Neonatal Hypoglycemia NICU Night Team Curriculum 1.
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Transcript of Neonatal Hypoglycemia NICU Night Team Curriculum 1.
Neonatal Hypoglycemia
NICU Night Team CurriculumNICU Night Team Curriculum
1
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. Mom’s 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 cyanosisHEENT: 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 glucose 34 mg%
What is your What is your primary concern in primary concern in
this patient?this patient?
Neonatal HypoglycemiaNeonatal Hypoglycemia
Impaired glucose metabolism
Serum blood glucose < 40 mg/dLOR
Point of Care testing (accucheck, Dexi) <45
Why was a Dexi checked in Why was a Dexi checked in this patient?this patient?
She is at risk for developing hypoglycemia
Definition: A plasma glucose of less than 40 Definition: A plasma glucose of less than 40 mg/dlmg/dl
Plasma glucose is higher than whole blood Plasma glucose is higher than whole blood glucose by 15%glucose by 15%
Hypoglycemia
Fetal Glucose MetabolismFetal Glucose Metabolism
• Fetus does not produce glucoseFetus does not produce glucose• Maternal glucose is the only source of Maternal glucose is the only source of
fetal glucosefetal glucose• Baseline fetal blood glucose is 60-70% Baseline fetal blood glucose is 60-70%
of maternal serum glucoseof maternal serum glucose
Physiology
Glucose metabolism after birthGlucose metabolism after birth
Cessation of maternal glucose supply
Blood glucose Nadir( ~1-2 hrs after birth)
Physiology
Glucose Metabolism After BirthGlucose 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 neonatal Etiology of neonatal hypoglycemiahypoglycemia
1.1. Increased utilization Increased utilization (e.g.: (e.g.: hyperinsulinism)hyperinsulinism)
2.2. Decreased production/storesDecreased production/stores
3.3. Increased utilization and/or Increased utilization and/or decreased productiondecreased production
Increased UtilizationIncreased Utilization
• Diabetic motherDiabetic mother• Large for gestational age (LGA) infantLarge for gestational age (LGA) infant• ErythroblastosisErythroblastosis• Islet cells hyperplasiaIslet cells hyperplasia• Beckwith-Wiedemann syndromeBeckwith-Wiedemann syndrome• Insulin producing tumorsInsulin producing tumors• Maternal tocolytic therapy with B-Maternal tocolytic therapy with B-
sympathomimetric agentssympathomimetric agents• Malposition of umbilical artery catheterMalposition of umbilical artery catheter
Decreased Decreased Production/StoresProduction/Stores
• PrematurityPrematurity• Intrauterine growth retardation(IUGR)Intrauterine growth retardation(IUGR)• Inadequate caloric intakeInadequate caloric intake• Delayed onset of feedingDelayed onset of feeding
Increased utilization AND Increased utilization AND Decreased productionDecreased production
• Perinatal stress eg. shock, sepsis, asphyxiaPerinatal stress eg. shock, sepsis, asphyxia• Enchange transfusionEnchange transfusion• Defect in carbohydrate metabolism eg. glycogen Defect in carbohydrate metabolism eg. glycogen
storage diseasestorage disease• Endocrne deficiency eg. adrenal insufficiency, Endocrne deficiency eg. adrenal insufficiency,
hypopituitarismhypopituitarism• Defect in amino acid metabolismDefect in amino acid metabolism• PolycythemiaPolycythemia• Maternal therapy with B-blockerMaternal therapy with B-blocker
When do you screen? When do you screen?
1.1. Symptoms that could be due to Symptoms that could be due to hypoglycemia.hypoglycemia.
2.2. At risk infants.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 Who is at risk?at risk?
• Infants of diabetic mothersInfants of diabetic mothers• Maternal use of B-adrenergic agonist/ antagonistMaternal use of B-adrenergic agonist/ antagonist• IUGRIUGR• LGALGA• PretermPreterm• PolycythemiaPolycythemia• AsphyxiaAsphyxia• Sick infantSick infant
When is the ideal time to screen high risk infants?
ScreeningScreening
Blood glucose or point of care testing Blood glucose or point of care testing (POC) should be done in high risk (POC) should be done in high risk
infants within the first 1 to 2 hours infants within the first 1 to 2 hours after birthafter birth
Back to our case:
1. Term LGA infant2. IDM with poor blood glucose control3. Tachypnea 4. Hypoglycemia
Why do you think she developed hypoglycemia?
Hyperinsulinism
Pathophysiology : infants of diabetic mothers
•Feeding?• IV therapy?•Medication?
How do you treat this patient?
Management – Oral Management – Oral FeedsFeeds
• Can be used in asymptomatic infantsCan be used in asymptomatic infants• Only formula (never administer glucose water!!)Only formula (never administer glucose water!!)• Follow up blood glucose within 1 hour of feeding.Follow up blood glucose within 1 hour of feeding.• If the glucose level doesn’t rise, a more If the glucose level doesn’t rise, a more
aggressive therapy may be needed.aggressive therapy may be needed.
Management – IV Management – IV therapytherapy
Indications:Indications:• Inability to tolerate oral feedingInability to tolerate oral feeding• Symptomatic infantSymptomatic infant• Lack of response with oral feedsLack of response with oral feeds• Glucose < 25 mg/dL, regardless of patient’s Glucose < 25 mg/dL, regardless of patient’s
symptomssymptoms
Management – IV Management – IV therapytherapy
Urgent treatmentUrgent treatment• Bolus 2 ml/kg of D10WBolus 2 ml/kg of D10W• Do not use 25% or 50% glucose !!Do not use 25% or 50% glucose !!• Follow bolus with continuous dextrose fluidFollow bolus with continuous dextrose fluid
Continuing IV fluid Continuing IV fluid • Start infusion of glucose at a rate of 6-8 Start infusion of glucose at a rate of 6-8
mg/kg/minmg/kg/min• Glucose infusion rate formula (GIR):Glucose infusion rate formula (GIR):
GIR = %IV fluid x rate(ml/hr)GIR = %IV fluid x rate(ml/hr)
6 x BW(kg)6 x BW(kg)
Management – IV Management – IV therapytherapy
Management – IV Management – IV therapytherapy
• Re-check serum glucose 20-30 min after bolus Re-check serum glucose 20-30 min after bolus and hourly until stableand hourly until stable– If glucose is normal and stable, feeding may be If glucose is normal and stable, feeding may be
continued and glucose infusion taperedcontinued and glucose infusion tapered– If glucose can’t be maintained > 50 mg/dL, increase GIR If glucose can’t be maintained > 50 mg/dL, increase GIR
by 1-2 mg/kg/hrby 1-2 mg/kg/hr– If glucose can’t be maintained > 50 mg/dL, with a GIR If glucose can’t be maintained > 50 mg/dL, with a GIR
12 mg/kg/min, medication should be added.12 mg/kg/min, medication should be added.
Management – Management – MedicationMedication
Persistent hypoglycemia despite a GIR > 12 Persistent hypoglycemia despite a GIR > 12 mg/kg/min.mg/kg/min.
• Work up – Critical Labs:Work up – Critical Labs:– Serum cortisol, insulin, growth hormone when glucose is Serum cortisol, insulin, growth hormone when glucose is
low and prior to treatmentlow and prior to treatment– DO NOT wait >5 minutes for labs prior to treating DO NOT wait >5 minutes for labs prior to treating
hypoglycemiahypoglycemia
• MedicationMedication– Hydrocortisone Hydrocortisone – GlucagonGlucagon– Diazoxide Diazoxide
HydrocortisoneHydrocortisone
• Dose: 10 mg/kg/day IV q 12 hrsDose: 10 mg/kg/day IV q 12 hrs• Indication: Hypoglycemia despite GIR > 12 Indication: Hypoglycemia despite GIR > 12
mg/kg/minmg/kg/min• Send hormone level before starting Send hormone level before starting
hydrocortisone!!!hydrocortisone!!!
GlucagonGlucagon
• Dose: 0.025-0.3 mg/kg IM/IV Dose: 0.025-0.3 mg/kg IM/IV (maximum 1 mg)(maximum 1 mg)
• Should cause recovery of hypoglycemiaShould cause recovery of hypoglycemia• May not work ifMay not work if
– Reduced glycogen storesReduced glycogen stores– Glycogen storage diseaseGlycogen storage disease
DiazoxideDiazoxide
• Dose: 2-5 mg/kg/dose PO q 8 hrs.Dose: 2-5 mg/kg/dose PO q 8 hrs.• Indication: Infants who have persistent Indication: Infants who have persistent
hyperinsulinemia (e.g.. hyperinsulinemia (e.g.. Nesidioblastosis)Nesidioblastosis)
Remember, he was tachypneic
Urgent 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%). 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
ReferenceReference• Wilker RE. Hypoglycemia and hyperglycemia. In: Cloherty JP, Eichenwald EC, Stark AR, eds. Manual Wilker RE. Hypoglycemia and hyperglycemia. In: Cloherty JP, Eichenwald EC, Stark AR, eds. Manual
of Neonatal care. 5of Neonatal care. 5thth ed. Lippincott Williams & Wilkins; Philadelphia; 2008: 540-549 ed. Lippincott Williams & Wilkins; Philadelphia; 2008: 540-549• Cornblath M, Ichord R. Hypoglycemia in the neonate. Semin Perinatol 2000;24:136-149Cornblath 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 Sperling MA, Menon RK. Differential diagnosis and management of neonatal hypoglycemia. Pediatr
Clin North Am 2004;51:703-723Clin North Am 2004;51:703-723