Neonatal hypoglycaemia

Question 1

How does glucagon and insulin work in metabolism?

Answer 1

Glucagon is released by the alphas cells in the pancreas when blood sugar is too low, and causes…
Converts glycogen to glucose and creates glucose (inhibited by insulin and somatostatin (inhibits both insulin and glucagon). Part of sympathetic- stress-fight or flight

Insulin released beta cells in pancreas when blood sugar too high, and causes… glycogenesis, lipogenesis,, decreases glycogenolysis, stimulates uptake + use of glucose by muscle and connective tissue cells

Question 2

Insulin is formed from amino acids?

Answer 2

True

Question 3

Insulin reduces blood glucose levels?

Answer 3

True

Question 4

glucagon reduces blood glucose levels?

Answer 4

False

Question 5

Secretion of insulin is stimulated by low blood sugar levels?

Answer 5

False

Question 6

Secretion of insulin is stimulated by gastrin?

Answer 6

True- because gastrin is produced when you eat, and t

Question 7

The hypothalamus is involved in the secretion of insulin?

Answer 7

False, the pancreas is

Question 8

Insulin secretion is decreased by sympathetic stimulation?

Answer 8

True

Question 9

What is gluconeogenesis?

Answer 9

Body converts non-carbohydrate sources (like amino acids) in our liver into glucose

Question 10

What is lipogenesis?

Answer 10

Synthesis of fatty acids and storage of fat in adipose tissue

Question 11

What is glycogenesis?

Answer 11

Conversion of glucose to glycogen, especially in liver and skeletal muscles

Question 12

What is glycogenolysis?

Answer 12

Breakdown of glycogen into glucose

Question 13

What is lipolysis?

Answer 13

Breakdown of fat and other lipids by hydrolysis (reaction with water) to release fatty acids

Question 14

How do healthy newborns regulate their blood sugar?

Answer 14

Healthy newborns initially use glucose in their blood to provide energy, when this is used they then break down their brown fat stores into lactates and ketones to provide energy, until feeding established

Question 15

What is neonatal hypoglycaemia?

Answer 15

Plasma glucose conc. below 2.6 mmol/l (can vary per trust)
Insufficient circulating glucose to meet the metabolic demands of the body, particularly the brain
May be symptomatic or asymptomatic
Cerebral blood flow becomes deranged below 2.0 mmol.l
Don’t take BMs until 2 hours after birth- it will be low

Question 16

What infants are at risk of neonatal hypoglycaemia and why?

Answer 16

Premature- because brown fat stores aren’t there and developed until 3rd trimester
IUGR/SGA- low brown fat reserves
Sepsis- body working harder to fight infection
Hypothermic- needs extra glucose and oxygen to keep warm
Babies of mothers with IDDM/GDM
Perinatal stress/asphyxia
Inborn errors of metabolism, e.g. PKU
Beckwith-Wiedemann Syndrome (overgrowth syndomr-macrosomia)

Question 17

What are the general symptoms?

Answer 17

Abnormal cry
Poor feeding
Hyporthermia

Question 18

What are the cardio respiratory symptoms?

Answer 18

Tachypnea
Apnea
Cyanois

Question 19

What are the neurologic symptoms?

Answer 19

Tremors/jitteriness
Irritability
Lethargy
Hypotonic
Seizure

Question 20

Why does neonatal hypoglycaemia occur in preterm infants?

Answer 20

Majority of glycogen stored in 3rd trimester
Brown fat is laid down in the last few weeks of the pregnancy
At TERM 5-8% of liver and muscle weight is glycogen storage
Available stores rapidly depleted
Immature counter regulatory response to low glucose concentration

Question 21

Why does neonatal hypoglycaemia occur in SGA babies?

Answer 21

Low glycogen and fat stores
Inadequate metabolic control
Chronically stressed fetus may use most of the placentally transferred glucose for growth and survival

Question 22

Why does neonatal hypoglycaemia occur in the infant of a diabetic mother?

Answer 22

Glucose crosses placenta/insulin does not
Fetal glucose level 70-80% of mother’s
Infant produces insulin in response to higher blood sugars
At cord clamping, glucose supply is removed but insulin production in infant remains elevated
May take several days to down regulate insulin production

Question 23

How can it be prevented and treated?

Answer 23

Keep babies warm
Identify at risk groups 
Follow local guidelines
Keep warm and dry 
Feed within 60 mins of delivery 
Frequent feeding, at least 3 hourly
Supportive feeding
Appropriate monitoring 
Staff competent when blood sampling 
Measure blood glucose before 2nd feed 
Glucose gel- needs feeding as well
EBM/formula 
Naso-Gastric tube
Intravenous glucose

Question 24

Local trust blood glucose measurements?

Answer 24

Use national guidelines for exam

Question 25

WHat is glucose gel?

Answer 25

Aim to prevent admission to NNU
Follow local guideline for use
40% glucose (GlucoGel)•0.5ml/kg (one finger tip)
Apply to buccal membranes
Follow with feed
Recheck blood sugar 30-60 minutes
3 rounds
Be

Question 26

What are the benefits of using glucose gel?

Answer 26

Keep mother and baby together
Potentially no interruption in breastfeeding 
Decrease use of formula
Easy to administer
Low cost
Reduced admission to neonatal care

Question 27

What are the issues with the heel prick test?

Answer 27

Potential disruption in bonding/breastfeeding
Repeated heel sticks
Invasive procedures
Uncertainty in what “right” number should be
Discrepancy in accuracy of handheld glucometer and lab glucose values – handheld glucometer underestimates
Variation in specimen handling and obtainment
Some Trusts advocate discarding 1st 2 drops of blood in heel prick test and measuring the 3rd drop

Question 28

Hypoglycaemic brain injury in neonates

Answer 28

No large scale research projects
Persistent/recurrent hypoglycaemia may lead to long term neurodevelopment sequalae
Preterm infants ↑ risk of CP
Term born with <1.5mmol/l → MRI cerebral injury 4-7 days
↑ risk of ADHD, ↓ fine motor control, ↓ perception

Question 29

As a midwife how can you offer continuing support?

Answer 29

Prior to feeds assess baby for: level of consciousness,
tone, temperature, respiratory rate, colour
Once baby has had two consecutive blood glucose measurements of 2.6mmol/L or above then blood glucose monitoring can be stopped
Parents should be advised about what signs and symptoms to be aware of
Continue support with breastfeeding until well established
Listen to the mother’s concern

Question 30

What does the ‘British Association of Perinatal Medicine for Identification and management of neonatal hypoglycaemia in the full term’ (2017) recommend for the management of neonatal hypoglycaemia?

Answer 30

Identification of at risk infants
Breastmilk is ideal source of energy and breastfeeding should be encouraged
Parents should be given full information (including written) about why their baby is receiving extra support/care
Ward based blood gas analysers rather than handheld devices should be used for neonatal blood glucose measurement
Buccal/oral dextrose gel used for low blood glucose
Severe or persistent hypoglycaemia needs urgent medical review
Practitioners need to be able to distinguish between reluctant feeders and abnormal feeding