Management of neonatal hypoglycemia.
Hypoglycemia is common in neonates especially those with risk factors (see below). It’s crucial to know how to deal with this condition as it is having potential and deleterious sequelae if it is not recognized early and left untreated. There is no a standard cutoff level in determining hypoglycemia, some references regard any level below 55mg/dl as hypoglycemia while some define hypoglycemia as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter. However any glucose level below 40mg/dl we regard as hypoglycemia.
*Risk factors for having hypoglycemia:
Prematurity, small for gestational age, IUGR, macrosomia, maternal diabetes, hypothermia, perinatal asphyxia and sometimes it can be caused by genetic or metabolic diseases.
Note: neonates who are at increased risk of developing hypoglycemia, esp. IODM, their RBS should be checked in the first hour of life and after 2-3 hours of birth (when it reaches it’s nadir), every 2 hrs in the first 6 hours, then every 4-6 hour in the first 24 hour.
*Manifestations of neonatal hypoglycemia:
It may be asymptomatic or there may be; hypotonia, lethargy, apathy, poor feeding, jitteriness, seizures, congestive heart failure, cyanosis, tachycardia, apnea and hypothermia.
Management of neonatal hypoglycemia:
* If the blood glucose is 30-40mg/dl and the neonate is asymptomatic and can take oral feeding, start to feed and check glucose level 2 hourly. While if the neonate can not take oral feeding (e.g. because of respiratory distress), or symptomatic or blood glucose < 30mg/dl, give 2ml/kg of 10%GW (in case of seizure 4ml/kg) followed by continuous IV glucose administration at a rate of 6-8mg/kg/minute (GIR: glucose infusion rate), if still hypoglycemic GIR can be increased up to 12mg/kg/minute. Remember RBS should be checked every 1-2 hour until stabilizes, then every 3-4 hour for at least 24 hour after stabilization.
1.5ml 50%GW + 8.5ml 5%GW = 10ml 10%GW. OR
2ml 50%GW + 8ml NS = 10%GS.
then infuse 2ml/kg or 4ml/kg in case of seizure.
For calculating Glucose infusion rate (GIR) see the attached photo at the end of the article.
*If still hypoglycemic despite above treatment; give steroids e.g. Hydrocortisone vial 50mg/m2/day or Dexamethasone 1-2.5mg/kg/dose every 6 hour IV.
*If still hypoglycemia give Glucagon 200-300 mcg/kg maximum 1mg/day will be given IM, SC or by continuous IV infusion.
*Other medications that can be used like: Octreotide 7-12 mcg/kg/day maximum 40 mcg/kg/day SC or by IV continuous infusion. Diazoxide 10-15 mg/kg/day can be given orally every 8 hr.
Once neonate’s blood glucose levels have been stable for 12 hours, IV glucose may be tapered by 1-2 mg/kg/min maintaining preprandial glucose levels > 40 mg/dl.