Neonatal hypoglycaemia

NEONATAL HYPOGLYCEMIA PROBLEM AND PRACTICAL

ISSUES

Department of Paediatrics

Thaahira,19 year old booked primi Came at ₄₀ weeks gestation No history of gestational diabetes or PIH All three trimesters - uneventful.

CASE - B/o Thaahira

Date of birth: ₅⁄₉⁄₁₃ at 8.15 p.m FTNVD/40 weeks/ male baby

Birth weight: ₂.₀₇₄kg /Cried soon after birth/ SMALL FOR DATE.

NEONATAL HYPOGLYCEMIA -<40mg/dl irrespective of gestational age and weight

GRBS at 10.00 a.m, 6/9/13 (14 hrs of life ) was 40mg/dl.

Baby was asymptomatic.(ASYMPTOMATIC HYPOGLYCAEMIA)

No sufficient breast milk available , advised formula feed .

Baby not tolerating formula feeds , shifted to NICU by 11·45 a.m 6/9/13 (at 16 hrs of life).

Baby was cannulated at 12·00pm on left arm (Cannula I) , 6 ml of 10% dextrose given as bolus.

Advice: 1. half hrly monitoring of GRBS till sugars are stable 2. Formula feed/Expressed Breast milk (EBM) 10ml

fourth hourly 3. IVF -10% Dextrose ,5 drops/minute at a glucose

infusion rate of 4mg/kg/minute. Sugar after starting dextrose infusion :108 mg/dl

Baby’s I.V cannula went out by 4 am on 7/9/13 (32 hours of life).

I.V cannula staying time for the first cannula - 16 hours ,

recannulated on left leg (Cannula II)

Baby not tolerating oral feeds even now. 1 . Domstal drops two drops sixth hourly 2.. Inj.calcium gluconate 2ml in alternate 6

hrly fluids.

second day of life(7/9/13) Around 5.00 pm ( 45 hours of life) baby was

having jitteriness .We checked GRBS. The Glucometer readings were erratic and

unreliable First glucometer - First reading - 455 Second reading – 490 Second glucometer – 390 Third glucometer - - 33

Simultaneous lab glucose value – 20mg/dl

Dr. Karthikeyan’s advice over phone 1.Inj.Dextrose 10% 6ml IV bolus stat 2.Inj.Hydrocortisone 25mg IV stat and 10mg TDS 3. IVF-10ml 25% Dextrose + 28ml 10% Dextrose + 2ml

Calcium Gluconate at an infusion rate of 6.7ml/hr GLUCOSE INFUSION RATE was 8mg/kg/minute 4.Inj.Emeset 0.3ml IV TDS 5.Expressed Breast milk(EBM) two hourly 6 Feeding through NGT if vomiting persists∙ 7.Hourly monitoring of GRBS

IV cannula went out for the second time at 5.45pm, 7/9/13 (45 hours of life)

I .V cannula staying time for second cannula - 13.45hrs . By 6.00 p.m recannulated on right leg (cannula III) , stat

medications given. 7.00pm, 7/9/13( 47 hours of life) lab glucose value was

76mg/dl 10 00pm,∙ 7/9/13 (50 hours ) , GRBS was 51mg/dl advice: increase the IV infusion rate to 8ml/hr Baby tolerating EBM 10 ml 2 hrly Thereafter GRBS was maintained above 70mg/dl

Third day of life (8/9/13, Sunday) By 8/9/13, 12.45pm IV cannula was out for the third

time. I.V cannula staying time for the third cannula -

18.45 hours. Baby recannulated on left arm (Cannula IV) 4.00pm GRBS - 145mg/dl ,IV infusion rate was

reduced to 4ml/hr Baby tolerated 15ml of EBM two hrly . By 8.00pm IV infusion rate reduced to 2ml/hr and

by 2.00am to 1ml/hr

Fourth day of life(9/9/13) At 6.00am IV cannula went out for the fourth time. I.V cannula staying time for the fourth

cannula- 17 hours. No peripheral veins available

for further cannulation!!!!. Fortunately baby’s blood sugar was maintained

without I.V infusion of dextrose

Fourth day

Advice : 1. four hourly monitoring of GRBS 2. Continue EBM two hourly 3. Syr.calcimax 0.5ml each feeds

Fifth day of life (10/9/13) Baby was put to mother’s breast , failed

to suck well due to nipple retraction . nipples’ retraction was corrected by

continuous efforts of syringing. Baby started sucking well.

After 24hours of successful breastfeeding , baby shifted to mother’s side on the sixth day (11/9/13) of life .

Baby discharged on the seventh day (12/9/13) of life in good condition on direct breast feeds.

NEONATAL HYPOGLYCEMIA -<40mg/dl irrespective of gestational age and weight

Group I – Substrate deficiency (Reduced stores)

1·Prematurity 2.Small for date babies 3.Infant of PIH mother 4.VLBW (Very Low Birth Weight babies) Group II – Hyperinsulinaemia A. Transient 1.Infant of diabetic mother 2.leucine sensitivity B.Permanent Nesidioblastosis (Insulinomas)

NEONATAL HYPOGLYCAEMIA -CAUSES

Group III – Endocrine causes 1 ·Growth hormone deficiency 2. Cortisol deficiency (congenital adrenal

hyperplasia ) 3 Addison’s disease 4 Hypothyroidism Group IV- Metabolic causes 1.Glucose phosphatase deficiency 2. Disorders of fructose metabolism 3. Short chain and medium chain

Acyl Co A dehydrogenase deficiencies 4. Galactosemia

1.SYMPTOMATIC Symptoms like1. lethargy2. Jitteriness3. apnoea4. Cyanosis5. respiratory distress 6. seizures

2.ASYMPTOMATIC

50% risk of neurological damage with the symptomatic hypoglycemia

In our case hypoglycemia is probably due to substrate deficiency (SFD)

Maximum Glucose Infusion Rate in our case - 9 mg/kg/minute

GIR >12mg/kg/minute – suspect Hyperinsulinism

1. Lack of facilities- Infusion pump - which is vital in

managing hypoglycemic patients to give a steady infusion of glucose

Iatrogenic hyperinsulinism can happen if infusion is not even

Multi channel monitor with neonatal BP measurement is NA

ISSUES IN THE MANAGEMENT

2.Nursing care I.V lines are precious in neonates

Average cannula staying time should be 48-72 Hrs

In our case 4 cannulas were needed within 48 hrs

Nursing care suboptimal

3.Unreliability of Glucometers in management

Glucometer values will be normally 10mg/dl >lab values

Our glucometers showed high glucose levels when the baby was hypoglycemic

4.Trained residents experienced in Neonatal care

Glucose infusion >12.5% dextrose should be given through central veins

Persons experienced in umbilical Venous catheterization or other central lines should be available.

THANK YOU