Neonatal hypoglycemia

Background

• 3 births per 1000 with hypoglycemia

Risks

• Maternal DM (hyperinsulin)
• Premies (cannot store glycogen)
• Sick kids (depleted glycogen)
• Growth restricted babies (depleted glycogen)
• Macrosomic kids

Clinical Features

• Jitteriness and irritability
• Apnea and cyanosis
• Hypotonia
• Convulsions

Differential DIagnosis

• Decreased substrate availability
  • Intra-uterine growth retardation
  • Glycogen storage disease
  • Inborn errors of metabolism (e.g., fructose intolerance)
  • Prematurity
  • Prolonged fasting without IV glucose
• Hyperinsulinemia:
  • Infant of diabetic mother
  • Islet cell hyperplasia
  • Erythroblastosis fetalis
  • Exchange transfusion
  • Beckwith-Wiedemann Syndrome
  • Maternal �-mimetic tocolytic agents
  • ?High? umbilical arterial catheter
  • Abrupt cessation of IV glucose
• Other endocrine abnormalities:
  • Pan-hypopituitarism
  • Hypothyroidism
  • Adrenal insufficiency
• Increased glucose utilization:
  • Cold stress
  • Increased work of breathing
  • Sepsis
  • Perinatal asphyxia
• Miscellaneous conditions:
  • Polycythemia
  • Congenital heart disease
  • CNS abnormalities

Persistent

• Too much insulin:
  • idiopathic, asphyxia, rhesus diagnoses, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
• Not enough anti-insulin:
  • hypopituitarism, adrenal hyperplasia
• Inborn errors of metabolism
  • glycogen storage disease, fatty oxidation errors

Evaluation

• Blood glucose level
  • blood glucose <40mg/dL (preterm infants repeated levels below <50)

There is a normal fall in glucose @ 2-4hr of life

Management

Pediatric Hypoglycemia Dextrose Chart

Category	Age	Glucose	Treatment	Initial IV Bolus	Maintenance Dose
Neonatal	<2mo	<40	D10W	2.5-5 mL/kg	6 mL/kg/h
Pediatric	2mo-8yrs	<60	D25W	2 mL/kg	D10W: 6 mL/kg/h for first 10 kg + 3 mL/kg/h for 11–20 kg + 1.5 mL/kg/h for each additional kg >20 kg
Adult	>8yrs	<70	D50W	50mL (1 amp) OR 1 mL/kg

Recheck 5 minutes after dose and repeat dose if low.

Consider glucagon IM/SQ if IV access is not readily available

• Glucometer reading 20-40mg/dL, infant is term and is able to feed:
  • Draw blood for stat blood glucose.
  • Feed 5 mL/kg of D5W.
  • Repeat blood glucose or Glucometer 20 min after feeding.
• Glucometer reading:
  • <20mg/dL or
  • <40mg/dL and NPO or preterm or
  • <40mg/dL after feeding or
  • <40mg/dL and symptomatic
    • Draw blood for stat glucose measurement.
    • Give IV bolus of 2-3 mL/kg of D10W.
    • Begin continuous infusion of D10W at 4-6mg/kg/min.
    • If infant of diabetic mother, begin D10W at 8-10mg/kg/min (100-125 cc/kg/d).
    • Repeat blood glucose in 20 min and pursue treatment until blood sugar >40mg/dL.
• For persistent hypoglycemia despite above measures:
  • Increase rate of glucose infusion stepwise in 2mg/kg/min*increments up to 12-15mg/kg/min glucose. Use increased volume with caution in infants where volume overload is a concern. Maximal concentration of glucose in peripheral IV is D12.5.
  • If infant requires IV dextrose concentrations >12.5%, insert central venous catheter.
  • Do not use D25W or D50W IV or large IV volume boluses as this creates rebound hypoglycemia in infants who are hyperinsulinemic. In addition, administration of D25W or D50W can cause dangerous increase in plasma osmolarity.
• If hypoglycemia is not controlled with above measures: Obtain Endocrine Consult to guide further diagnostic evaluation and management. While awaiting consult, send blood (while blood sugar is low) for glucose, plasma cortisol, growth hormone and insulin concentrations. Further management may include glucocorticoids, diazoxide, somatostatin or pancreatectomy.
• Weaning IV dextrose infusion: When blood glucose has been stable for 12-24 h, begin decreasing IV infusion by 1-2 mL/hr q3-4 hours if blood glucose remains �60mg/dL.

Calculate rate of glucose administration

Use either of the following formulas:

• (% glucose x mL/kg/d)/144 = glucose infusion rate (mg/kg/min)
• (% glucose x mL/h)/(6 x body weight in kg) = glucose infusion rate (mg/kg/min)

Persistent Hypoglycemia

• Check insulin, GH, cortisol
• Increase volume by 30cc/kg/d
• Increase glucose to 12.5%
• Glucagon infusion

If continues for >7 d: send insulin, cortisol, growth hormone

See Also

• Diabetes Mellitus (Main)
• Hypoglycemia (Peds)

References

Authors

Ross Donaldson, Daniel Ostermayer, Claire, Neil Young, Michael Holtz