1. Dr.Salika Jayasundara (MO/SCBU)
General Hospital – Kegalle
Sri Lanka

2. 
References

Medscape references neonatal hypoglycemia
Author: Hilarie Cranmer, MD, MPH, FACEP
Updated: Sep 15, 2011

AAP Guidelines for Neonatal Hypoglycemia(2011)

Neonatal hypoglycaemia and blood glucose level
monitoring
Queensland Maternity and Neonatal Clinical
Guidelines (February 2012 )

3. 
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The definition of clinically significant hypoglycemia
remains one of the most confused issues in
neonatology.
Blood glucose level ( AAP guidelines 2011)
< 30 mg/dL (1.65 mmol/L) in the first 24 hrs of life
< 40 mg/dL (2.2 mmol/L) after 24 hrs

severe hypoglycemia is:
< 24mg/dl (1.4 mmol/L )

4. 
Hypoglycemia is the most common metabolic
problem in neonates

Overall Incidence = 1- 5/1000 live births
 Normal
newborns – 10% if feeding is delayed for
3-6 hours after birth
 At-Risk Infants – 30%
 LGA – 8%
 Preterm – 15%
 SGA – 15%
 IDM – 20%

5. 
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Glucose is the primary fuel for the brain.
The brain needs a steady supply of
glucose to function normally.
Glucose is the fetus’s only source of
carbohydrate.
Cerebral glucose utilization accounts for
90% of the neonate’s glucose consumption

6. 
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Fetal plasma glucose is 60 – 80% of the maternal
glucose level.
The fetus stores glucose in the form of glycogen
(liver, heart, lung, and skeletal muscle).
Most of the glycogen is made and stored in the last
month of the 3rd trimester.
The fetus has limited ability to convert glycogen to
glucose and must rely upon placental transfer of
glucose to meet energy needs.
When the infant is born, the cord is cut and so is the
major supply of glucose!

7. 
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serum glucose levels decline after birth until
age 1-3 hours, then they spontaneously
increase.
Liver glycogen stores become rapidly
depleted within hours of birth, and
gluconeogenesis, primarily from alanine, can
account for 10% of glucose turnover in the
newborn infant by several hours of age.
Certain groups of babies may be unable to
make the appropriate metabolic adaptations
to extra uterine life and are considered ‘at
risk’ of severe and/or persistent
hypoglycaemia.

8. 
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< 37 weeks gestation
Infant of a diabetic mother
Small for gestational age
Large for gestational age
Stressed/ill neonates
Exposure to certain medications
 Treatment of preterm labor
 Treatment of hypertension
 Treatment of type 2 diabetes
 Benzothiazide diuretics
 Tricyclic
antidepressants in the 3rd trimester

9. 1. Decreased substrate availability:
•IUGR
•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 drugs (( Terbutaline, Propanolol,
Chlorpromazine and benzothiazides )
•Abrupt cessation of IV glucose

10. 3. Increased glucose utilization:
•Hypothermia
•Sepsis
•Increased work of breathing
•Perinatal asphyxia
4. Other endocrine abnormalities:
•Pan-hypopituitarism
•Adrenal insufficiency
•Hypothyroidism
5. Miscellaneous conditions:
•Polycythemia
•CNS abnormalities
•Congenital heart disease

11. Summary
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Limited Glycogen Stores
Hyperinsulinism
Diminished Glucose Production
Limited Glucose Delivery

12. 
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The clinical signs of hypoglycemia are neither
sensitive nor specific.
Any baby that is unwell or who has signs that
cannot be readily explained should have their
BGL checked.
Babies with signs specific for hypoglycemia
require urgent pediatric review and
management with IV therapy.

13. 
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Jitteriness
Tachypnoea
Cyanosis
Apnoea
Seizures
Cardiac arrest
Irritability
Hypotonia
Lethargy
High-pitched cry
Hypothermia
Poor sucking
Sweating
pallor

14. 
It is not necessary to screen asymptomatic ,
appropriately grown term babies that do not have
risk factors.

Babies should have BGL screens if:
they have any risk factors (one or more)
they are unwell
they have any unexplained abnormal signs that
may be due to hypoglycaemia

15. 
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Well babies with risk factors
controversial
initially at 1, 2, and 4 hours of age
Then every 4 to 6 hours
or pre second feed (within 3 hours of birth)
then check pre-feeds
Unwell babies with/without clinical signs
immediately, repeat BGL checks regularly ( 6hrly)
Confirm any glucometer BGL less than 2.0 mmol/L
by blood gas machine or laboratory analysis.
However do not wait for this confirmation before
starting appropriate treatment

17. IV glucose bolus 10% dextrose 2 – 3 ml/kg
 Followed by iv infusion
10% dextrose 5 -8 mg/kg/min
(60-100ml/kg/day)
B/O diabetic mother 8-10mg/kg/min
Recheck level in 30-60mints & monitor every
2-4 hrly
 For persistent hypoglycemia

increase rate stepwise up to 10-15mg/kg/min
Maximal concentration of glucose in peripheral IV is
D12.5.
>12.5%, insert central venous catheter

18. 
Weaning IV dextrose infusion
start when BGL is stable for 12-24 hrs

To calculate rate of glucose administration
% glucose x mL/kg/d = glucose infusion rate
144
(mg/kg/min)
or
% glucose x mL/h = glucose infusion rate
6 x body weight (kg)
(mg/kg/min)


19. 
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Consider pharmacological intervention for severe,
persistent or recurrent hypoglycaemia
Glucagon
200 microgram/kg IV/IM stat
10-50 microgram/kg/hr infusion
Hydrocortisone 1 mg/kg/dose IV 6 hourly
Diazoxide , Octreotide , Hydrochlorothiazide
need further Ix to find the cause
Ex:- Insulin (±C-peptide) , Cortisol , Ketones
GH , Adrenocorticotrophic hormone
serum amino acid profile ,ammonia ,
free fatty acids,MRI ,urine analysis

20. 
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Selective Neuronal necrosis in multiple brain
regions including the superficial cortex,
dentate gyrus,hippocampus and caudate and
putamen
In preterm infants predisposes to IVH
Impaired cognitive and motor function
Imaging studies in term infants and selected
preterm infants

21. 
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Maintain temperature with skin to skin
contact at delivery room
Early and frequent feedings
Increase awareness of conditions that
predispose an infant to hypoglycemia
Early screening of at-risk infants

22. 
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The clinical signs of hypoglycemia are neither
sensitive nor specific
Any baby that is unwell or who has signs that
cannot be readily explained should have their BGL
checked.
NEVER give a bolus of dextrose without also
increasing the background rate or concentration of
IV dextrose infusion.
Hypoglycaemia is treatable condition

23. THANK YOU!