Hypoglycemia in the Neonate

The definition of hypoglycemia in infants is a current medical controversy, as asymptomatic hypoglycemia is generally not related to significant morbidity, and many healthy neonates have been found to have transiently low blood glucose concentrations. However, due to uncertainty about the level and duration of hypoglycemia that causes brain damage, an operational threshold has been defined. Currently, it is standard practice to treat and evaluate newborns with a plasma glucose concentration less than 40 mg/dl on the first day of life, and less than 40 to 50mg/dl after 24 hours of age.

Risk Factors

1. Premature infants
2. Infants of diabetic mothers
3. Infants who are small or large for gestational age (SGA or LGA)
4. Infants with sepsis or history of birth asphyxia
5. Infants of mothers treated with hypoglycemic or beta-adrenergic agents (tocolytics)
6. Insulinomas
7. Hypopituitarism and adrenal insufficiency
8. Erythroblastosis fetalis
9. Inborn errors of metabolism- glycogen storage diseases, aminoacidurias, organic acidemias, fatty acid oxidation defects, galactosemia

Common Symptoms

1. Tremors, jitteriness
2. Change in level of consciousness (irritability, stupor, lethargy)
3. Apnea, bradycardia, cyanosis, tachycardia, tachypnea
4. Hypothermia
5. Poor feeding or poor suck
6. Seizures
7. OR, infants may be asymptomatic and diagnosed because fall into high risk group

Diagnosis

1. Maternal history of drugs, diabetes, preterm or post term delivery

2. Growth parameters abnormal

3. Septic appearing

4. Family history of metabolic disorder

When a patient presents acutely with hypoglycemic symptoms, it is imperative to rapidly assess blood glucose measurements at the bedside, often using a reflectance meter or a Chemstrip. These values should be confirmed by laboratory measurement.

If hypoglycemia persists and does not respond to routine therapies, then the neonate must be evaluated for hyperinsulinemia, endocrinopathies, and inborn errors of metabolism.

Complications

Prolonged or recurrent low blood glucose levels are well known to cause seizures and neruologic sequelae. Unfortunately, the level of blood glucose and the duration of time that it remains low enough to cause damage are unknown. For this reason, in order to prevent the terrible sequelae that may result from prolonged hypoglycemia, it is imperative that it is discovered early and quickly corrected. It is unknown if asymptomatic hypoglycemia can cause brain damage.

Treatment

1. Introduce early enteral feedings with formula

2. If not taking oral fluids, IV glucose should be administered

3. Follow up to make sure that normal glucose levels are maintained

4. Corticosteroids

5. Glucogon if there are adequate liver stores of glycogen

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