Neonatal Hypoglycemia - جامعة آل البيت...1) Persisting or recurring beyond the first 7-14 days of life **Prompt recognition is essential!! These conditions are associated

kamlah olaimat 25\7\2010

Neonatal Hypoglycemia

Presented By :

Kamlah Olaimat

25\7\2010


Definition

The S.T.A.B.L.E. Program defines hypoglycemia as:

“Glucose delivery or availability is inadequate to meet glucose demand” (Karlsen, 2006)

Also its defined as a serum glucose value < 40mg\dl in term and preterm infant .


What is Normal?

Defining a normal glucose level remains controversial

50 – 110 mg/dl (Karlsen, 2006)

> 40 mg/dl (Verklan & Walden, 2004)

> 30 term, > 20 preterm (Kenner & Lott, 2004)

> 45 mg/dl (Cowett, R. as cited by Barnes-Powell, 2007)

There is no evidence to support the hypothesis that preterm infants can tolerate lower glucose level than term infant


Incidence of Hypoglycemia

Overall Incidence = 1- 5/1000 live births

Normal newborns – 10% if feeding is delayed for 3-6 hours after birth

At-Risk Infants – 30%LGA – 8%

Preterm – 15%

SGA – 15%

IDM – 20%


Why is hypoglycemia a problem?

Glucose is the primary fuel for the brain.

The brain needs a steady supply of glucose to function normally.

Glucose is the fetus’s only source of carbohydrate.


Why is hypoglycemia a problem?

“Compared with adults, infants have a higher brain to body weight ratio, resulting in higher glucose demand in relation to glucose production capacity”.

“Cerebral glucose utilization accounts for 90% of the neonate’s glucose consumption”.


Mechanism of hypoglycemia

Hyperinsulinism with increased glucose utilization ( infant of DM)

Decreased production and storage of glycogen and fat ( preterm infant , IUGR)

Increased utilization and decreased production of glucose (prenatal stress )


Preparation for Birth

Fetal plasma glucose is 60 – 80% of the maternal glucose level.

The fetus stores glucose in the form of glycogen (liver, heart, lung, and skeletal muscle).

Most of the glycogen is made and stored in the last month of the 3rd trimester.



The fetus has limited ability to convert glycogen to glucose and must rely upon placental transfer of glucose to meet energy needs.

When the infant is born, the cord is cut and so is the major supply of glucose!



The transition from fetus to newborn creates a significant energy drain on the newborn.

The newborn is now required to meet increased metabolic demands while changing the energy source from a placenta-supplied source to an external food source.


Infants at Highest Risk

< 37 weeks gestationInfant of a diabetic motherSmall for gestational ageLarge for gestational ageStressed/ill infantsExposure to certain medications

Treatment of preterm laborTreatment of hypertensionTreatment of type 2 diabetesBenzothiazide diureticsTricyclic antidepressants in the 3rd trimester


Factors that negatively affect glucose availability after birth

Inadequate Glycogen

Increased Utilization of Glucose

Excessive Insulin


Inadequate Glycogen

Glycogen stores increase rapidly in the last month of the 3rd

trimester

Preterm infants are born before this occurs. What little glycogen is available is used up rapidly and their supply is depleted.


Inadequate Glycogen

SGA – birth weight < 10 percentile. Chronically stressed infants have higher metabolic demands and use up available glucose for growth and survival.

Markedly post-mature infants are at increased risk due to increased metabolic demand.


Increased Utilization of Glucose

Sick/Stressed infantsCauses increase in metabolic demand

Uses up glucose quickly.

These include all sick, premature and SGA infants.


Excessive Insulin - IDM

Infants of Diabetic MothersMany consequences for the neonate

Single most important factor in determining the outcome for the infant is maternal glucose control


IDM – Risks > general population

Birth injury is doubled

C/S is tripled

NICU admission is quadrupled

Stillbirth is x 5 greater

Congenital anomalies are x 2 – 5 greater


IDM - Incidence

106,000 in 1999

Rate of Type II Diabetes has increased by 33% in past 20 years

Women at highest riskAfrican-American

Hispanic

American Indian

Asian

Obese


IDM – Effects on Fetus

Glucose crosses the placentaInsulin does not cross the placentaResults – fetus produces own insulin in the presence of elevated glucose from the motherExcessive formation of oxygen radicals that damage the mitochondriaThis increase in oxidative stress results disrupts vascularization of the developing tissues.


IDM – fetal anomalies

Hyperglycemia alters the expression of regulating genes leading to altered cellular mitosis and the normal timing of cell death. Excessive cell death results in fetal anomalies.Caudal regression syndromeHydronephrosisRenal agenesisCystic kidneysIntestinal atresias

Caudal Regression Syndrome

Spectrum of malformation cessation of growth of rostral portion of spinal cord

abnormal neural, muscular, skeletal and vascular components

Caudal Regression with limbsintact but malformed

SirenomeliaAbsence of hind limbs, external genitalia, anus and rectum; Potter sequence secondary renal agenesis


Effect on CNS

Anencephaly

Spina bifida

Caudal dysplasia

CNS damage as a result of Birth trauma (macrosomia)

Glucose and electrolyte abnormalities

Perinatal asphyxia


Other Effects on the Neonate

RDS

CHD VSD

Asymmetric septal hypertrophy

Thickened myocardium

Transposition of the greater vessels

Polycythemia and vascular sludging


Nursing Management

Complete evaluation and review of systems

Early breast or bottle feeding within 30 minutes

Glucose monitoring within 1 hour

Monitor pre-feeding levels thereafter


Monitoring

Serum glucose

level is the gold

standard

Bedside glucose

levels are for

screening

Monitor at least hourly until glucose level has stabilized

Know your hospital policy for monitoring infants at risk for hypoglycemia


Signs & Symptoms of Hypoglycemia

Jitteriness

Irritability

Hypotonia

Lethargy

High-pitched cry

Hypothermia

Poor suck

Tachypnea

Cyanosis

Apnea

Seizures

Cardiac arrest


Treatment

Oral feedings as tolerated

If glucose is very low or the infant is not able to feed orally:

2ml/kg of D10W IV bolus

Follow up screenings within 30 minutes

Repeat bolus if glucose is < 50 mg/dl

If unable to stabilize glucose consider increasing IV rate or glucose concentration




Prevention

Increase awareness of conditions that predispose an infant to hypoglycemia

Early screening of at-risk infants

Early and frequent feedings

Maintain temperature


What if hypoglycemia occurs prolonged, recurrent or

persistent?

Recurrent of Persistent Hypoglycemia:

1) Require infusions of large amounts of glucose (>1216 mg/kg/min) to maintain normoglycemia


What if hypoglycemia occurs prolonged, recurrent or persistent?

1) Persisting or recurring beyond the first 7-14 days of life**Prompt recognition is essential!!

These conditions are associated with severe disease at substantial risk of developing severe mental retardation and epilepsy.

These include many conditions stated previously including: Hormone deficiencies, Hyperinsulinism syndromes, Defects in carbohydrate, amino acid, fatty acid metabolism


What tests should you do?What is your management?

Assay for insulin, C-peptide, growth hormone, lactate, free fatty acids, T4, TSH,

Urine for reducing substances, ketones, organic acidsManagement includes: Glucagons (0.3 mg/kg/dose bolus or infusion 1-2

mg/day); Add 1 mg to 24 ml of D10W and run at 1 ml/hour through separate lie

Continue to increase the glucose infusion rate to 12-15mg\kg\min

Corticosteroid , hydrocortisone 5mg\kg\d Diazoxide 3-5 mg\kg\d . IV , IM , SC Human growth hormone


“A man with a watch knows what time it is. A man with two watches is never sure”

Thank you for your attention. I hope it was interesting.

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References

Barnes-Powell, L. (2007). Infants of Diabetic Mothers: The effects of hyperglycemia on the fetus and neonate. Neonatal Network, 26(5) p. 283-289.

Karlsen, K. (2006) The S.T.A.B.L.E. Program. Pre-transport/Post-resuscitation Stabilization Care of /sick Infants, Guidelines for Neonatal Healthcare Providers. 5th Edition.

Kenner, C., Lott, J. (2004). Neonatal Nursing Handbook. Elsevier.

Verklan, M., & Walden, M. (2004). Core Curriculum for Neonatal Intensive Care Nurses. Elsevier.

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Neonatal Hypoglycemia - جامعة آل البيت...1) Persisting or recurring beyond the first 7-14 days of life **Prompt recognition is essential!! These conditions are associated