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Similar to Neonatal hypoglycemia
Neonatal hypoglycemia
- 1. Postnatal Glucose Homeostasis inInfants American Academy of Pediatrics
- 2. Neonatal Hypoglycemia • Commonin healthy neonates by 1 to 2 hours after birth • No specific plasma glucose concentration or duration of hypoglycemia that can predict permanent neurologic injury in high-risk infants.
- 3. Clinical Signs • Non-specific –Jitteriness, cyanosis, seizure, apneic episodes, tachypnea, weak or high-pitched cry, floppiness, lethargy, poor feeding, eye rolling • To attribute signs and symptoms to neonatal hypoglycemia (NH), the Whipple triad must be fulfilled: – (1) low blood glucose concentration; (2) signs consistent with NH; (3) resolution of signs and symptoms after restoring blood glucose concentration to normal values
- 4. Who are atrisk? • Pathophysiology – Impaired glucogenesis and or ketogenesis: excessive insulin production, altered counterregulatory hormone production, an inadequate substrate supply, or a disorder of fatty acid oxidation. Small for gestational age Large for gestational age Infant of diabetic mother Late-preterm infants
- 5. When do wescreen? • Neonatal glucose concentrations decrease after birth, to as low as 30 mg/dL during the first 1 to 2 hours after birth, and then increase to higher and relatively more stable concentrations, generally above 45 mg/dL by 12 hours after birth. • Asymptomatic, at risk infant: first few hours of birth, continued through multiple feed-fast cycles • Late preterm and SGA infants: pre-feeding for 1st 24 hours. Repeat if still <45mg/dL
- 6. Management • A reasonable(although arbitrary) cutoff for treating symptomatic infants is 40 mg/ dL. • Minibolus of glucose – 200mg glucose per kg, 2ml/kg dextrose in 10% water (D10W) IV • Continuous infusion – D10W at 80-100ml/kg/day • GOAL: Maintain plasma glucose concentration in symptomatic infants between 40-50mg/dL
Editor's Notes
- #6 Data on the optimal timing and intervals for glucose screening are limited. It is controver- sial whether to screen the asymptom- atic at-risk infant for NH during this normal physiologic nadir. No studies have demonstrated harm from a few hours of asymptomatic hypoglycemia during this normal postnatal period of establishing “physiologic glucose homeostasis.”9 Infants born to mothers with diabetes may develop asymptomatic NH as early as 1 hour after birth18 and usually by 12 hours of age.18 In contrast, infants who are large for gestational age or small for gestational age may develop low plasma glucose concentrations at as early as 3 hours of age,19 and these infants may be at risk of NH for up to 10 days after birth.20 Therefore, at-risk in- fants should be screened for NH with a frequency and duration related to risk factors specific to the individual in- fant.
- #8 Figure 1 is divided into 2 time periods (birth to 4 hours and 4 –12 hours) and accounts for the changing values of glucose that occur over the first 12 hours after birth. The recommended values for intervention are intended to provide a margin of safety over con- centrations of glucose associated with clinical signs. The intervention recom- mendations also provide a range of values over which the clinician can de- cide to refeed or provide intravenous glucose. The target glucose concentra- tion is greater than 45 mg/dL before each feeding. At-risk infants should be fed by 1 hour of age and screened 30 minutes after the feeding. This recom- mendation is consistent with that of the World Health Organization. Gavage feeding may be considered in infants who are not nippling well. Glucose screening should continue until 12 hours of age for infants born to moth- ers with diabetes and those who are large for gestational age and maintain plasma glucose concentrations of greater than 40 mg/dL. Late-preterm infants and infants who are small for gestational age require glucose moni- toring for at least 24 hours after birth, because they may be more vulnerable to low glucose concentrations, espe- cially if regular feedings or intrave- nous fluids are not yet established.20 If inadequate postnatal glucose ho- meostasis is documented, the clinician must be certain that the infant can maintain normal plasma glucose con- centrations on a routine diet for a rea- sonably extended period (through at least 3 feed-fast periods) before dis-