Hypoglycemia in newborns

HYPOGLYCEMIA IN NEWBORN

HYPOGLYCEMIA IN NEWBORN

AMRUTHA RAMAKRISHNAN

1ST YR MSc NSG

AMRUTHA RAMAKRISHNAN

1ST YR MSc NSG

B Glucose levels in NBBB Glucose levels in NBB

• At birth – 60 – 70% (2/3) of mother’s B glucose level

• In first 24 hrs – Falls• Next 24 hrs – Transient

rise• 3 – 4 days of age –

Dangerously low levels• Thereafter – Stability

achieved1

10

432Days of life

20

30

40

50

60

70

80

B G

luco

se (

mg%

)

Hypoglycemia in Newborn?Hypoglycemia in Newborn?

• Serum glucose <40 mg%

• In preterm infants, repeated blood glucose levels below 50 mg/dL may be associated with neurodevelopmental delay.

• Definition• The operational threshold for

hypoglycemia is defined as that concentration of plasma or whole blood glucose at which clinicians should consider intervention, based on the evidence currently available in literature.

High risk High riskLBW Preterm infants (SGA) (IDM) (LGA) Rh-hemolytic disease

High riskHigh risk

• therapy with terbutaline propranolol lebatolol and oral hypoglycemic agents

• IUGR.• sick neonate• Infants on TPN

ETIOLOGYETIOLOGY

• increased utilization of glucose (Hyperinsulinism)

• decreased production or stores

• increased utilization &/ decreased production / other causes

HyperinsulinismHyperinsulinism

Diabetic mothers

Maternal tocolytic therapy

Maternal chlorpropamide therapy

Beckwith- weidmann syndrome

Abrupt cessation of high glucose infusions

exchange transfusion of blood containing high

glucose concentration

Beckwith-Weidmann syndromeBeckwith-Weidmann syndrome

Decreased production or storesDecreased production or stores

Preterm (SGA & LGA)

IUGR (Preterm & post term)

Inadequate calorie intake

increased utilization &/ decreased production / other

causes

increased utilization &/ decreased production / other

causes Perinatal stress

Defects in CHO metabolism

Endocrine deficiency

Polycythemia

Time schedule for screeningTime schedule for screening

• IDMs

• asymptomatic hypoglycemia very early viz. 1 to 2 hours and rarely beyond 12 hours

• preterm and SGA may be at risk up to 36 h (range 0.8 to 34.2 h)

Symptomatology of infants

Time schedule for screening

At risk neonates 2, 6, 12, 24, 48, and 72 hrs

Sick infantsSepsis, asphyxia, shock inthe active phase of illness

Every 6-8 hrs

Stable VLBW infants onparenteral nutrition

Initial 72 h: every 6 to 8 hrs;after 72 hrs in stable babies: once a day

When should be screening is stopped

When should be screening is stopped

INFANTS TIME

At risk End of 72 hrs

infant on IV fluids Has two consecutive values >50 mg/dL on total oral feeds afterstopping of the IV fluids.

Infant whose blood sugar normalized on oral feed

Consider at risk and monitor for 48 hours

Method of Glucose estimationMethod of Glucose estimation

• Bed side reagent strips (Glucose oxidase):

• Laboratory diagnosis

Clinical signs associated with hypoglycemia

Clinical signs associated with hypoglycemia

•Asymptomatic

•Symptomatic

SymptomaticSymptomatic

• stupor,• jitteriness,• tremors, • apathy, • episodes of cyanosis, • convulsions, • intermittent apneic spells • tachypnea, weak• .

SymptomaticSymptomatic

• and high pitched cry,• limpness and lethargy, • difficulty in feeding, • eye rolling• sweating, • sudden pallor,• hypothermia and • cardiac arrest

Management of asymptomatic hypoglycemia

Management of asymptomatic hypoglycemia

• Blood sugar 20-40 mg/dL

asymptomatic hypoglycemia

• Trial of oral feeds (expressed breast milk or formula) and

• Repeat blood test after 1 hour.• If repeat blood sugar is more than 50• mg/dL, two hourly feeds is ensured

with 6 hourly monitoring for 48 hrs• If repeat blood sugar is <40 mg/dL, IV

Dextrose is started and• further management is as for

symptomatic hypoglycemia

ASYMPTOMATICASYMPTOMATIC

• Blood sugar levels <20 mg/dL

asymptomatic

hypoglycemia

• IV Dextrose is started at 6 mg/kg/min of glucose;

• Further management is as for symptomatic hypoglycemia

symptomatic hypoglycemiasymptomatic hypoglycemia

• including seizures, a bolus of 2 mL/kg of 10% dextrose (200mg/kg)

• Immediately after the bolus, a glucose infusion at an initial rate of 6-8 mg/kg/min should be started.

• Check blood sugar after 30 to 60 min and then every 6 hour until blood sugar is >50 mg/dL.

symptomatic hypoglycemiasymptomatic hypoglycemia

• Repeat subsequent hypoglycemic episodes may be treated by increasing the glucose infusion rate by 2 mg/kg/min until a maximum of 12 mg/kg/min.

• After 24 hours of IV glucose therapy, once two or more consecutive blood glucose values are >50 mg/dL, the infusion can be tapered off

• the rate of 2 mg/kg/min every 6 hours with BGL monitoring.

symptomatic hypoglycemiasymptomatic hypoglycemia

• oral feeds.• 4 mg/kg/min of glucose infusion is

reached• and oral intake is adequate and the blood

sugar values are consistently >50 mg/dL, the infusion can be stopped without further tapering.

Recurrent / resistant hypoglycemia

Recurrent / resistant hypoglycemia

• when there is a failure to maintain normal blood sugar levels despite a glucose infusion of 12 mg/kg/min or when stabilization is not achieved by 7 days of therapy. High levels of glucose infusion may be needed in the infants to achieve euglycemia

TreatmentTreatment

• Hydrocortisone 5 mg/kg/day IV or PO in two divided doses for 24 to 48 hrs

• Diazoxide 10-25 mg/kg/day in three divided doses PO.

• Glucagon 100 mg/kg subcutaneous or intramuscular (max 300 mg)

• Octreotide (synthetic somatostatin in dose of 2-10 μg/kg/day subcutaneously two to three times a day.

PreventionPrevention

• Early feeding - as soon as the infant is ready, preferably within 1 hour of birth.

• What feed? – Breastmilk (colostrum) Not dextrose-water.

• Assess risk factors and symptoms. Assess for presence of the following risk factors and symptoms

PreventionPrevention