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1、Neonatal Hypoglycemia,NICU Night Team Curriculum,1,Objectives,Define neonatal hypoglycemia Know the causes of neonatal hypoglycemiaKnow signs and symptoms of hypoglycemia Understand treatment,Case,39 wk F born by NSVD to a 22 y/o G1P0 mom with diet controlled GDM A1.Moms blood sugars throughout the
2、pregnancy ranged from 120-160.Maternal serologies were negative,pregnancy otherwise unremarkable.APGARS were 8 and 9 at 1 and 5 minutes,respectively.BW was 4,000 g.,Physical Examination,VS:T 36.5 P 148 RR 80 BP 55/38 mmHg HC 34 cm(75%),Lt 50 cm(75%),BW 4,000(97%)GA:Well appearing F,NAD,no cyanosisHE
3、ENT:AF 2x2 cm,no cleft lip and palateHeart:RR,no murmurLungs:Tachypneic breathing with even breath sounds throughout,no retractions,no flaring Abdomen:Soft ND,no hepatosplenomegaly Genitalia:Normal female genitalia Extremities:No deformities,MAEE,Labs,1 hour of life:Hematocrit 56%Dexi 30 mg%Serum gl
4、ucose 34 mg%,What is your primary concern in this patient?,Neonatal Hypoglycemia,Impaired glucose metabolism,Serum blood glucose 40 mg/dLORPoint of Care testing(accucheck,Dexi)45,Why was a Dexi checked in this patient?,She is at risk for developing hypoglycemia,Definition:A plasma glucose of less th
5、an 40 mg/dlPlasma glucose is higher than whole blood glucose by 15%,Hypoglycemia,Fetal Glucose MetabolismFetus does not produce glucoseMaternal glucose is the only source of fetal glucoseBaseline fetal blood glucose is 60-70%of maternal serum glucose,Physiology,Glucose metabolism after birth,Cessati
6、on of maternal glucose supply,Blood glucose Nadir(1-2 hrs after birth),Physiology,Glucose Metabolism After Birth,Cessation of maternal glucose supply,Surge in glucagon,catecholamineDecrease insulin,Gluconeogenesis:Hepatic glycogen,amino acid,fatty acid metabolism,Normal blood glucose,Etiology of neo
7、natal hypoglycemia,Increased utilization(e.g.:hyperinsulinism)Decreased production/storesIncreased utilization and/or decreased production,Increased Utilization,Diabetic motherLarge for gestational age(LGA)infantErythroblastosisIslet cells hyperplasiaBeckwith-Wiedemann syndromeInsulin producing tumo
8、rsMaternal tocolytic therapy with B-sympathomimetric agentsMalposition of umbilical artery catheter,Decreased Production/Stores,PrematurityIntrauterine growth retardation(IUGR)Inadequate caloric intakeDelayed onset of feeding,Increased utilization AND Decreased production,Perinatal stress eg.shock,s
9、epsis,asphyxiaEnchange transfusionDefect in carbohydrate metabolism eg.glycogen storage diseaseEndocrne deficiency eg.adrenal insufficiency,hypopituitarismDefect in amino acid metabolismPolycythemiaMaternal therapy with B-blocker,When do you screen?,Symptoms that could be due to hypoglycemia.At risk
10、 infants.,What are signs and symptoms of hypoglycemia?,Signs and Symptoms of Hypoglycemia,Symptoms are NON-SPECIFICJitterinessApnea IrritabilityGruntingLethargySeizures,Who is at risk?,Infants of diabetic mothersMaternal use of B-adrenergic agonist/antagonistIUGRLGAPretermPolycythemiaAsphyxiaSick in
11、fant,When is the ideal time to screen high risk infants?,Screening,Blood glucose or point of care testing(POC)should be done in high risk infants within the first 1 to 2 hours after birth,Back to our case:,Term LGA infantIDM with poor blood glucose controlTachypnea Hypoglycemia,Why do you think she
12、developed hypoglycemia?Hyperinsulinism,Pathophysiology:infants of diabetic mothers,Feeding?IV therapy?Medication?,How do you treat this patient?,Management Oral Feeds,Can be used in asymptomatic infantsOnly formula(never administer glucose water!)Follow up blood glucose within 1 hour of feeding.If t
13、he glucose level doesnt rise,a more aggressive therapy may be needed.,Management IV therapy,Indications:Inability to tolerate oral feedingSymptomatic infantLack of response with oral feedsGlucose 25 mg/dL,regardless of patients symptoms,Management IV therapy,Urgent treatmentBolus 2 ml/kg of D10WDo n
14、ot use 25%or 50%glucose!Follow bolus with continuous dextrose fluid,Continuing IV fluid Start infusion of glucose at a rate of 6-8 mg/kg/minGlucose infusion rate formula(GIR):,GIR=%IV fluid x rate(ml/hr)6 x BW(kg),Management IV therapy,Management IV therapy,Re-check serum glucose 20-30 min after bol
15、us and hourly until stableIf glucose is normal and stable,feeding may be continued and glucose infusion taperedIf glucose cant be maintained 50 mg/dL,increase GIR by 1-2 mg/kg/hrIf glucose cant be maintained 50 mg/dL,with a GIR 12 mg/kg/min,medication should be added.,Management Medication,Persisten
16、t hypoglycemia despite a GIR 12 mg/kg/min.Work up Critical Labs:Serum cortisol,insulin,growth hormone when glucose is low and prior to treatmentDO NOT wait 5 minutes for labs prior to treating hypoglycemiaMedicationHydrocortisone GlucagonDiazoxide,Hydrocortisone,Dose:10 mg/kg/day IV q 12 hrsIndicati
17、on:Hypoglycemia despite GIR 12 mg/kg/minSend hormone level before starting hydrocortisone!,Glucagon,Dose:0.025-0.3 mg/kg IM/IV(maximum 1 mg)Should cause recovery of hypoglycemiaMay not work ifReduced glycogen storesGlycogen storage disease,Diazoxide,Dose:2-5 mg/kg/dose PO q 8 hrs.Indication:Infants
18、who have persistent hyperinsulinemia(e.g.Nesidioblastosis),Remember,he was tachypneicUrgent treatment:D10W 2 mL/kg IV bolus followed by continuous IV fluid,Back to our case:How would you treat our patient?,Board Question,A term infant was born to a pre-ecclamptic mother.BW was 2,000 g(10th%).Physica
19、l exam was normal.Blood glucose at 2 hour of age was 30 mg/dLWhat is your next step in management?a.D10W bolus of 4 mL b.D10W continuous IV infusion at 6.5 ml/hr c.20 mL of oral glucose water d.20 mL of infant formula,Board Question,A term infant was born to a pre-ecclamptic mother.BW was 2,000 g(10
20、th%).Physical exam was normal.Blood glucose at 2 hour of age was 30 mg/dLWhat is your next step management?a.D10W bolus of 4 mL b.D10W continuous IV infusion at 6.5 ml/hr c.20 mL of oral glucose water d.20 mL of infant formula,Reference,Wilker RE.Hypoglycemia and hyperglycemia.In:Cloherty JP,Eichenwald EC,Stark AR,eds.Manual of Neonatal care.5th ed.Lippincott Williams 51:703-723,
