1. HYPOGLYCEMIA

2. defination
• The normal conc. Of blood glucose level in newborn
infant is 2-7mmol/l(35-120mg/dl
• In healthy term infants, serum glucose values are
rarely less than 35 mg/dL between 1 and 3 hr of life,
less than 40 mg/dL from 3 to 24 hr, and less than 45
mg/dlafter 24 hr
• Ablood glucose concentration below
2mmol/l(35mg/dl) is defind as neonatal
hypoglycemia

3. ….cont..
• Clinically hypoglycemia may also be defined as the
presence of neurologic (lethargy, coma, apnea,
seizures) or sympathomimetic (pallor, palpitations,
diaphoresis) manifestations that respond to
glucose,
• Mild hypoglycemia defind as blood glucose conc.
b/n1.5-2mmol/l(25-35mg/dl)
• Sever hypoglycemia is defind as blood glucose conc.
Below1.5mmol/l(25mg/dl)

4. CLASSIFICATION OF HYPOGLYCEMIA IN INFANTS AND
CHILDREN
1. NEONATAL TRANSIENT HYPOGLYCEMIA- Associated
with Inadequate Substrate or Immature Enzyme
Function in Otherwise Normal Neonates
2.Transient Neonatal Hyperinsulinism Present in:
Infant of diabetic mother,Small for gestational
age,Discordant twin,Birth asphyxia

5. …Cont…
3.NEONATAL, INFANTILE, OR CHILDHOOD PERSISTENT
HYPOGLYCEMIA
hormonal disorder
counter regulatory hornon def.
Glycogenolysis and Gluconeogenesis Disorders
Lipolysis Disorders
Fatty Acid Oxidation Disorders

6. WHICH INFANTS HAVE AN INCREASED RISK OF
HYPOGLYCAEMIA?
1.Hyperinsulinism like
• Infants of mothers with diabetes mellitus or gestational
diabetes
• infants with severe erythroblastosis fetalis,
• insulinomas,
• familial or sporadic hyperinsulinemia,
• Beckwith syndrome (an inherited disease that is
characterized by macroglossia, umbilical hernia,
hypoglycemia, abnormal enlargement of the viscera)
• panhypopituitarism

7. …Cont…
2.Increased metabolic demands: Hypoglycemia may
develop in very immature or severely ill infants as a
result of increased metabolic needs disproportionate to
substrate stores and the calories supplied like in
• low-birthweight infants with respiratory distress
syndrome
• perinatal asphyxia
• Polycythemia
• hypothermia,
• systemic infections
• infants in heart failure with cyanotic congenital heart
disease, are at increased risk.

8. …cont…
3.IUGR/prematurity: experienced intrauterine
malnutrition due to
• reduced hepatic glycogen stores and total body fat,
• impaired gluconeogenesis
• diminished free fatty acid oxidation
• low cortisol production rates
4. Genetic causes- primary metabolic defects, such as
Galactosemia,glycogen storage disease,fructose
intolerance etc.

9. Clinical manifastation
• Hypoglycaemia may produce NO CLINiCAL SIGNS
or present with non specific signs only.
• Often an infant has some signs of brain stimul
ation and other signs of brain depression at the
same time ,
• This makes the clinical diagnosis of hypoglycaemia
very variable difficult and unreliable.

10. …Cont…
• When present, the signs and symptom of
hypoglycaemia are:
1. DEPRESSION OF BRAIN FUNCTION. The infant may be
lethargic and hypotonic, feed poorly, have a weak cry,
apnoea, cyanosis or an absent Moro reflex.
2. OVERSTIMULATION OF BRAIN FUNCTION. The infant
may be jittery with a high pitched cry, a fixed stare and
fisting, have abnormal eye movements or convulsions.
3. EXCESSIVE SWEATING. This sign may not be present
especially in preterm infants
• cardiac arrest and failure also occur

11. Diagnosis of hyperglycemia
• The clinical diagnosis is difficult and often missed
.Therefore, it is essential that all infants at risk of
hypoglycaemia , and infants with clinical signs that
may be caused by hypoglycaemia, be screened with
reagent strips .
• Diagnosis of hypoglycemia by reagent strips should
be confirmed with alaboratory blood glucose
measurement.

12. Prevention of hypoglycemia
• The following steps must b e taken to prevent
hypoglycaemia:
1. Identify all infants at high risk of developing
hypoglycaemia.
2. Monitor the blood glucose concentration of these
infants with reagent strips so that afalling blood glucose
can be detected before hypoglycaemic levels are
reached.
3. Feed all infants as soon as possible after delivery,
espe cially preterm, underweight for gestational age
and wasted infants, as well as infants of diabetic
women.

13. …cont…
4. Whenever possible, milk feeds should b e given.
Both clear feeds orally and oral dextrose feeds
shouldn’t be used in newborn infants as they are
low in energy and may result in hypoglycaemia .
5. If milk feeds can not be given, then an intravenous
infusion of Neonatalyte should be comm
enced.Neonatalyte contains 10 % glucose.
6. Prevent hypothermia.

14. treatment
• When symptoms other than seizures are present, an
intravenous bolus of 200 mg/kg (2 mL/kg) of 10%
glucose is effective in elevating the blood glucose
concentration.
• In the presence of convulsions, 4 mL/kg of 10% glucose
as a bolus injection is indicated
• After initial therapy, a glucose infusion should be given
at 8 mg/kg/min
• If hypoglycemia recurs, the infusion rate and
concentration should be increased until 15-20% glucose
is used

15. …cont…
• if the infusion is inadquat to eleminate the
symptoms hyperinsulinemia is probably present
and diazoxide should be administered
• If the diazoxide is unsuccessful, octreotide may be
useful
• many infants with severe persistent
hyperinsulinemic hypoglycemia undergo subtotal
pancreatectomy

16. monitoring
• The serum glucose level should be measured every
2 hr after initiating therapy until several
determinations are above 40 mg/dL.
• Subsequently, levels should be measured every 4-6
hr and the treatment gradually reduced and finally
discontinued when the serum glucose value has
been in the normal range and the baby
asymptomatic for 24-48 hr.
• Treatment is usually necessary for a few days to a
week, rarely for several wks

17. prognosis
• The prognosis is good in asymptomatic patients
with hypoglycemia of short duration
• Symptomatic infants with hypoglycemia,
particularly
- low-birthweight infants,
-those with persistent hyperinsulinemic
hypoglycemia,
- and infants of diabetic mothers, have a poorer
prognosis for subsequent normal intellectual
development than asymptomatic infants do.

18. Fluid and electrulyte management
in term and preterm newborns

19. introduction
• Disorders of fluid and electrolyte balance are
among the commonest derangements encountered
in preterm and critically sick neonates
• The aim of fluid and electrolyte therapy is to ensure
a smooth transition from the aquatic in-utero
environment to the dry ex- utero environment

20. Changes in body water and solute after parturition
• After birth, there is efflux of fluid from the
intracellular fluid (ICF) to the extracellular fluid
(ECF) compartment.
• This increase in the ECF compartment floods the
neonatal kidneys eventually resulting in a salt and
water diuresis by 48-72 hours.
• Loss of this excess ECW results in physiological
weight loss in the first week of life.

21. …cont…
• Since the ECW compartment is larger in more
preterm neonates, the weight loss is greater in
preterm neonates.
• Failure to loose this ECF may be associated with
morbidities like patent ductus arteriosus (PDA),
necrotizing enterocolitis (NEC) and chronic lung
disease (CLD) in preterm neonates

22. Renal function
• Kidneys in the neonate have a limited capacity to
excrete both concentrated and dilute urine
• the neonatal kidney has a limited capacity both to
excrete and to conserve sodium.
• Therefore, sodium supplementation should be
started after ensuring initial diuresis(48-72hrs)

23. …cont…
• Sodium requirement ranges from 3-5 mEq/kg/day in
preterm neonates after the first week of life.
• Failure to provide this amount of sodium may be
associated with poor weight gain
• Very low birth weight infants on exclusive breast
feeding may need sodium supplementation in addition
to breast milk until 32-34 weeks corrected age

24. Fluid losses
1.sensible loss-kidneys and gastro-intestinal system
2.Insensible loss-evaporation from the skin(70%) and
respiratory tract(30%).
• The emphasis in fluid and electrolyte therapy
should be on prevention of excessive IWL rather
than replacement of increased IWL

25. Managment
Management of fluid in newborn depends on
gestational age and birth weight
1.Day 1: Term babies and babies with birth weight >
1500 grams. total fluid therapy would be 60
ml/kg/day of 10% dextrose
2.Day 1: Preterm baby with birth weight 1000-1500
grams.

26. …cont…
• the fluid requirement will be higher due to
increased IWL and increased weight loss .
• using caps, socks and plastic barriers under the
radiant warmer reduce the IWL
• Using this method we have found 80 ml/kg/day of
10% dextrose to be adequate on day 1 of life

27. …cont…
3. Day 2 -7: Term babies and babies with birth weight
>1500 grams.
• As the infant grows and receives enteral milk feeds,
the solute load presented to the kidneys increases
and the infant requires more fluid to excrete the
solute load.
• Water is also required for fecal losses and for
growth purposes.

28. …cont…
• The fluid requirements increase by 15-20 ml/kg/day
until a maximum of 150 ml/kg/day
• Sodium and potassium should be added after 48 h
of age and glucose infusion should be maintained at
4-6 mg/kg/min

29. …cont…
4.Day 2 –7: Preterm babies with birth weight 1000-
1500 grams
• As the skin matures in a preterm baby, the IWL
progressively decreases and becomes similar to
aterm baby by the end of the first week.
• Plastic barriers, caps and socks are used throughout
the first week in order to reduce IWL from the
immature skin.

30. …cont…
• Fluids need to be increased at 10-15 ml/kg/day
until a maximum of 150 ml/kg/day.
• Sodium and potassium should be added after 48
hours and glucose infusion should be maintained at
4-6 mg/kg/min
5.>Day 7: Term babies and babies with birth weight
>1500 grams Fluids should be given at 150-160
ml/kg/day

31. …cont…
6.Day 7: Preterm babies with birth weight 1000-1500
grams Fluids should be given at 150-160 ml/kg/day
• and sodium supplementation at 3-5 mEq/kg should
continue till 32-34 weeks corrected gestational age

32. Monitoring of fluid and electrolyte status
1.Body weight
2.Clinical examination-for any sign of dehydration.
• Infants with 10% (100 ml/kg) dehydration may
have sunken eyes and fontanel, cold and clammy
skin, poor skin turgor and oliguria
• Infants with 15% (150ml/kg) or more dehydration
would have signs of shock (hypotension,
tachycardia and weak pulses)

33. …cont…
3.Serum biochemistry:
4.Urine output, specific gravity (SG) and osmolarity:
5.Serum blood urea nitrogen (BUN), creatinine

34. starting electrolytes in fluid therapy
• Sodium and potassium should be started in the IV
fluids after 48 hours, each in a dose of 2-3
meq/kg/day.
• Calcium may be used in a dose of 4 ml/kg/day (40
mg/kg/day) of calcium gluconate for the first 3 days
in certain high-risk situations

35. Referance
1. Nelson Textbook of Pediatrics (19th Edition)
2. Fluid and electrolyte management in term
and preterm neonates(AIIMS- NICU protocols
2008)
3.Internat