Neonatal_Hypoglycemia_Flashcards
What is considered neonatal hypoglycemia?
Neonatal hypoglycemia is commonly defined as a blood glucose level of < 2.6 mmol/L.
Why can normal term babies manage early hypoglycemia without issues?
Normal term babies can use alternate fuels like ketones and lactate, which helps them manage early hypoglycemia without adverse effects.
What are some causes of persistent or severe neonatal hypoglycemia?
Causes include preterm birth, maternal diabetes mellitus, intrauterine growth restriction (IUGR), hypothermia, neonatal sepsis, inborn errors of metabolism, nesidioblastosis, and Beckwith-Wiedemann syndrome.
What are typical features of neonatal hypoglycemia?
Features can include jitteriness, irritability, tachypnea, pallor, poor feeding/sucking, weak cry, drowsiness, hypotonia, seizures, apnea, and hypothermia.
How is asymptomatic neonatal hypoglycemia managed?
Management involves encouraging normal feeding, whether breast or bottle, and monitoring blood glucose levels.
What is the management for symptomatic neonatal hypoglycemia or very low blood glucose levels?
Management includes admitting the newborn to the neonatal unit and starting an intravenous infusion of 10% dextrose.
summarise
Neonatal hypoglycaemia
Normal term babies often have hypoglycaemia especially in the first 24 hrs of life but without any sequelae, as they can utilise alternate fuels like ketones and lactate. There is no agreed definition of neonatal hypoglycaemia but a figure of < 2.6 mmol/L is used in many guidelines.
Transient hypoglycaemia in the first hours after birth is common.
Persistent/severe hypoglycaemia may be caused by:
preterm birth (< 37 weeks)
maternal diabetes mellitus
IUGR
hypothermia
neonatal sepsis
inborn errors of metabolism
nesidioblastosis
Beckwith-Wiedemann syndrome
Features
may be asymptomatic
autonomic (hypoglycaemia → changes in neural sympathetic discharge)
‘jitteriness’
irritable
tachypnoea
pallor
neuroglycopenic
poor feeding/sucking
weak cry
drowsy
hypotonia
seizures
other features may include
apnoea
hypothermia
Management depends on the severity of the hypoglycaemia and if the newborn is symptomatic
asymptomatic
encourage normal feeding (breast or bottle)
monitor blood glucose
symptomatic or very low blood glucose
admit to the neonatal unit
intravenous infusion of 10% dextrose
A baby boy is born by vaginal delivery at 37 weeks after his mother was induced due to pre-eclampsia. All routine foetal ultrasounds and monitoring throughout pregnancy were normal and the boy appears healthy at birth, with APGAR scores of 8 and 9 at 1 and 5 minutes.
As the baby’s mother was taking labetalol at the time of delivery, the baby is fed within 30 minutes of birth (with infant formula per maternal choice) and the blood glucose is checked after 4 hours. This is 2.1mmol/L. The baby’s observations are normal but he appears pale and ‘jittery’.
What is the appropriate management?
Admit to NICU for intravenous 10% dextrose
Admit to NICU for intravenous 20% dextrose and arrange screening for underlying metabolic disorders
Admit to NICU for nasogastric feeding
Encourage normal feeding and re-assess blood glucose in 4 hours
Give more formula now and re-assess blood glucose in 1 hour
Neonatal hypoglycaemia: if symptomatic or very low blood glucose admit to neonatal unit and give IV 10% dextrose
Important for meLess important
Admit to NICU for intravenous 10% dextrose is correct. Neonatal hypoglycaemia needs to be treated if the baby is symptomatic (as in this case) or if the blood glucose is very low (often quoted as under 1mmol/L). This baby has been put on a hypoglycaemia pathway as maternal antenatal labetalol use can increase the risk of neonatal hypoglycaemia.
Admit to NICU for intravenous 20% dextrose and arrange screening for underlying metabolic disorders is not correct. Firstly, 10% dextrose is advised by NICE. Secondly, this baby’s symptomatic hypoglycaemia is almost certainly due to maternal labetalol use. Screening for an underlying cause such as a metabolic disorder would be indicated if the hypoglycaemia was persistent or did not respond to treatment. It is not indicated currently.
Admit to NICU for nasogastric feeding is not the correct option. As this baby is symptomatic of hypoglycaemia, he must receive immediate treatment. Intravenous dextrose will raise his blood glucose more rapidly than enteral feeding would.
Encourage normal feeding and re-assess blood glucose in 4 hours would be appropriate if the baby was asymptomatic. However, as this is not the case, he requires urgent treatment to restore his blood glucose and prevent the worsening of his condition.
Give more formula now and re-assess blood glucose in 1 hour is incorrect. As he is symptomatic, he needs to be moved to NICU for close monitoring and treatment to quickly restore his blood glucose. This will be best achieved with intravenous glucose.
Summary of neonatal hypoglycaemia
Neonatal hypoglycaemia
Normal term babies often have hypoglycaemia especially in the first 24 hrs of life but without any sequelae, as they can utilise alternate fuels like ketones and lactate. There is no agreed definition of neonatal hypoglycaemia but a figure of < 2.6 mmol/L is used in many guidelines.
Transient hypoglycaemia in the first hours after birth is common.
Persistent/severe hypoglycaemia may be caused by:
preterm birth (< 37 weeks)
maternal diabetes mellitus
IUGR
hypothermia
neonatal sepsis
inborn errors of metabolism
nesidioblastosis
Beckwith-Wiedemann syndrome
Features
may be asymptomatic
autonomic (hypoglycaemia → changes in neural sympathetic discharge)
‘jitteriness’
irritable
tachypnoea
pallor
neuroglycopenic
poor feeding/sucking
weak cry
drowsy
hypotonia
seizures
other features may include
apnoea
hypothermia
Management depends on the severity of the hypoglycaemia and if the newborn is symptomatic
asymptomatic
encourage normal feeding (breast or bottle)
monitor blood glucose
symptomatic or very low blood glucose
admit to the neonatal unit
intravenous infusion of 10% dextrose
You are called to the post natal ward to review an 8 hour old baby born by elective caesarian section at 39 weeks gestation. After reading the case notes you discover the use of maternal labetalol for high blood pressure. On examination the baby appears jittery and hypotonic. What is the most appropriate next step?
Record temperature and ensure adequately wrapped
Perform full septic screen
Measure blood glucose levels
Start empirical antibiotics for early onset sepsis
Re-examine after next feed
Measure blood glucose levels
A jittery and hypotonic baby may suggest neonatal hypoglycaemia. The use of maternal labetalol is a risk factor and these babies must have their blood glucose measured. Neonatal abstinence syndrome may also present in this way and so the use of maternal opiates or illicit drug use in pregnancy should also be ascertained.
The neonatal junior doctor has been asked to review a 3 hour old term baby by the midwife. There were no antenatal concerns and the mother had not been on any medication antenatally, and is keen to breastfeed. The midwife was concerned because the baby appeared lethargic and had not latched to the breast as yet. She has taken a heel prick blood sugar test from the baby.
Glucose 2.3 mmol/L (4.0-5.9)
On examination the baby was easily rousable and appeared to be rooting. He had a good suck and handled well. He had a normal tone, was not jittery and cardiovascular examination was normal. He had not yet passed urine or opened his bowels.
What should the neonatal junior doctor do as the first step in her management plan of this baby?
Admit the baby to the neonatal unit for a glucose infusion
Ask the breastfeeding support team to come and support mum and baby with attempting a further feed now
Encourage the mother to give a formula feed to the baby
Give buccal glucose and then measure blood sugar again pre next feed in 4 hours
Recheck the blood sugar in 2 hours
Ask the breastfeeding support team to come and support mum and baby with attempting a further feed now
Transient hypoglycaemia in the first hours after birth is common
This mother would like to breastfeed and should have access to support to be able to do so. Skin-to-skin contact should be encouraged and support regarding latching given. If the baby is not feeding effectively then the mother can be taught to hand express and the colostrum given to the baby bia a different method. Once a feed is given effectively, the blood glucose can be taken again prior to the next feed (no more than 3 hours apart). If a feed is not able to be given effectively, then alternative options should be considered at that point.
Buccal glucose can be given to babies who are asymptomatic but must be used in conjunction with a feeding plan, which should not allow the baby to go for more than 3 hours between feeds.
This baby has no risk factors for hypoglycaemia and has not had a first feed. He has asymptomatic hypoglycaemia and has a blood sugar over 1mmol/L and therefore does not need admission for intravenous therapy.
If mother is keen to breastfeed, she should be given the information and support to encourage her to do so, rather than encouraged to switch to formula after one attempt with a well, asymptomatic term baby.
This baby has not yet had a feed and is mildly hypoglycaemic. Therefore action should be taken and the blood sugar checked again following the intervention (ideally prior to the next feed).
Identification and Management of Neonatal Hypoglycaemia in the Full Term Infant (2017). A BAPM Framework for Practice.
A baby is 12 hours old and was born at term. The mother had gestational diabetes during her pregnancy. The mother has chosen to formula feed exclusively. The baby is currently comfortable on the postnatal ward, and her latest capillary blood glucose reading is 2.3mmol/L. The examination is normal.
What would be the next step in management?
Encourage breastfeeding
Encourage formula feeding
Refer to lactation consultant
Use glucose gel alongside normal feeding method
Admit to neonatal unit and start 10% dextrose
Encourage formula feeding
Neonatal hypoglycaemia: if asymptomatic then encourage normal feeds and monitor glucose
Encouraging formula feeding is the correct answer - the question states that the mother has chosen to formula feed exclusively. The baby has asymptomatic hypoglycemia (a risk factor being maternal gestational diabetes), so the regular feeding method should be encouraged and capillary blood glucose to be repeated after.
You would not encourage breastfeeding or refer to a lactation consultant here as the mother’s choice is to formula feed.
Use of glucose adjuncts such as 10% dextrose intravenously or glucose gel would only be required if there was persistent hypoglycaemia despite the regular feeding method, or if the baby was symptomatic, so these answers are incorrect.
A 2-hour-old baby boy is brought back to the postnatal ward with his mother following an uncomplicated spontaneous vaginal delivery. The baby appears well, his APGAR scores were satisfactory and he has already established breastfeeding.
As the boy’s mother was taking labetalol during pregnancy, a routine capillary blood glucose test is performed. This gives a reading of 2.3 mmol/L.
What is the most appropriate management?
Admit the baby to the neonatal care unit for close observation
Admit the baby to the neonatal care unit for intravenous glucose
Continue breastfeeding and monitor blood glucose
Give a formula feed and re-check blood glucose thereafter
Reassure the mother that this result is normal for a newborn
Continue breastfeeding and monitor blood glucose
Neonatal hypoglycaemia: if asymptomatic then encourage normal feeds and monitor glucose
Continue breastfeeding and monitor blood glucose is the appropriate management of this newborn’s hypoglycaemia. Blood glucose is not routinely checked in newborns unless there are concerns or there are risk factors for hypoglycaemia - in this case, the maternal use of labetalol is a risk factor. This baby’s reading of 2.3 mmol/L indicates mild hypoglycaemia (generally defined as under 2.6 mmol/L in the newborn). This is not uncommon. If there are no symptoms of hypoglycaemia (such as jitteriness, poor feeding, lethargy, etc.) then it is appropriate to continue the current feeding method (breastfeeding in this case) and monitor the blood glucose.
Admit the baby to the neonatal care unit for close observation is not necessary as transient neonatal hypoglycaemia is common and this baby is asymptomatic.
Admit the baby to the neonatal care unit for intravenous glucose would be necessary if the baby was symptomatic of hypoglycaemia or had very severe hypoglycaemia (e.g. blood glucose under 1 mmol/L) or if the hypoglycaemia was persistent despite feeding.
Give a formula feed and re-check blood glucose thereafter is not necessary. Babies with mild, asymptomatic hypoglycaemia can continue their normal feeds. For this baby, that is breastfeeding.
Reassure the mother that this result is normal for a newborn would be incorrect, as a blood glucose of under around 2.6 mmol/L in a newborn is indicative of hypoglycaemia.
