2. +
INTRODUCTION
Common metabolic problem
Blood glucose in newborns are generally lower than older children &
adult
Fetal glucose level maintained at 2/3 of maternal B.glucose by
transplacental route
Glucose level fall in Ist 1-2 hrs,lowest value at age of 3 hrs, increase
and stabilise by 4 hrs.
preterm and SGA may be at highest risk up to 36 h (range 0.8 to
34.2 h)
There is no single value below which brain injury definitely occur.
2
3. +
DEFINITION
The operational threshold for hypoglycemia is defined as that
concentration of plasma or whole blood glucose at which clinicians
should consider intervention.
it do not define normal or abnormal
It is <45 mg % regardless of gestational age and whether or not
symptoms are present
Whipple’s triad:
low glucose level documented by accurate lab method
Signs and symptoms of hypoglycemia
Resolution of signs and symptoms on restoration of blood glucose
levels.
3
4. +
MECHANISM
Clinically significant NH is the result of an imbalance between
glucose supply and other fuels such as ketone bodies, which
are released from fat.
NH caused by a lower glucose threshold for suppression of
insulin secretion
Decreased expression of enzymes in pathways of hepatic
glycogenolysis, gluconeogenesis,or ketogenesis.
4
6. +
ETIOLOGY
Delay in feeding
Low birth weight infants specially<2000 grams
Preterm infants ( 35 weeks)
Small for gestational age infants (SGA) : birth weight <10th
percentile
Infant of diabetic mothers (IDM)
Large for gestational age (LGA) infants: birth weight >90th
percentile
Infants with Rh-hemolytic disease ,erythroblastosis
6
7. +
Infants born to mothers receiving therapy with
terbutaline/propranolol/labetalol/oral hypoglycemic agents
Infants with morphological IUGR.
Any sick neonate such as those with perinatal asphyxia,
polycythemia, sepsis, shock ,etc., when they are in active phase of
illness.
Infant on TPN
Exchange transfusion
Heparinized blood with low glucose level
CPD blood (relatively hyperglycemic---reactive hypoglycemia
Routine screening is recommended in above mentioned conditions.
7
8. +
SCHEDULE FOR SCREENING
At risk neonates : 2, 6, 12, 24, 48, and 72 hrs
Sick infants : Every 6-8 hrs (individualize as needed)
TPN : Initial 72 h: every 6 to 8 hrs After 72 hr:
once a day
After Exchange : 2 hrs after infusing CPD blood
Infants exhibiting signs compatible with hypoglycemia at
any time also need to be investigated.
8
9. + PITFALL IN GLUCOSE ESTIMATION
1. glucose reagent strips
2. Laboratory diagnosis
3. continuous monitoring
capillary sugar value is 10% to 15% lesser than that of plasma
value
Arterial samples have slightly higher value compared to venous
or capillary
the BGL can fall by 14 to 18 mg/dL per hour in samples that
await analysis.
This problem can be avoided by transporting the blood in tubes
that contain a glycolytic inhibitor such as fluoride."
9
10. +
CLINICAL FEATURE
1. ASYMPTOMATIC.
2. SYMPTOMATIC
Tremors, jitteriness ,irritability,seizures, lethargy, poor feeding,vomiting
,limpness,weak or high pitched cry ,cyanosis
Episodes of sweating, sudden pallor, hypothermia and cardiac arrest
have also been reported.
CLINICALCONFIRMATION-whipples triad
10
11. +
MANAGEMENT
Infants With Asymptomatic Hypoglycemia
1. If any time Blood sugar 20-45 mg/dL
Trial of oral feeds (expressed breast milk or formula) and repeat
blood test after 1 hour.
a. Repeat BGL is >45 mg/dL, two hourly feeds is
ensured 6 hourly monitoring of BGL for 48 hrs. the target blood
glucose value is 50 to 120 mg/dL.
b.Repeat BGL is <45 mg/dL IV Dextrose is started at
6 mg/kg/min of glucose
2. If any time Blood sugar levels <20 mg/dL
IV Dextrose is started at 6 mg/kg/min of glucose
11
12. +
Infants With Symptomatic Hypoglycemia
12
Symptomatic
hypoglycemia
Bolus 2 ml/kg 10%
dextrose
IV glucose infusion @ 6 mg/kg/min
Monitor hourly till euglycemic and
then 6 hrly
Blood sugar >50
mg/dL
Stable for 24 hours on IV fluids;
2 values of blood sugar >50
mg/dL
Weaning at 2 mg/kg/min every
6 hrs;
↑ oral feeds;
Monitoring to continue 6 hrly
Stop IV fluids when
the rate is 4 mg/kg/min
and the infant is stable
Stop monitoring when 2
values are more than 50 on
Blood sugar <50
mg/dL
Increase glucose @ 2
mg/kg/min till
euglycemia
Increase till the glucose
infusion rate is >12
mg/kg/min
Resistant hypoglycemia
Hydrocortisone
Diazoxide (not in SGA)
Glucagon (not in SGA)
13. + glucose infusion preferably using an infusion pump and without
any interruption.
Do not stop glucose infusion abruptly as severe rebound
hypoglycemia may occur.
Avoid using more than 12.5% dextrose infusion through a
peripheral vein due to the risk of thrombophlebitis.
If there is persistent hypoglycemia, check the intravenous line
for functioning. Also recheck the intravenous fluid preparation
and infusion rate.
GIR(mg/kg/min) = % dextrose x ml/kg/day
144
13
14. +
Resistant/recurrent Hypoglycemia
when infant fails to maintain normal BGL
despite a GIR of 12 mg/kg/min
when stabilization is not achieved by 7 days
of therapy
14
17. +
Hydrocortisone
10mg/kg/day in 2 div doses
MOA-decrease peripheral glucose utilisation, increase
gluconeogenesis,increase effects of glucagon
Rapidly tapered off in few days
Before administration of HC ,obtain blood samples for insulin and
cortisol levels
17
18. +
Glucagon
Mobilising hepatic glycogen stores
Infants with good glycogen stores
Not in preterms and malnourished
0.025-0.3 mg/kg IM
Diazoxide (2-5mg/kg q8h PO) – in persistent hyperinsulinemia
Epinephrine
Subtotal pancreatectomy
18
20. +
Na /K-adrenal insufficiency
MRI brain-hypothalamic/pituitary pathology
CT abdomen-islet cell adenoma
Genetic testing – to look for mutations
20
21. + Samples to detect insulin levels should be drawn at the time of low
BG
Criteria for Diagnosing Hyperinsulinism Based on “Critical” Samples
1. Hyperinsulinemia (p.insulin >2 μU/mL)
2. Hypofattyacidemia (p. FFA<1.5 mmol/L)
3. Hypoketonemia (p. β-hydroxybutyrate: <2.0 mmol/L)
4. Inappropriate glycemic response to glucagon, 1 mg IV (rise >40
mg/dL)
21
26. +
MANAGEMENT
The major long-term sequelae of severe, prolonged
hypoglycemia are mental retardation, recurrent
seizure activity, or both.
Permanent neurologic sequelae are present in 25–50%
ofbabies with severe recurrent symptomatic
hypoglycemia
These sequelae are more likely when alternative fuel
sources are limited, as occurs with hyperinsulinemia
Anticipation and prevention –key to management of
infants with risk factors for HG
26