Neonatal Hypoglycemia

1. Causes
   1. Decreased Glucose stores
      1. Prematurity
      2. Intrauterine Growth Retardation (IUGR)
      3. Hypoxia or asphyxia
      4. Sepsis
      5. Hypothermia
      6. Congenital Heart Disease
      7. Glycogen Storage Disease
      8. Glucagon deficiency
      9. Adrenal Insufficiency
      10. Galactosemia
      11. Fructose intollerance
   2. Hyperinsulinism
      1. Mother with Diabetes Mellitus
      2. Erythroblastosis Fetalis
      3. Exchange Transfusion in Newborns
      4. Beckwith-Wiedemann Syndrome
      5. Nesidioblastosis
      6. Islet Cell adenoma
      7. Leucine sensitivity
   3. Maternal Medications
      1. Salicylates
      2. Beta-Sympathomimetics
      3. Chlorpropamide
      4. Benzothiadiazide
2. Associated Conditions in children of diabetic mothers
   1. Perinatal asphyxia
   2. Birth Trauma (Shoulder dystochia)
   3. Congenital anomalies
   4. Hypocalcemia
   5. Hyperbilirubinemia
   6. Respiratory distress syndrome
   7. Polycythemia
   8. Feeding problems
   9. Renal vein thrombosis
3. Symptoms
   1. Jittery or Tremors
   2. Lethargic
   3. Hypotonia
   4. Apnea
   5. Hypothermia
   6. Cyanosis
   7. Seizures
   8. Weak or high pitched cry
   9. Poor feeding
4. Labs
   1. Blood Glucose Monitoring
      1. Hours of life: 1, 2, 3, 6, 12, 24, and 48 hours
      2. Increase frequency of checks for symptoms
   2. Serum Calcium
      1. Check if lethargic or jittery despite normal Glucose
   3. Hematocrit
      1. For signs of Polycythemia
   4. Neonatal Bilirubin (as indicated)
   5. Arterial Blood Gas
      1. Indicated for signs of respiratory distress
5. Radiology
   1. Chest XRay indicated for respiratory distress
6. Management: General Approach
   1. Monitor Blood Sugar closely at above intervals
   2. Glucose 35 to 45 mg/dl
      1. Oral Glucose replacement (see below)
      2. Parenteral Glucose replacement if symptomatic
   3. Glucose 25-34 mg/dl
      1. Attempt oral Glucose replacement (see below)
      2. Parenteral Glucose replacement usually indicated
   4. Glucose <25 mg/dl
      1. Parenteral Glucose Replacement (initially with bolus)
      2. Strongly consider NICU Admission
      3. Glucagon if Intravenous Access delayed
         1. Dose: 0.1 mg/kg/dose to 1 mg max IM or SQ q30 min
         2. Not effective in SGA infants
7. Oral Glucose Replacement
   1. Gavage or oral feedings hourly until Glucose normal
   2. Use 5% Dextrose in Water (D5W) or Infant Formula
8. Parenteral Glucose Replacement
   1. Preparation of Glucose Solutions
      1. D10W = 1:4 Dilution of D50W in sterile water
      2. Do NOT use >12.5% Glucose solutions in newborns
   2. Intravenous Glucose Maintenance
      1. Load: 2 ml/kg D10W at 2 ml/min
      2. Maintenance: 80 ml/kg/day D10W
   3. Emergent Glucose replacement
      1. Dose: 0.5-1.0 g/kg (5-10 ml/kg D10W) IV over 20 min