Hpoglycemia

Question 1

Describe the normal transitional process of blood glucose concentrations in newborn infants following birth

Answer 1

In healthy term infants, following birth, blood glucose concentrations may transiently decrease as the source of glucose transitions from a continuous supply from the mother to an intermittent supply from milk feeds. Plasma glucose concentrations typically fall within the first two hours, reaching a nadir at 2.2 mmol/l, then stabilize in the range of 2.5 – 4 mmol/l by 4 to 6 hours.v

Question 2

Why is it important to differentiate normal transitional hypoglycemia from persistent hypoglycemia in newborns

Answer 2

It is important to differentiate normal transitional hypoglycemia from persistent hypoglycemia because persistent hypoglycemia, if left untreated, may lead to neurological and developmental sequelae. Identifying and addressing persistent hypoglycemia promptly is crucial to prevent long-term complications.

Question 3

What characterizes hypoglycemia in newborn infants?

Answer 3

Hypoglycemia in newborn infants occurs when the rate of glucose utilization exceeds that of glucose production. It manifests as low blood glucose concentrations and can lead to various neurological symptoms if left untreated.

Question 4

How can normal physiological hypoglycemia be distinguished from pathological hypoglycemia in newborns?

Answer 4

Normal physiological hypoglycemia is transient and resolves spontaneously as the infant’s glucose metabolism stabilizes. Pathological hypoglycemia, on the other hand, is persistent and may require intervention to correct. Monitoring blood glucose levels and assessing the infant’s clinical condition help in distinguishing between the

Question 5

Hypoglycemia

Answer 5

Whole blood glucose concentration < 2.6mmol/l

Question 6

Severe hypoglycemia

Answer 6

Whole blood glucose concentration < 1.5mmol/l
b. Any symptomatic hypoglycaemic newborn infant (seizures, apnoeas etc.) is
considered to have severe hypoglycaemia

Question 7

How are blood glucose concentrations typically measured in newborn infants?

Answer 7

Blood glucose concentrations in newborn infants are typically measured using blood glucometers with reagent strips, obtained through a heel or finger prick for whole blood glucose measurement. Laboratory blood glucose tests, which measure serum glucose concentrations, involve venous or arterial sampling of blood.

Question 8

What is the recommended action if severe hypoglycemia is detected using a blood glucometer?

Answer 8

If severe hypoglycemia is detected using a blood glucometer, it should be confirmed with a laboratory sample. However, abnormal results from the glucometer should be acted upon immediately in the interim to prevent any potential complications.

Question 9

How do whole blood glucose concentrations compare to serum glucose concentrations?

Answer 9

Whole blood glucose concentrations are approximately 15% lower than serum glucose concentrations. Additionally, in the presence of an elevated hematocrit, whole blood glucose concentrations may be further reduced.

Question 10

Why is it important to confirm severe hypoglycemia detected by a blood glucometer with a laboratory sample?

Answer 10

onfirming severe hypoglycemia detected by a blood glucometer with a laboratory sample is important to ensure the accuracy of the measurement and to guide appropriate management. Laboratory tests provide more precise measurements of serum glucose concentrations and help to confirm the severity of hypoglycemia

Question 11

Causes of hypoglycemia

Answer 11

1. Inadequate glucose supply
2. Increased glucose utilization

Question 12

Inadequate glucose supply

Answer 12

1. Inadequate intake
2. Inadequate glycogen stores
3. Impaired glucose production

Question 13

Inadequate intake

Answer 13

i. Infant factors: poor suck/cleft palate/anatomical
abnormalities
ii. Maternal factors: poor milk supply

Question 14

Inadequate glycogen
stores

Answer 14

i. Prematurity
ii. Low birth weight

Question 15

Impaired glucose
production

Answer 15

i. Inborn errors of metabolism (disorders of
gluconeogenesis and glycogenolysis)
ii. Endocrine disorders (disorders of cortisol
and growth hormone e.g. congenital adrenal
hypoplasia and hypopituitarism)
iii. Other: maternal treatment with betasympathomimetic agents/hypothermia/severe
hepatic dysfunction

Question 16

Increased glucose utilization

Answer 16

• Hyperinsulinism
  (may be transient or
  persistent)
• Without hyperinsulinism
  (situations of increased
  metabolic demand)

Question 17

Without hyperinsulinism
(situations of increased
metabolic demand)

Answer 17

i. Sepsis
ii. Cardiac failure
iii. Perinatal hypoxia
iv. Respiratory distress
v. Hypothermia

Question 18

Hyperinsulinism
(may be transient or
persistent)

Answer 18

i. Infant of diabetic mother
ii. Intrauterine growth restriction
iii. Perinatal hypoxia
iv. Persistent hyperinsulinemic hypoglycemia of infancy
v. Beckwith-Wiedemann syndrome
vi. Abrupt interruption of an infusion of a solution
with a high glucose concentration
vii. Polycythemia

Question 19

How is neonatal hypoglycemia often detected?

Answer 19

Neonatal hypoglycemia is frequently asymptomatic, and it may be detected through routine screening of “at-risk” infants or as an incidental finding during clinical assessment.

Question 20

Why is it important to identify situations of risk for neonatal hypoglycemia?

Answer 20

It is crucial to identify situations of risk for neonatal hypoglycemia primarily for screening purposes. Detecting hypoglycemia and instituting treatment in a timely manner can help prevent adverse neurological outcomes associated with untreated hypoglycemia.

Question 22

Which infants do not require routine screening for hypoglycemia in the postnatal wards?

Answer 22

Normal term infants in the postnatal wards typically do not require routine screening for hypoglycemia. However, at-risk infants or those with specific clinical indications may still undergo screening to ensure early detection and intervention if needed.

Question 23

Infants who are at risk of hypoglycemia

Answer 23

-Prematurity
-Small for gestational age (< 10th centile)
-Intrauterine growth restriction or wasting
-Infant of diabetic mother
-Large for gestational age (> 90th centile)
-Post-term particularly if wasted
-Infants who have experienced perinatal and postnatal stress due to: perinatal
hypoxia/ meconium aspiration syndrome/severe Rhesus disease/polycythemia/
hypothermia/ fluid restriction

Question 24

What are the neurogenic signs of hypoglycemia in symptomatic newborn infants?

Answer 24

jitteriness,
irritability,
tachypnea,
pallor,
sweating,
and other non-specific nervous system responses.

Question 25

What are the neuroglycopenic signs of hypoglycemia in symptomatic newborn infants?

Answer 25

poor suck or poor feeding, weak or high-pitched cry, change in the level of consciousness (lethargy, coma), and seizures. hypotonia

Question 26

How do neurogenic signs differ from neuroglycopenic signs in symptomatic newborn infants with hypoglycemia?

Answer 26

Neurogenic signs of hypoglycemia involve non-specific nervous system responses, such as jitteriness, irritability, and sweating, while neuroglycopenic signs reflect a decrease in glucose supply to the brain, resulting in symptoms like poor suck or feeding, weak or high-pitched cry, and changes in consciousness level.

Question 27

Why is it important to recognize both neurogenic and neuroglycopenic signs of hypoglycemia in newborn infants?

Answer 27

Recognizing both neurogenic and neuroglycopenic signs of hypoglycemia is important for prompt diagnosis and treatment. Identifying these signs early can help prevent further complications and ensure appropriate management of hypoglycemia in newborn infants.

Question 28

The goals of managing neonatal hypoglycemia are to:

Answer 28

i. Identify and prevent symptomatic hypoglycemia in at-risk infants. ii. Correct blood glucose levels in symptomatic infants. iii. Identify infants with a serious underlying hypoglycemic disorder, while avoiding unnecessary treatment of infants with normal transitional low blood glucose, which will resolve without intervention. iv. The long-term goal is to prevent long-term neurologic complications.

Question 29

Prevention

Answer 29

i. Identify infants at risk of hypoglycaemia. ii. Depending on gestational age, institute feeds and fluids immediately within first hour of birth. iii. Place healthy term infants onto the breast. iv. In cases of preterm or unwell newborn infants, tube feed if necessary. v. Start intravenous fluids containing 10% glucose if full volume milk feeds are contraindicated (prematurity). vi. Monitor blood glucose levels every 1–3 hours for the first 24–48 hours in infants at risk of hypoglycaemia. vii. Avoid hypothermia.

Question 30

Management of hypoglycaemia (1.5-2.6mmol/l)

Answer 30

i. Give a milk feed immediately or start intravenous fluids if milk feeds are contraindicated. ii. Keep infant warm. iii. If blood glucose still below normal to consider increasing either volume or frequency of feeds. iv. If blood glucose persistently below normal to treat as per emergency treatment of hypoglycaemia.

Question 31

Emergency treatment of severe hypoglycaemia

Answer 31

i. Admit to neonatal unit. ii. Establish intravenous access and bolus 3ml/kg 10% glucose. If unable to establish intravenous access, insert an umbilical venous catheter. iii. If unable to obtain venous access, glucagon at 0.2mg/kg/dose intramuscularly may be given. iv. Start an intravenous infusion of 10% glucose at 60-90mls/kg/24 hours depending on gestational age and day of life. v. If hypoglycaemia persists options include increasing feed and fluid volumes or increasing glucose concentration delivered. Never give 50% glucose intravenously or orally due to its hypertonicity. vi. Monitor blood glucose regularly with reagent strips. vii. Start milk feeds as soon as it is safe to do so and gradually build up feeds while decreasing intravenous fluids as blood glucose improves. viii.Do not stop intravenous glucose until milk feeds are well established. ix. It is important to consider sepsis in unwell newborn infants with persistent hypoglycaemia. Other differential diagnoses include metabolic or endocrine causes and one should investigate accordingly as guided by clinical and laboratory parameters. x. Any newborn infant with severe hypoglycaemia regardless of aetiology needs to be followed up long term to assess neurodevelopmental outcome.

Question 32

When is severe neonatal hypoglycemia considered an emergency

Answer 32

Severe neonatal hypoglycemia is considered an emergency when blood glucose concentrations are less than 1.5 mmol/l. It is also considered an emergency in any severely symptomatic newborn infant, particularly those who are having seizures.

Question 33

Why is severe hypoglycemia considered a well-known risk factor for adverse neurodevelopmental outcomes?

Answer 33

Severe hypoglycemia is considered a well-known risk factor for adverse neurodevelopmental outcomes because it can lead to neuronal cell death. Addressing severe hypoglycemia promptly is crucial to prevent neurological damage and ensure better long-term neurodevelopmental outcomes for the infant.