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 with hypoglycemia
  
 +
===Risks===
 +
*Maternal [[DM]] (hyperinsulin)
 +
*Premies (cannot store glycogen)
 +
*Sick kids (depleted glycogen)
 +
*Growth restricted babies (depleted glycogen)
 +
*Macrosomic kids
  
3 births per 1000 w/ hypoglycemia
+
==Clinical Features==
 
+
*Jitteriness and irritability
Risks:
+
*[[shortness of breath (peds)|Apnea and cyanosis]]
 
+
*Hypotonia
DM mothers (hyperinsulin)
+
*[[Seizure (peds)|Convulsions]]
 
 
Premies (can't store glycogen)
 
 
 
Sick kids (depleted glycogen)
 
 
 
Growth restricted babies (depleted glycogen)
 
 
 
Macrosomic kids
 
 
 
 
 
 
==Diagnosis==
 
 
 
 
 
blood glucose <40 mg/dL (preterm infants repeated levels below <50)
 
 
 
 
 
 
Signs & sx:
 
 
 
Jitteriness and irritability
 
 
 
Apnea and cyanosis
 
 
 
Hypotonia
 
 
 
Convulsions
 
 
 
 
 
 
 
 
 
There is nl. fall in glucose @ 2-4hr
 
 
 
 
 
 
==DDX==
 
 
 
 
 
1. Decreased substrate availability:
 
 
 
* Intra-uterine growth retardation
 
* Glycogen storage disease
 
* Inborn errors (e.g., fructose intolerance)
 
* Prematurity
 
* Prolonged fasting without IV glucose
 
2. 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
 
3. Other endocrine abnormalities:
 
 
 
* Pan-hypopituitarism
 
* Hypothyroidism
 
* Adrenal insufficiency
 
4. Increased glucose utilization:
 
 
 
* Cold stress
 
* Increased work of breathing
 
* Sepsis
 
* Perinatal asphyxia
 
5. 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==
 
 
 
 
 
1) Glucometer reading 20-40 mg/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.
 
 
 
 
 
 
2) Glucometer reading:
 
 
 
    (a) <20 mg/dL or
 
 
 
    (b) <40 mg/dL and NPO or preterm or
 
 
 
    (c) <40 mg/dL after feeding or
 
 
 
    (d) <40 mg/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 4-6 mg/kg/min.
 
 
 
-If infant of diabetic mother, begin D10W at 8-10 mg/kg/min (100-125 cc/kg/d).
 
 
 
-Repeat blood glucose in 20 min and pursue treatment until blood sugar >40 mg/dL.
 
  
 +
==Differential Diagnosis==
 +
===Neonatal hypoglycemia===
 +
*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 [[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
  
3) For persistent hypoglycemia despite above measures:
+
==Evaluation==
 
+
*Blood glucose level
-Increase rate of glucose infusion stepwise in 2 mg/kg/min* increments up to 12-15
+
**blood glucose <40mg/dL (preterm infants repeated levels below <50)
 
 
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.
+
''There is a normal fall in glucose @ 2-4hr of life''
  
-If infant requires IV dextrose concentrations >12.5%, insert central venous catheter.
+
*If no obvious precipitant, consider workup for [[inborn errors of metabolism]]
  
+
==Management==
 +
{{Pediatric hypoglycemia chart}}
  
*Do not use D25W or D50W IV or large IV volume boluses as this creates rebound
+
===General Treatment===
 
+
*Glucometer reading 20-40mg/dL, infant is term and is able to feed:
hypoglycemia in infants who are hyperinsulinemic. In addition, administration of D25W or
+
**Draw blood for stat blood glucose.
 
+
**Feed 5 mL/kg of D5W.
D50W can cause dangerous increase in plasma osmolarity.
+
**Repeat blood glucose or Glucometer 20 min after feeding.
 
+
*Glucometer reading:
+
**<20mg/dL or
 
+
**<40mg/dL and NPO or preterm or
4) If hypoglycemia is not controlled with above measures: Obtain Endocrine Consult to guide
+
**<40mg/dL after feeding or
 
+
**<40mg/dL and symptomatic
further diagnostic evaluation and management. While awaiting consult, send blood (while blood
+
***Draw blood for stat glucose measurement.
 
+
***Give IV bolus of 2-3 mL/kg of D10W.
sugar is low) for glucose, plasma cortisol, growth hormone and insulin concentrations. Further
+
***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).
management may include glucocorticoids, diazoxide, somatostatin or pancreatectomy.
+
***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.
5) Weaning IV dextrose infusion: When blood glucose has been stable for 12-24 h, begin
+
**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:  
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
* To calculate rate of glucose administration, use either of the following formulas:
+
**Further management may include [[glucocorticoids]], [[diazoxide]], somatostatin or pancreatectomy.
 
 
(% glucose x mL/kg/d)/144 = glucose infusion rate (mg/kg/min)
 
 
 
or
 
 
 
(% glucose x mL/h)/(6 x body weight in kg) = glucose infusion rate (mg/kg/min)
 
 
 
 
 
 
Mgmt:
 
 
 
31-44: PO feed, check in 1 & 2 hr
 
 
 
31-44 x 2: D10W 2cc/kg bolus
 
 
 
> 45 PO feed @ 1st and 3rd hr
 
 
 
 
 
 
Mgmt of 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
 
 
 
 
  
==Source==
+
===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%
  
Adapted from Pani
+
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==
 +
*[[Diabetes Mellitus (Main)]]
 +
*[[Hypoglycemia (Peds)]]
  
 +
==References==
 +
<References/>
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
 +
[[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