Difference between revisions of "Neonatal hypoglycemia"

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''This page is for <u>neonatal</u> hypoglycemia. See [[hypoglycemia]] for adult patients or [[non-neonatal hypoglycemia (peds)]].''
 
==Background==
 
==Background==
3 births per 1000 w/ hypoglycemia
+
*3 births per 1000 with hypoglycemia
  
 
===Risks===
 
===Risks===
#DM mothers (hyperinsulin)
+
*Maternal [[DM]] (hyperinsulin)
#Premies (can't store glycogen)
+
*Premies (cannot store glycogen)
#Sick kids (depleted glycogen)
+
*Sick kids (depleted glycogen)
#Growth restricted babies (depleted glycogen)
+
*Growth restricted babies (depleted glycogen)
#Macrosomic kids
+
*Macrosomic kids
  
==Diagnosis==
+
==Clinical Features==
blood glucose <40 mg/dL (preterm infants repeated levels below <50)
+
*Jitteriness and irritability
 +
*[[shortness of breath (peds)|Apnea and cyanosis]]
 +
*Hypotonia
 +
*[[Seizure (peds)|Convulsions]]
  
===Signs & Sx===
+
==Differential Diagnosis==
#Jitteriness and irritability
+
===Neonatal hypoglycemia===
#Apnea and cyanosis
+
*Decreased substrate availability
#Hypotonia
+
**Intra-uterine growth retardation
#Convulsions
+
**Glycogen storage disease
 +
**[[Inborn errors of metabolism]] (e.g., fructose intolerance)
 +
**Prematurity
 +
**Prolonged fasting without IV glucose
 +
*Hyperinsulinemia:
 +
**Infant of [[DM|diabetic mother]]
 +
**Islet cell hyperplasia
 +
**Erythroblastosis fetalis
 +
**[[Exchange transfusion]]
 +
**Beckwith-Wiedemann Syndrome
 +
**Maternal beta-mimetic [[tocolysis|tocolytic agents]]
 +
**?High? umbilical arterial catheter
 +
**Abrupt cessation of IV [[dextrose|glucose]]
 +
*Other endocrine abnormalities:
 +
**Pan-hypopituitarism
 +
**[[Hypothyroidism]]
 +
**[[Adrenal insufficiency]]
 +
*Increased glucose utilization:
 +
**Cold stress/[[hypothermia]]
 +
**Increased [[shortness of breath (peds)|work of breathing]]
 +
**[[Sepsis]]
 +
**Perinatal asphyxia
 +
*Miscellaneous conditions:
 +
**[[Polycythemia]]
 +
**[[Congenital heart disease]]
 +
**CNS abnormalities
 +
 +
===Persistent neonatal hypoglycemia===
 +
*Too much insulin:
 +
**Idiopathic, asphyxia, rhesus diagnoses, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
 +
*Not enough anti-insulin:
 +
**Hypopituitarism, [[CAH|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''
  
There is a normal fall in glucose @ 2-4hr
+
*If no obvious precipitant, consider workup for [[inborn errors of metabolism]]
  
==DDX==
+
==Management==
# Decreased substrate availability
+
{{Pediatric hypoglycemia chart}}
## Intra-uterine growth retardation
 
## Glycogen storage disease
 
## Inborn errors (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
 
 
===Ddx Persistent===
 
#Too much insulin:
 
##idiopathic, asphyxia, rhesus dx, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
 
#Not enough anti-insulin:
 
##hypopit, adrenal hyperplasia
 
#Inborn errors of metabolism:
 
##glycogen storage dz, fatty oxidation errors
 
  
==Treatment==
+
===General Treatment===
# Glucometer reading 20-40 mg/dL, infant is term and is able to feed:
+
*Glucometer reading 20-40mg/dL, infant is term and is able to feed:
##Draw blood for stat blood glucose.
+
**Draw blood for stat blood glucose.
##Feed 5 mL/kg of D5W.
+
**Feed 5 mL/kg of D5W.
##Repeat blood glucose or Glucometer 20 min after feeding.
+
**Repeat blood glucose or Glucometer 20 min after feeding.
# Glucometer reading:
+
*Glucometer reading:
## <20 mg/dL or
+
**<20mg/dL or
## <40 mg/dL and NPO or preterm or
+
**<40mg/dL and NPO or preterm or
## <40 mg/dL after feeding or
+
**<40mg/dL after feeding or
## <40 mg/dL and symptomatic
+
**<40mg/dL and symptomatic
###Draw blood for stat glucose measurement.
+
***Draw blood for stat glucose measurement.
###Give IV bolus of 2-3 mL/kg of D10W.
+
***Give IV bolus of 2-3 mL/kg of D10W.
###Begin continuous infusion of D10W at 4-6 mg/kg/min.
+
***Begin continuous infusion of D10W at 4-6mg/kg/min.
###If infant of diabetic mother, begin D10W at 8-10 mg/kg/min (100-125 cc/kg/d).
+
***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 >40 mg/dL.
+
***Repeat blood glucose in 20 min and pursue treatment until blood sugar >40mg/dL.
# For persistent hypoglycemia despite above measures:
+
*For persistent hypoglycemia despite above measures:
##Increase rate of glucose infusion stepwise in 2 mg/kg/min* increments up to 12-15 mg/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.
+
**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.
+
**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.
+
**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.
+
*If hypoglycemia is not controlled with above measures:  
# 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 �60 mg/dL.
+
**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.
  
 
===Calculate rate of glucose administration===
 
===Calculate rate of glucose administration===
 
Use either of the following formulas:
 
Use either of the following formulas:
#(% glucose x mL/kg/d)/144 = glucose infusion rate (mg/kg/min)
+
*(% 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)
+
*(% glucose x mL/h)/(6 x body weight in kg) = glucose infusion rate (mg/kg/min)
  
===Mgmt===
+
===Persistent Hypoglycemia===
*31-44: PO feed, check in 1 & 2 hr
+
*Check insulin, c-peptide, GH, cortisol, beta hydroxybutyrate, UA
*31-44 x 2: D10W 2cc/kg bolus
+
*Increase volume by 30cc/kg/d
*> 45 PO feed @ 1st and 3rd hr
+
*Increase glucose to 12.5%
  
===Persistent Hypoglycemia===
+
If continues for >3 d: consult endocrinology, or sooner
#Check insulin, GH, cortisol
+
 
#Increase volume by 30cc/kg/d
+
==Disposition==
#Increase glucose to 12.5%
+
*Admit
#Glucagon infusion
+
**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.
  
If continues for >7 d: send insulin, cortisol, growth hormone
+
==See Also==
 +
*[[Diabetes Mellitus (Main)]]
 +
*[[Hypoglycemia (Peds)]]
  
==Source==
+
==References==
Adapted from Pani
+
<References/>
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
[[Category:Endo]]
+
[[Category:Endocrinology]]
 +
[[Category:FEN]]

Latest revision as of 18:37, 6 October 2019

This page is for neonatal hypoglycemia. See hypoglycemia for adult patients or non-neonatal hypoglycemia (peds).

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

Differential Diagnosis

Neonatal hypoglycemia

Persistent neonatal hypoglycemia

  • Too much insulin:
    • Idiopathic, asphyxia, rhesus diagnoses, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
  • Not enough anti-insulin:
  • 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
  • Consider diluting the D25 or D50 bolus, with NS 1-to-1, as those concentrations may be sclerosing to veins
  • Recheck 5 minutes after dose and repeat dose if low.
  • Consider glucagon IM/SQ if IV access is not readily available

General Treatment

  • 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.

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, c-peptide, GH, cortisol, beta hydroxybutyrate, UA
  • Increase volume by 30cc/kg/d
  • Increase glucose to 12.5%

If continues for >3 d: consult endocrinology, or sooner

Disposition

  • Admit
    • 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.

See Also

References