Screening guidelines for newborns at risk for low blood glucose

Question 1

What are the symptoms of hypoglycemia

Answer 1

• CNS: jittery, tremor, apathy, apnea, seizures, weak or high pitched cry, eyes rolling
• RESP: cyanosis, tachypnea
• GI: difficulty with feeding
• CVS: pallor, sweating, cardiac arrest
• hypothermia

Question 2

what does the normal range of glucose depend on

Answer 2

gestation
nutritional status (glycogen stores)
size
clinical condition
energy needs

Question 3

Which babies are at high risk of hypoglycemia

Answer 3

large babies
SGA
IDM
preterm
perinatal asphyxia

Question 4

Are there long term consequences of hypoglycemia

Answer 4

asymptomatic: unclear. in preterm babies there is evidence linking hypoglycemia to lower HC and developmental scores
symptomatic: yes. symptomatic hypoglycemia results in neuronal injury,
→ short and long term neurological changes.

Question 5

Is all hypoglycemia bad

Answer 5

probably not (if asymptomatic)
12-14% of normal breast fed babies will have blood glucose levels less than 2.6 in the first three days of life

Question 6

What is the physiology of neonatal hypoglycemia

Answer 6

impaired gluconeogenesis
excessive insulin production
altered counter-regulatory hormone production
inadequate substrate supply

Question 7

Who should we screen and when

Answer 7

the infants considered high risk: preterm, LGA, IDM, SGA

at 2 hours of life (after 1 feed) and then Q3-6 hours

Question 8

What is the typical timing of neonatal hypoglycemia

Answer 8

Depends on the cause:
LGA and IDM: typically by 3 hours, upper limit 12 hours
Preterm and SGA: vulnerable up to 36 hours

Screening can then stop at 12 and 36 hours respectively

Question 9

How should we screen

Answer 9

send to lab (more reliable)
point of care can be unreliable

NB can have 10% variation between whole blood and plasma (latter is higher)

Question 10

What is the lower limit of the proposed normal BG

Answer 10

2.6

Question 11

What do you do: an at risk baby has a BG of less than 1.8 after their first feed

Answer 11

IV dextrose: TFI 80 10%

At this level you should manage with some expedience

Question 12

What do you do: an at risk baby has a BG of less than 2.0 after a feed

Answer 12

IV dextrose: TFI 80 10%

Because it’s after a feed.
If it’s not after a feed you can try to feed

Question 13

What do you do: an at risk baby has a BG 2.1

Answer 13

feed orally and recheck in 60 minutes

You are safe to use PO between 1.8-2.6 unless repeatedly low

Question 14

What do you do: an at risk baby has a BG of 2.1 → you feed and recheck after 60 minutes and it is 2.4

Answer 14

Consider IV dextrose

Question 15

What are your options for managing asymptomatic hypoglycemia

Answer 15

Oral feeds: increased frequency of BF, supplement
IV dextrose
Meds: glucagon, steroids, octreotide, diaxoside

No trials have demonstrated a benefit of one over the other

Question 16

Do you bolus glucose

Answer 16

a single minibolus of 2 ml/kg 10% at the start of an infusion more rapidly achieves steady state levels, but the benefit in asymptomatic babies is uncertain.

Due to the short duration of action of glucose, repeated miniboluses without an increase in the infusion rate is not recommended.

Question 17

When do you recheck after an intervention

Answer 17

IV: 30 minutes
PO: 60 minutes

Question 18

How do you treat symptomatic neonates

Answer 18

They should be treated with IV dextrose, especially if they have neurological signs

Question 19

What do you do: you are titrating up and up on your dextrose infusion with repeated episodes of hypoglycemia. When do you add a pharmacological interfvention

Answer 19

when GIR is over 10 mg.kg.min

Question 20

What is the first line pharmacological measure

Answer 20

glucagon bolus 0.1 mg/kg to 0.3 mg/kg

Then can do infusion: 20 ug/kg/hr

Question 21

Any counfounding concerns you should watch out for

Answer 21

Watch the sodium! They get dilutional hyponatremia

try not to exceed 100 ml/kg/day

Question 22

When do you wean IV dextrose

Answer 22

when stables sugars x 12 hours

Question 23

Do all kids get screened

Answer 23

No
Routine screening of appropriate-for-gestational-age infants at term do not

Only screen: IDM, LGA, SGA, preterm