Neonatal Neonatal HyperglycemiaHyperglycemia

DefinitionDefinition

►Hyperglycemia Hyperglycemia generally is defined generally is defined as plasma glucose as plasma glucose concentration concentration greater than 8.05 to greater than 8.05 to 8.33 mmol/L8.33 mmol/L

► regardless of the regardless of the neonate’s neonate’s gestational age or gestational age or weightweight

SignsSigns

► dehydration -dehydration -osmotic diuresis osmotic diuresis

►weight lossweight loss► failure to thrivefailure to thrive► feverfever► glycosuriaglycosuria► ketosisketosis►metabolic acidosis.metabolic acidosis.►Mostly Mostly

asymptomaticasymptomatic

EtiologyEtiology

1)Glucose infusion1)Glucose infusion

2)Lipids2)Lipids

3)Stress3)Stress

4)Insulin dependent DM4)Insulin dependent DM

5)Others-drugs5)Others-drugs

Glucose infusionGlucose infusion

►high rates of exogenous glucose given high rates of exogenous glucose given to preterm neonates in infusions and to preterm neonates in infusions and TPN exceeding the endogenous rates TPN exceeding the endogenous rates of glucose production (4-8mg/kg/min)of glucose production (4-8mg/kg/min)

►Formula for calculating glucose Formula for calculating glucose infusion rate: infusion rate:

►Mg/kg/min = %dextrose x rate/wtx6Mg/kg/min = %dextrose x rate/wtx6

LipidsLipids

► Increased plasma free fatty acid Increased plasma free fatty acid concentrations concentrations Decrease peripheral glucose utilizationDecrease peripheral glucose utilization inhibit the effect of insulin to suppress inhibit the effect of insulin to suppress

hepatic glucose production. hepatic glucose production.

StressStress

►Stress due toStress due to Disease processDisease process Medical interventionMedical intervention Surgical interventionSurgical intervention

►During stress there is release of During stress there is release of epinephrine,glucocorticoids and epinephrine,glucocorticoids and glucagon.glucagon.

► Epinephrine decreases insulin secretion Epinephrine decreases insulin secretion

from the pancreatic beta cell and interferes from the pancreatic beta cell and interferes with peripheral insulin action. with peripheral insulin action.

►Glucagon promotes glycogenolysis and Glucagon promotes glycogenolysis and release of hepatic glucose. release of hepatic glucose.

►Glucocorticoids also enhance hepatic Glucocorticoids also enhance hepatic enzyme activity in the gluconeogenic enzyme activity in the gluconeogenic pathway, which releases glucose into the pathway, which releases glucose into the circulation.circulation.

Insulin Dependent DMInsulin Dependent DM

► Transient neonatal Transient neonatal diabetes mellitus diabetes mellitus (TNDM) presents early (TNDM) presents early in postnatal life-C-in postnatal life-C-peptide and plasma peptide and plasma insulin are lowinsulin are low

► A rebound in C-A rebound in C-peptide concentration peptide concentration typically marks the typically marks the resolution.resolution.

► If it doesn’t resolve it indicates If it doesn’t resolve it indicates permanent neonatal DMpermanent neonatal DM

►endogenous insulin deficiency due to endogenous insulin deficiency due to failure of pancreatic beta cellsfailure of pancreatic beta cells

drugsdrugs

►TheopyllineTheopylline►DexamathasoneDexamathasone►Prostaglandin EProstaglandin E

ComplicationsComplications

►Dehydration-osmotic diuresisDehydration-osmotic diuresis► Intraventricular hemorrhageIntraventricular hemorrhage

-increase serum osmolarity-increase serum osmolarity-rapid shifting of water-rapid shifting of water

► Ischemic events-brainIschemic events-brain-hyperosmolarity-hyperosmolarity-lactic acidosis-lactic acidosis-decrease regional cerebral blood flow-decrease regional cerebral blood flow

►Steatosis-impairment of hepatic Steatosis-impairment of hepatic secretions of triglyceridessecretions of triglycerides Due to aggressive glucose administrationsDue to aggressive glucose administrations

►Prolonged ventilationProlonged ventilation

-lipogenesis causes increase co2-lipogenesis causes increase co2

-increase need for -increase need for ventilation-LBW/ELBWventilation-LBW/ELBW

► Electrolyte Electrolyte imbalanceimbalance-infants with -infants with

glycosuria-increase glycosuria-increase in sodium excretion in sodium excretion

-due to increase -due to increase filtered sodium loadfiltered sodium load

Aims of treatmentAims of treatment

► Identify underlying etiologyIdentify underlying etiology►Prevent complicationsPrevent complications►Administer continous insulin Administer continous insulin

infusionsafely to maintain euglycemia infusionsafely to maintain euglycemia and adequate calorie intakeand adequate calorie intake

ManagementManagement

►RBS-confirmationRBS-confirmation►Monitor urine for glycosuria and urine Monitor urine for glycosuria and urine

volume (mL/kg/hr) to ensure adequate volume (mL/kg/hr) to ensure adequate fluid balance fluid balance

► If baby needs additional fluids to If baby needs additional fluids to counter renal and extrarenal losses counter renal and extrarenal losses (phototherapy) consider using 5% (phototherapy) consider using 5% dextrose or 0.45% saline dextrose or 0.45% saline

►Seek and treat serious underlying Seek and treat serious underlying disorders especially infection (septic disorders especially infection (septic screen and antibiotics). screen and antibiotics).

► Achieve adequate sedation and pain Achieve adequate sedation and pain relief relief

►Calculate glucose delivery rateCalculate glucose delivery rate More than 10mg/kg/min-reduce to 6-More than 10mg/kg/min-reduce to 6-

10mg/kg/min 10mg/kg/min

► If hyperglycemia still persist-consider If hyperglycemia still persist-consider insulin sliding scaleinsulin sliding scale

-0.02unit/kg to 0.05unit/kg per hour-0.02unit/kg to 0.05unit/kg per hour►Enteral feeding-promotes pancreatic Enteral feeding-promotes pancreatic

function and secretion of insulinfunction and secretion of insulin►Hypocount monitored 2-4 hourly-Hypocount monitored 2-4 hourly-

prevent hypoglycemiaprevent hypoglycemia