The document discusses neonatal hypoglycemia, including its definition, symptoms, risk factors, treatment, and monitoring. Some key points:
- Neonatal hypoglycemia is defined as a blood glucose level below certain thresholds in the first 24 hours and thereafter. It is a common problem in newborns.
- Babies at higher risk include preterms, those of diabetic mothers, or experiencing other stresses. Symptoms can be nonspecific.
- Treatment involves glucose administration via IV bolus or infusion to raise blood glucose to the normal range. Frequent monitoring is needed until levels stabilize.
- Persistent or resistant hypoglycemia may require additional drugs or referral to a specialist to investigate underlying
2. Introduction
• Glucose or dextrose is a vital source of nutrient energy and
is required continuously by the fetus.
• Neonate needs this as either intermittent oral feeds or
continuous IV fluids.
• Hypoglycemia can cause long term neurologic sequelae.
The important steps in preventing and treating
hypoglycemia are
to identify neonates at risk of developing hypoglycemia
to recognize symptoms of hypoglycemia, early feeding and
to initiate IV fluid therapy, where ever needed.
3. Neonates at risk of hypoglycemia
o Babies weighing less than 2.0 kg birth weight,
o preterm babies,
o LGA (large for gestational age) babies especially
those weighing more than 3.5 kg,
o infants of diabetic mothers,
o those with delayed cry at birth, any sick neonate
who is not sucking or accepting feeds are all at
risk of developing hypoglycemia.
o The other risk factors for hypoglycemia are RDS,
polycythemia, shock, and hypothermia
4. Definition of hypoglycemia
• Neonatal hypoglycemia, defined as a plasma
glucose level of less than 30 mg/dL (1.65
mmol/L) in the first 24 hours of life and less
than 45 mg/dL (2.5 mmol/L) thereafter,
• Neonatal hypoglycemia is the most common
metabolic problem in newborns.
5. Symptoms of hypoglycemia
• The symptoms of hypoglycemia are very nonspecific and
can mimic any illness.
• The common symptoms are:
• Not looking well
• Lethargic,
• Weak cry,
• Poor feeding,
• Temperature instability like hypothermia,
• Poor respiratory effort: shallow breathing, apnea or
cyanosis
• CNS symptoms like: excessive jitteriness, convulsions or
hypotonia.
6. Factors which increase the risk of
hypoglycemia
• Various factors which increase the risk of
hypoglycemia are hypothermia & cold Stress,
cold environment, wet baby and inadequate
feeding.
7. Etiology
• The causes of neonatal hypoglycemia include the following:
• Persistent hyperinsulinemic hypoglycemia of infancy (PHHI)
• Limited glycogen stores (eg, prematurity, intrauterine
growth retardation)
• Increased glucose use (eg, hyperthermia, polycythemia,
sepsis, growth hormone deficiency)
• Decreased glycogenolysis, gluconeogenesis, or use of
alternate fuels (eg, inborn errors of metabolism, adrenal
insufficiency)
• Depleted glycogen stores (eg, asphyxia-perinatal stress,
starvation)
9. Treatment
• To raise the blood sugar value to normal range,
give 200 mg/kg of dextrose i.e. 2 ml /kg of 10%
dextrose as bolus slowly over 3-5 minutes and
start maintenance fluids with a dextrose infusion
rate (DIR) of 6 – 8 mg/kg/min.
• The maximum strength of dextrose that can be
given through a peripheral vein is 12.5%.
• Repeat Dextrostix after 15-30 minutes, if still low,
repeat bolus and increase (DIR) by 1 – 2
mg/kg/min or the maintenance fluids by 10 – 20
ml/kg/day.
10. • For example in a low birth weight baby on first day of life
give 80ml/kg/ day i.e. 80 x wt of the baby
• e.g. 1.8 kg i.e. 144 ml/day. Divide by 24 to obtain fluid per
hour (144 / 24 = 6 ml/hr).
• Take a measured volume set, fill 1/4th or 6 hrs fluid i.e. 24
ml and deliver at a rate of 6 micro drops/min (number of
drops per minute is equal to rate of fluid/hour).
• The dextrose infusion rate can be calculated by the
following formula:
Fluid rate (ml/kg/day) x % of Dextrose to be used x 0.007 =
DIR (mg/kg/min).
o e.g. If a baby is on 100 ml/kg/day of 10% dextrose, the DIR
is 7 mg/kg/min. You may also use the reference charts to
calculate the DIR.
11. How to monitor blood glucose in
hypoglycemia
• In asymptomatic babies measure blood glucose within 2 hrs of
birth, preferably before feeds.
• Frequency & duration depends on clinical features and glucose
value, initial frequency may be 2 hrly, and later 4 hrly and finally 8 -
12 hrly.
• Monitoring is usually done for 72 hrs after birth in at risk newborns
or till glucose levels remain normal for 48 – 72 hrs.
• Symptomatic babies: may require more frequent monitoring.
• Maintain the same DIR till the blood glucose is stable for at least 6 –
8hrs and then decrease the DIR by not greater than 1 – 2
mg/kg/min every 2 hours with adequate monitoring.
12. Resistant or Persistent Hypoglycemia:
• Resistant or Persistent Hypoglycemia:
• Requirement of a dextrose infusion rate or more than
12 mg/ kg/min suggests resistant hypoglycemia.
• Any hypoglycemia persisting beyond one week despite
adequate management suggests persistent
hypoglycemia.
• One should rule out hyperinsulinemic state or inborn
errors of metabolism.
• Increase the DIR to 12–15 mg/kg/min, keeping in mind
that more than 12.5% dextrose should not be given
through a peripheral vein and a central venous
catheterization is required.
13. • In resistant or persistent hypoglycemia the
following drugs should be considered: –
• Hydrocortisone: 10 mg/kg/day in two divided
doses intravenously
• Glucagon: 100 – 300 ug/kg/dose IM to a
maximum of 3 doses in babies with adequate
glycogen stores
• Diazoxide: 2 – 5 mg/kg/dose every 8 hrly orally
• Octreotide : Synthetic somatostatin in a dose of
2–10 ug/kg/day subcutaneously q 8 -12 hourly
• Babies with persistent or resistant hypoglycemia
should be REFERRED to a specialize center for
farther investigations