Neonatal hypoglycemia: Difference between revisions
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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 | *3 births per 1000 with hypoglycemia | ||
===Risks=== | ===Risks=== | ||
*DM | *Maternal [[DM]] (hyperinsulin) | ||
*Premies ( | *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 | ||
== | ==Clinical Features== | ||
*Jitteriness and irritability | *Jitteriness and irritability | ||
*Apnea and cyanosis | *[[shortness of breath (peds)|Apnea and cyanosis]] | ||
*Hypotonia | *Hypotonia | ||
*Convulsions | *[[Seizure (peds)|Convulsions]] | ||
==Differential | ==Differential Diagnosis== | ||
* Decreased substrate availability | ===Neonatal hypoglycemia=== | ||
** Intra-uterine growth retardation | *Decreased substrate availability | ||
** Glycogen storage disease | **Intra-uterine growth retardation | ||
** Inborn errors (e.g., fructose intolerance) | **Glycogen storage disease | ||
** Prematurity | **[[Inborn errors of metabolism]] (e.g., fructose intolerance) | ||
** Prolonged fasting without IV glucose | **Prematurity | ||
* Hyperinsulinemia: | **Prolonged fasting without IV glucose | ||
** Infant of diabetic mother | *Hyperinsulinemia: | ||
** Islet cell hyperplasia | **Infant of [[DM|diabetic mother]] | ||
** Erythroblastosis fetalis | **Islet cell hyperplasia | ||
** Exchange transfusion | **Erythroblastosis fetalis | ||
** Beckwith-Wiedemann Syndrome | **[[Exchange transfusion]] | ||
** Maternal | **Beckwith-Wiedemann Syndrome | ||
** ?High? umbilical arterial catheter | **Maternal beta-mimetic [[tocolysis|tocolytic agents]] | ||
** Abrupt cessation of IV glucose | **?High? umbilical arterial catheter | ||
* Other endocrine abnormalities: | **Abrupt cessation of IV [[dextrose|glucose]] | ||
** Pan-hypopituitarism | *Other endocrine abnormalities: | ||
** Hypothyroidism | **Pan-hypopituitarism | ||
** Adrenal insufficiency | **[[Hypothyroidism]] | ||
* Increased glucose utilization: | **[[Adrenal insufficiency]] | ||
** Cold stress | *Increased glucose utilization: | ||
** Increased work of breathing | **Cold stress/[[hypothermia]] | ||
** Sepsis | **Increased [[shortness of breath (peds)|work of breathing]] | ||
** Perinatal asphyxia | **[[Sepsis]] | ||
* Miscellaneous conditions: | **Perinatal asphyxia | ||
** Polycythemia | *Miscellaneous conditions: | ||
** Congenital heart disease | **[[Polycythemia]] | ||
** CNS abnormalities | **[[Congenital heart disease]] | ||
**CNS abnormalities | |||
===Persistent=== | ===Persistent neonatal hypoglycemia=== | ||
*Too much insulin: | *Too much insulin: | ||
** | **Idiopathic, asphyxia, rhesus diagnoses, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism) | ||
*Not enough anti-insulin: | *Not enough anti-insulin: | ||
** | **Hypopituitarism, [[CAH|adrenal hyperplasia]] | ||
*Inborn errors of metabolism | *[[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'' | |||
*If no obvious precipitant, consider workup for [[inborn errors of metabolism]] | |||
==Management== | |||
{{Pediatric hypoglycemia chart}} | |||
==Treatment== | ===General Treatment=== | ||
* Glucometer reading 20- | *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: | ||
** < | **<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. | ***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- | ***Begin continuous infusion of D10W at 4-6mg/kg/min. | ||
***If infant of diabetic mother, begin D10W at 8- | ***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 > | ***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 | **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 | *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=== | ===Calculate rate of glucose administration=== | ||
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*(% 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) | ||
===Persistent Hypoglycemia=== | ===Persistent Hypoglycemia=== | ||
*Check insulin, GH, cortisol | *Check insulin, c-peptide, GH, cortisol, beta hydroxybutyrate, UA | ||
*Increase volume by 30cc/kg/d | *Increase volume by 30cc/kg/d | ||
*Increase glucose to 12.5% | *Increase glucose to 12.5% | ||
If continues for > | 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== | ==See Also== | ||
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*[[Hypoglycemia (Peds)]] | *[[Hypoglycemia (Peds)]] | ||
== | ==References== | ||
<References/> | |||
[[Category: | [[Category:Pediatrics]] | ||
[[Category: | [[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
- Jitteriness and irritability
- Apnea and cyanosis
- Hypotonia
- Convulsions
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 diabetic mother
- Islet cell hyperplasia
- Erythroblastosis fetalis
- Exchange transfusion
- Beckwith-Wiedemann Syndrome
- Maternal beta-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/hypothermia
- Increased 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, 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
- If no obvious precipitant, consider workup for inborn errors of metabolism
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:
|
Adult | >8yrs | <70 | D50W | 50mL (1 amp) OR 1 mL/kg |
- Consider diluting the D25W or D50W 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.