
• Blood glucose level remain unstable beyond 5
to 7 days respectively

22. Investigation to be done
• Sr insulin, cortisol (adrenal insufficiency), TSH
• Ammonia, Lactate urine for ketone and
reducing substance for Metabolic disorder
(galactosemia, glycogen storage disease,
organic acidemia and mitochondrial disorder)
• Rarely 17 OHP, GALT assay, TMS, Growth
harmone , glucagon level

23. Note
• Persistent hyperinsulinemia (PHHI) is
diagnosed if there is hyper insulinemia plasma
insulin > 2uU/ml, in presence of documented
lab hypoglycemia

24. Note..
• Drugs like hydrocortisone, diazoxide,
octreotide , nifedipin, or glucagon may be
prescribed only in consultation with pediatric
endocrinologist

25. • Hydrocortisone 5 mg/kg/day IV or PO in two divided doses
for 24 to 48 hrs
• Diazoxide can be given orally 10-25 mg/kg/day in three
divided doses . Diazoxide acts by keeping the KATP channels
of the Beta-cells of the pancreas open, thereby reducing
the secretion of insulin. It is therefore useful in states of
unregulated insulin secretion like in insulinomas.
• Glucagon 100 ug/kg subcutaneous or intramuscular (max
300 ug) – maximum of three doses. Glucagon acts by
mobilizing hepatic glycogen stores, enhancing
gluconeogenesis and promoting ketogenesis. These effects
are not consistently seen in small-for-gestational age
infants. Side effects of glucagon include vomiting, diarrhea
and hypokalemia and at high doses it may stimulate insulin
release.
• Octreotide (synthetic somatostatin in dose of 2-10
μg/kg/day subcutaneously two to three times a day.

26. Best practice for prevention of
neonatal hypoglycemia
• Support and prompt early exclusive breast
feeding
( sucrose fortified milk 5gm of sucrose in
100ml milk is shown to raise blood glucose
level to prevent hypoglycemia*)
• Prevent hypothermia
• Do not feed 5%,10% or 25% D as a substitue
for breast feeding (risk of rebound
hypoglycemia is more)
* However risk of contamination cannot be ruled out