Difference between revisions of "Neonatal hypoglycemia"

(Source)
Line 3: Line 3:
  
 
===Risks===
 
===Risks===
#DM mothers (hyperinsulin)
+
*DM mothers (hyperinsulin)
#Premies (can't store glycogen)
+
*Premies (can't 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==
 
==Diagnosis==
Line 13: Line 13:
  
 
===Signs & Sx===
 
===Signs & Sx===
#Jitteriness and irritability
+
*Jitteriness and irritability
#Apnea and cyanosis
+
*Apnea and cyanosis
#Hypotonia
+
*Hypotonia
#Convulsions
+
*Convulsions
  
 
There is a normal fall in glucose @ 2-4hr
 
There is a normal fall in glucose @ 2-4hr
  
 
==DDX==
 
==DDX==
# Decreased substrate availability
+
* Decreased substrate availability
## Intra-uterine growth retardation
+
** Intra-uterine growth retardation
## Glycogen storage disease
+
** Glycogen storage disease
## Inborn errors (e.g., fructose intolerance)
+
** Inborn errors (e.g., fructose intolerance)
## Prematurity
+
** Prematurity
## Prolonged fasting without IV glucose
+
** Prolonged fasting without IV glucose
# Hyperinsulinemia:
+
* Hyperinsulinemia:
## Infant of diabetic mother
+
** Infant of diabetic mother
## Islet cell hyperplasia
+
** Islet cell hyperplasia
## Erythroblastosis fetalis
+
** Erythroblastosis fetalis
## Exchange transfusion
+
** Exchange transfusion
## Beckwith-Wiedemann Syndrome
+
** Beckwith-Wiedemann Syndrome
## Maternal �-mimetic tocolytic agents
+
** Maternal �-mimetic tocolytic agents
## ?High? umbilical arterial catheter
+
** ?High? umbilical arterial catheter
## Abrupt cessation of IV glucose
+
** Abrupt cessation of IV glucose
# Other endocrine abnormalities:
+
* Other endocrine abnormalities:
## Pan-hypopituitarism
+
** Pan-hypopituitarism
## Hypothyroidism
+
** Hypothyroidism
## Adrenal insufficiency
+
** Adrenal insufficiency
# Increased glucose utilization:
+
* Increased glucose utilization:
## Cold stress
+
** Cold stress
## Increased work of breathing
+
** Increased work of breathing
## Sepsis
+
** Sepsis
## Perinatal asphyxia
+
** Perinatal asphyxia
# Miscellaneous conditions:
+
* Miscellaneous conditions:
## Polycythemia
+
** Polycythemia
## Congenital heart disease
+
** Congenital heart disease
## CNS abnormalities
+
** CNS abnormalities
 
   
 
   
 
===Persistent===
 
===Persistent===
#Too much insulin:
+
*Too much insulin:
##idiopathic, asphyxia, rhesus dx, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
+
**idiopathic, asphyxia, rhesus dx, Beckwith-Weiderman, Nesiodoblastosis (autosomal recessive hyperinsulinism)
#Not enough anti-insulin:
+
*Not enough anti-insulin:
##hypopit, adrenal hyperplasia
+
**hypopit, adrenal hyperplasia
#Inborn errors of metabolism:
+
*Inborn errors of metabolism:
##glycogen storage dz, fatty oxidation errors
+
**glycogen storage dz, fatty oxidation errors
  
 
==Treatment==
 
==Treatment==
# Glucometer reading 20-40 mg/dL, infant is term and is able to feed:
+
* Glucometer reading 20-40 mg/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
+
** <20 mg/dL or
## <40 mg/dL and NPO or preterm or
+
** <40 mg/dL and NPO or preterm or
## <40 mg/dL after feeding or
+
** <40 mg/dL after feeding or
## <40 mg/dL and symptomatic
+
** <40 mg/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 4-6 mg/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 8-10 mg/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 >40 mg/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 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.
##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: 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.
# 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.
+
* 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.
  
 
===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===
 
===Mgmt===
Line 91: Line 91:
  
 
===Persistent Hypoglycemia===
 
===Persistent Hypoglycemia===
#Check insulin, GH, cortisol
+
*Check insulin, GH, cortisol
#Increase volume by 30cc/kg/d
+
*Increase volume by 30cc/kg/d
#Increase glucose to 12.5%
+
*Increase glucose to 12.5%
#Glucagon infusion
+
*Glucagon infusion
  
 
If continues for >7 d: send insulin, cortisol, growth hormone
 
If continues for >7 d: send insulin, cortisol, growth hormone

Revision as of 19:15, 25 March 2015

Background

3 births per 1000 w/ hypoglycemia

Risks

  • DM mothers (hyperinsulin)
  • 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 a normal fall in glucose @ 2-4hr

DDX

  • Decreased substrate availability
    • 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

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

  • 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.
  • Glucometer reading:
    • <20 mg/dL or
    • <40 mg/dL and NPO or preterm or
    • <40 mg/dL after feeding or
    • <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.
  • 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.
    • 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.
  • 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.

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)

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

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

See Also

Source

Adapted from Pani