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Definition
The S.T.A.B.L.E. Program defines hypoglycemia as:
Glucose delivery or availability is inadequate to meet glucose demand
(Karlsen, 2006)
What is Normal?
Defining a normal glucose level <2.6mmol/l in term or preterm
Inadequate Glycogen
Glycogen stores increase rapidly in the last month of the 3rd trimester Preterm infants are born before this occurs. What little glycogen is available is used up rapidly and their supply is depleted.
Inadequate Glycogen
SGA birth weight < 10 percentile. Chronically stressed infants have higher metabolic demands and use up available glucose for growth and survival. Markedly post-mature infants are at increased risk due to increased metabolic demand.
Nursing Management
Identify infant at risk On admission, 1, 2, 4 hours later, then once hypocount stable 6 hourly for 24-48 hours If well baby at risk immediate feeding Unwell baby- start iv dextrose 10%
Treatment
HPC< 1.5/ baby symptomatic IV D10% 2ml/kg, followed by D10% 6090ml/kg/day (day 1 of life) HPC 1.5-2.5 feeding
Prevention
Increase awareness of conditions that predispose an infant to hypoglycemia Early screening of at-risk infants Early and frequent feedings Maintain temperature
Persistent hypoglycemia
Re-evaluate infant Sent RBS Increase D10% by 30ml/kg/day or use dextrose 12.5% or 15%(through central line) If still hypoglycemic despite of >10mg/kg/min, conseder glucagon IV30100mcg/kg/hr max 0.5mg/dose Dont use glucagon in SGA/adrenal insufficiency baby Otherwise can use hydrocortisone 2.55mg/kg/dose bd
Clinical approach
Rule out liver failure, septicemia, severe systemic illness, SGA, maternal DM etc. When is hypoglycemia relation to feeding? Any hepatomegaly?
Transient neonatal hypoglycemia Prematurity, intrauterine growth retardation, perinatal asphyxia Maternal hyperglycemia due to diabetes or iatrogenic glucose administration Sepsis Prolonged fasting (e.g., due to inadequate breast milk or condition interfering with feeding) Congenital hypopituitarism Congenital hyperinsulinism, several types, both transient and persistent Inborn errors of carbohydrate metabolism such as glycogen storage disease
Blood to be taken Ketones serum, urine Blood lactate Blood ammonia Free fatty acid Serum cortisol, insulin, growth hormone
Young children
Prolonged fasting Diarrheal illness in young children, especially rotavirus gastroenteritis Idiopathic ketotic hypoglycemia Isolated growth hormone deficiency, hypopituitarism Insulin excess Hyperinsulinism due to several congenital disorders of insulin secretion Insulin injected for type 1 diabetes Hyperinsulin Hyperammonia syndrome (HIHA) due to Glutamate dehydrogenase 1 gene. Can cause mental retardation and epilepsy in severe cases.[22] Gastric dumping syndrome (after gastrointestinal surgery) Other congenital metabolic diseases; some of the common include Maple syrup urine disease and other organic acidurias Type 1 glycogen storage disease Type III glycogen storage disease. Can cause less severe hypoglycemia than type I Phosphoenolpyruvate carboxykinase deficiency, causes metabolic acidosis and severe hypoglycemia. Disorders of fatty acid oxidation Medium chain acylCoA dehydrogenase deficiency (MCAD) Familial Leucine sensitive hypoglycemia [23] Accidental ingestions Sulfonylureas, propranolol and others Ethanol (mouthwash, "leftover morning-after-the-party drinks")