neonatal hypoglycemia

Neonatal Hypoglycemia: Neonatal Hypoglycemia: Evidences and Practice Evidences and Practice Prof. Pushpa Raj Sharma Department of Child Health • Inability to breast feed and weight <2500 g were independently associated with hypoglycaemia. Mortality was 45.2% compared to 19.6% in normoglycaemic neonates (p < 0.001). Osier FH, Berkley JA, Ross A, Sanderson F, Mohammed S, Newton CR. Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome. Arch Dis Child. 2003 Jul;88(7):621-5. • 41% newborn infants had mild (less than 2.6 mmol/l) and 11% had moderate hypoglycaemia: Hospital based study. Pal DK, Manandhar DS, Rajbhandari S, Land JM, Patel N, de L Costello AM. Arch Dis Child Fetal Neonatal Ed. 2000 Jan;82(1):F46-51. Why This Topic is Important? Why This Topic is Important? Koivisto M, Blaco-Sequeiros M, Krause U. Neonatal Koivisto M, Blaco-Sequeiros M, Krause U. Neonatal symptomatic hypoglycaemia: a follow-up study of 151 symptomatic hypoglycaemia: a follow-up study of 151 children. Dev Med. Child Neurol 1972; 14:603-14 children. Dev Med. Child Neurol 1972; 14:603-14  Their conclusions? TIME is most important factor affecting onset of sx and SYMPTOMATIC hypoglycemia with convulsions has poor prognosis for permanent CNS damage, while asymptomatic hypoglycemia without convulsions appears to have no influence on CNS pathology Long term neurological outcomes  Lucus A, Morley R, Cole TJ. Adverse neurodevelopmental outcome of moderate neonatal hypoglycemia. British Medical Journal 1988; 297:1304-1308  661 preterm infants (BW <1850 g) surviving >48hrs  Weekly glucose level taken; reagent strips q6h for first 48-72 hours (if <1.5 or 2 low values below 2.5  blood test)  Treated by feeds/iv or bolus if less than 1 mmol/l or sx  At 18 months  92% assessed with Bayley motor and development scale  Results examined by statistical adjustment for differences between infants with and without hypoglycemia Lucus A, Morley R, Cole TJ. Lucus A, Morley R, Cole TJ.  Their findings? <2.6 on 3 to 30 separate days  associated with reductions in Bayley motor ad mental development scores even after adjusting for confounding factors <2.6 on 5 or more consecutive days  increased risk (3.5 fold) of CP Kinnala et al. Cerebral magnetic resonance Kinnala et al. Cerebral magnetic resonance imaging and ultrasonography findings after imaging and ultrasonography findings after neonatal hypoglycemia. Pediatrics 103; 1999 neonatal hypoglycemia. Pediatrics 103; 1999  Investigated neuroradiologic changes in the brains of infants after transient neonatal hypoglycemia via MRI and U/S  Def’n of hypoglycemia: <2.5 mM WITH symptoms  Treatment included feeds, IV, hydrocortisone  MRI and US at fullterm and at 2m in 18 symptomatic fullterms (6 babies with SGA, 2 infants of diabetic mom) without any other pathology and 19 term controls Kinnala et al. Cerebral magnetic resonance Kinnala et al. Cerebral magnetic resonance imaging andultrasonography findings after imaging andultrasonography findings after neonatal hypoglycemia. Pediatrics 103; 1999 neonatal hypoglycemia. Pediatrics 103; 1999 Results?  39% of hypoglycemic infants had abnormalities detected on MRI  4 showed patchy hyperintensity lesions in occipital periventricular white matter of the thalamus; lesions recovered by 2 months with only 1 neurologically affected  Controls  10% had caudothalamic cysts  Relative risk of hypoglycemic child compared with normoglycemic child to have ay abnormality detected in the brain was 3.7 (4x more often)  Developmental assessment at 11 months  94% normal; 1 infant had rightsided hemiplegia ad tremors Glucose Physiology in a Nutshell! Glucose Physiology in a Nutshell! FETUS:  Energy as glucose, lactate, FFAs, ketones, surplus amino acids  Gluconeogenesis & ketogenesis virtually absent  Energy stored at rapid rate (100 cal of fat/day in 9 th month!) AT DELIVERY:  Adaptive response  surge in plasma glucagon & decrease in plasma insulin  mobilizes glucose & fatty acids from glycogen & triglyceride depots Glucose Physiology II…. Glucose Physiology II…. NEONATE:  Stores become insufficient so must rely on gluconeogenesis  Glucose is main oxidative fuel, but neonates can oxidize ketone bodies, lactate & amino acids  Glucose requirements exceed those of adults mainly b/c of increased ratio of brain to body mass  Low blood glucose values are usually NOT related to any significant problem but are 2 0 to normal process of metabolic adaptation to extrauterine life Definition of neonatal Definition of neonatal hypoglycemia hypoglycemia • The definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology. Cornblath M, Hawdon JM, Williams AF, Aynsley-Green A, Ward- Platt MP, Schwartz R, Kalhan SC. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics. 2000 May;105(5):1141-5. [...]... Krause U Neonatal symptomatic hypoglycaemia: a follow-up study of 151 children Dev Med Child Neurol 1972; 14:603-14 Lucas A, Morley R, Cole TJ Adverse deurodevelopmental outcome of moderate neonatal hypoglycemia BMJ 297: 1304-1308, 1988 Pal DK, Manandhar DS, Rajbhandari S, Land JM, Patel N, de L Costello AM Neonatal hypoglycaemia in Nepal 1 Prevalence and risk factors Arch Dis Child Fetal Neonatal. ..Approaches to defining neonatal hypoglycemia! Clinical Manifestations  Must fulfill Whipple’s Triad a) Low glucose b) S&S consistent with hypoglycemia (eg Jitteriness, tremors, lethargy, seizures, apnea, cyanotic spells, hypotonia, difficulty feeding, hypothermia, coma) c) Resolution... Nepal 1 Prevalence and risk factors Arch Dis Child Fetal Neonatal Ed 2000 Jan;82(1):F46-51 Cornblath et al Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds Pediatrics 105: 153-157, 2000 Conrblath M and Ichord R Hypoglycemia in the neonate Seminars in Perinatology 24: 136-151, 2000 “A man with a watch knows what time it is A man with two watches is never... D10W >60 cc/kg/day (if can’t feed) • Prevent cold stress What if hypoglycemia occurs prolonged, recurrent or persistent? Recurrent of Persistent Hypoglycemia: 1) Require infusions of large amts of glucose (>1216 mg/kg/min) to maintain normoglycemia What if hypoglycemia occurs prolonged, recurrent or persistent? 1) Persisting or recurring beyond the first 7-14 days of life **Prompt recognition is essential!!... plasma at which the individual demonstrates a unique response to the abnormal milieu caused by the inadequate delivery of glucose to a target organ Cornblath et al Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds Pediatrics 105: 153-157, 2000  Provides large margin of safety by designating the lower level of glucose that a neonate can safely tolerate based on... SURGE and REBOUND HYPOGLYCEMIA  Try to use a max of 2 boluses of D10W • Always think about your maintenance fluid If at TFI 120cc/kg/day for premie and 100cc/kg/day in term in first 24 hours, consider switching to D12.5W or D15W What can be done to prevent it? • Early feeding • Supplements by gavage if can’t suck • IV D10W >60 cc/kg/day (if can’t feed) • Prevent cold stress What if hypoglycemia occurs... statistical definition of glucose values < or = to 2 SD below the mean in the population of well full term & LBW infants “in neonates any value below 40 mg/dL (2.8 mM) be viewed with suspicion”: Sperling MA in Hypoglycemia; Chapter 77, page 420 Nelson’s Textbook of Paediatrics, 15 th ed Operational Threshold • Indication for intervention  Based on evidence currently available in the literature Concentration . after neonatal hypoglycemia. Pediatrics 103; 1999 neonatal hypoglycemia. Pediatrics 103; 1999  Investigated neuroradiologic changes in the brains of infants after transient neonatal hypoglycemia. definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics. 2000 May;105(5):1141-5. Approaches to defining neonatal Approaches to defining neonatal hypoglycemia! hypoglycemia! Clinical. to extrauterine life Definition of neonatal Definition of neonatal hypoglycemia hypoglycemia • The definition of clinically significant hypoglycemia remains one of the most confused