Neonatal HypoglycemiaNeonatal Hypoglycemia

Stan Jack, D.O.Stan Jack, D.O.

Saint Joseph Hospital Family Saint Joseph Hospital Family Practice ResidencyPractice Residency

Neonatal Hypoglycemia - Neonatal Hypoglycemia - SignificanceSignificance

• Persistent or recurrent Persistent or recurrent hypoglycemia can result in impaired hypoglycemia can result in impaired neurologic development and neurologic development and intellectual functionintellectual function

• Other sequela include spasticity, Other sequela include spasticity, ataxia, and seizure disorderataxia, and seizure disorder

Neonatal Hypoglycemia - Neonatal Hypoglycemia - DefinitionDefinition

• Plasma glucose <40 mg/dL on the Plasma glucose <40 mg/dL on the first day of lifefirst day of life

• Plasma glucose <40-50 mg/dL after Plasma glucose <40-50 mg/dL after 24 hours of age24 hours of age

Note: whole blood glucose ~15% Note: whole blood glucose ~15% lower than plasma glucose lower than plasma glucose measurementsmeasurements

Neonatal Hypoglycemia - Neonatal Hypoglycemia - PathogenesisPathogenesis

• Glucose in utero comes from motherGlucose in utero comes from mother

• After cord cut, glucose in newborn After cord cut, glucose in newborn falls during first 2 hours, stabilizing falls during first 2 hours, stabilizing by 4-6 hrs (transition period)by 4-6 hrs (transition period)

• Dependent on glycogen storage Dependent on glycogen storage depletion and carbohydrate intakedepletion and carbohydrate intake

Neonatal Hypoglycemia - Neonatal Hypoglycemia - CausesCauses• Diminished glucose production (premature, Diminished glucose production (premature,

IUGR)IUGR)

• Increased glucose utilization secondary to Increased glucose utilization secondary to hyperinsulinism (infants of diabetic mothers, hyperinsulinism (infants of diabetic mothers, Beckwith-Weidmann, erythroblastosis, Beckwith-Weidmann, erythroblastosis, perinatal asphyxia)perinatal asphyxia)

• Maternal tx with beta blockersMaternal tx with beta blockers

• SepsisSepsis

Neonatal Hypoglycemia - Neonatal Hypoglycemia - Causes (continued)Causes (continued)

• PolycythemiaPolycythemia

• Metabolic disorders (inborn errors of Metabolic disorders (inborn errors of carbohydrate / amino acid metabolism)carbohydrate / amino acid metabolism)

• Endocrine disorders (low levels of Endocrine disorders (low levels of cortisol, growth hormone, epinephrine, cortisol, growth hormone, epinephrine, or glucagon)or glucagon)

• Heart failureHeart failure

Neonatal Hypoglycemia - Neonatal Hypoglycemia - Clinical ManifestationsClinical Manifestations

• Frequently asymptomaticFrequently asymptomatic

• Jittery, tremulousJittery, tremulous

• Decreased toneDecreased tone

• Irritable or lethargic; seizuresIrritable or lethargic; seizures

• Apnea, bradycardia, cyanosis, tachypneaApnea, bradycardia, cyanosis, tachypnea

• Poor feedingPoor feeding

Neonatal Hypoglycemia - Neonatal Hypoglycemia - ScreeningScreening

• Not routinely monitored unless at Not routinely monitored unless at risk for hypoglycemia (next slide)risk for hypoglycemia (next slide)

• If screening done, obtain sample If screening done, obtain sample before feedingsbefore feedings

Neonatal Hypoglycemia - Neonatal Hypoglycemia - Risk FactorsRisk Factors

• PrematurityPrematurity

• Small or large for gestational ageSmall or large for gestational age

• Infants of diabetic mothersInfants of diabetic mothers

• ICU infants (i.e. sepsis)ICU infants (i.e. sepsis)

• Infants of mothers treated with beta Infants of mothers treated with beta blockersblockers

Neonatal Hypoglycemia - Neonatal Hypoglycemia - ManagementManagement

• If lower than 40 mg/dL, surveillance If lower than 40 mg/dL, surveillance until feedings well established and until feedings well established and glucose normalglucose normal

• If asymptomatic and term, obtain If asymptomatic and term, obtain blood sample and immediately offer blood sample and immediately offer breast or formula feeding (consider breast or formula feeding (consider gavage); recheck 20-30 minutes after gavage); recheck 20-30 minutes after feedingfeeding

Neonatal Hypoglycemia - Neonatal Hypoglycemia - Management (continued)Management (continued)• If symptomatic OR not tolerating enteral feeds If symptomatic OR not tolerating enteral feeds

OR plasma glucose <20-25 OR if persistently OR plasma glucose <20-25 OR if persistently <40 even after feeds, start parenteral glucose<40 even after feeds, start parenteral glucose

• Bolus 200 mg/kg (2 ml/kg 10% dextrose in Bolus 200 mg/kg (2 ml/kg 10% dextrose in H2O) over 1 minute followed by glucose H2O) over 1 minute followed by glucose infusion of 8 mg/kg per minuteinfusion of 8 mg/kg per minute

• If requirements high (>12.5%) may need If requirements high (>12.5%) may need central venous cathetercentral venous catheter

Neonatal Hypoglycemia - Neonatal Hypoglycemia - SummarySummary

• Prolonged hypoglycemia may result Prolonged hypoglycemia may result in long-term morbidityin long-term morbidity

• May be asymptomaticMay be asymptomatic

• Screening is based on risk factorsScreening is based on risk factors

Neonatal Hypoglycemia - Neonatal Hypoglycemia - Summary (continued)Summary (continued)• If asymptomatic and glucose is If asymptomatic and glucose is

moderately low, begin with feeding and moderately low, begin with feeding and surveillancesurveillance

• Symtomatic infants with very low glucose Symtomatic infants with very low glucose levels will need parenteral replacementlevels will need parenteral replacement

• Do not hesitate to run things by your Do not hesitate to run things by your upper level, attending, or the upper level, attending, or the neonatologistneonatologist