Neonatal Hypoglycemia

NICU Night Team Curriculum

Objectives
Define neonatal hypoglycemia
Know the causes of neonatal
hypoglycemia
Know 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 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 cyanosis

HEENT: AF 2x2 cm, no cleft lip and palate
Heart: RR, no murmur
Lungs: 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 glucose 34 mg%

What is your
primary concern in
this patient?

Neonatal Hypoglycemia
Impaired glucose
metabolism

Serum blood glucose < 40 mg/dL

OR
Point of Care testing (accucheck, Dexi) <45

Why was a Dexi checked in this

patient?

She is at risk for developing

hypoglycemia

Hypoglycemia
Definition: A plasma glucose of less than 40
mg/dl
Plasma glucose is higher than whole blood
glucose by 15%

Physiology
Fetal Glucose Metabolism
Fetus does not produce glucose
Maternal glucose is the only source of
fetal glucose
Baseline fetal blood glucose is 60-70%
of maternal serum glucose

Physiology
Glucose metabolism after birth
Cessation of maternal
glucose supply

Blood glucose Nadir

( ~1-2 hrs after birth)

Glucose Metabolism After Birth

Cessation of maternal
glucose supply
Surge in glucagon, catecholamine
Decrease insulin
Gluconeogenesis:
Hepatic glycogen, amino acid, fatty acid metabolism

Normal blood glucose

Etiology of neonatal
hypoglycemia
1. Increased utilization (e.g.:
hyperinsulinism)

2. Decreased production/stores
3. Increased utilization and/or
decreased production

Increased Utilization

Diabetic mother
Large for gestational age (LGA) infant
Erythroblastosis
Islet cells hyperplasia
Beckwith-Wiedemann syndrome
Insulin producing tumors
Maternal tocolytic therapy with Bsympathomimetric agents
Malposition of umbilical artery catheter

Decreased
Production/Stores

Prematurity
Intrauterine growth retardation(IUGR)
Inadequate caloric intake
Delayed onset of feeding

Increased utilization AND

Decreased production

Perinatal stress eg. shock, sepsis, asphyxia

Enchange transfusion
Defect in carbohydrate metabolism eg. glycogen
storage disease
Endocrne deficiency eg. adrenal insufficiency,
hypopituitarism
Defect in amino acid metabolism
Polycythemia
Maternal therapy with B-blocker

When do you screen?

1. Symptoms that could be due to
hypoglycemia.
2. At risk infants.

What are signs and

symptoms of
hypoglycemia?

Signs and Symptoms of

Hypoglycemia
Symptoms are NON-SPECIFIC

Jitteriness
Apnea
Irritability
Grunting
Lethargy
Seizures

Who is at risk?

Infants of diabetic mothers

Maternal use of B-adrenergic agonist/ antagonist
IUGR
LGA
Preterm
Polycythemia
Asphyxia
Sick infant

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:

1.
2.
3.
4.

Term LGA infant

IDM with poor blood glucose control
Tachypnea
Hypoglycemia

Why do you think she

developed hypoglycemia?
Hyperinsulinism

Pathophysiology : infants of diabetic mothers

How do you treat this

patient?
Feeding?
IV therapy?
Medication?

Management Oral
Feeds

Can be used in asymptomatic infants

Only formula (never administer glucose water!!)
Follow up blood glucose within 1 hour of feeding.
If the glucose level doesnt rise, a more
aggressive therapy may be needed.

Management IV
therapy

Indications:
Inability to tolerate oral feeding
Symptomatic infant
Lack of response with oral feeds
Glucose < 25 mg/dL, regardless of patients
symptoms

Management IV
therapy
Urgent treatment
Bolus 2 ml/kg of D10W
Do not use 25% or 50% glucose !!
Follow bolus with continuous dextrose fluid

Management IV
therapy
Continuing IV fluid
Start infusion of glucose at a rate of 6-8
mg/kg/min
Glucose infusion rate formula (GIR):

GIR

%IV fluid x rate(ml/hr)

6 x BW(kg)

Management IV
therapy
Re-check serum glucose 20-30 min after bolus
and hourly until stable
If glucose is normal and stable, feeding may be
continued and glucose infusion tapered
If glucose cant be maintained > 50 mg/dL, increase GIR
by 1-2 mg/kg/hr
If glucose cant be maintained > 50 mg/dL, with a GIR
12 mg/kg/min, medication should be added.

Management
Medication
Persistent hypoglycemia despite a GIR > 12
mg/kg/min.
Work up Critical Labs:
Serum cortisol, insulin, growth hormone when glucose is
low and prior to treatment
DO NOT wait >5 minutes for labs prior to treating
hypoglycemia

Medication

Hydrocortisone
Glucagon
Diazoxide

Hydrocortisone
Dose: 10 mg/kg/day IV q 12 hrs
Indication: Hypoglycemia despite GIR > 12
mg/kg/min
Send hormone level before starting
hydrocortisone!!!

Glucagon
Dose: 0.025-0.3 mg/kg IM/IV
(maximum 1 mg)
Should cause recovery of hypoglycemia
May not work if
Reduced glycogen stores
Glycogen storage disease

Diazoxide
Dose: 2-5 mg/kg/dose PO q 8 hrs.
Indication: Infants who have persistent
hyperinsulinemia (e.g.. Nesidioblastosis)

Back to our case:

How would you treat our patient?
Remember, he was tachypneic
Urgent treatment:D10W 2 mL/kg IV bolus followed
by continuous IV fluid

Board Question
A term infant was born to a pre-ecclamptic mother. BW was
2,000 g (<10th%). Physical exam was normal.
Blood glucose at 2 hour of age was 30 mg/dL
What 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 (<10th%). Physical exam was normal.
Blood glucose at 2 hour of age was 30 mg/dL
What 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 & Wilkins; Philadelphia; 2008: 540-549
Cornblath M, Ichord R. Hypoglycemia in the neonate. Semin Perinatol 2000;24:136-149
Sperling MA, Menon RK. Differential diagnosis and management of neonatal hypoglycemia. Pediatr
Clin North Am 2004;51:703-723