NEONATAL HYPOGLYCAEMIA

A. Definition:
Blood sugar < 2.6 mmol/L (approximately 45 mg/dl) in a term or premature infant.

B. Prevention and Early Detection

Anticipation & prevention, when possible, are keys to the management of
hypoglycaemia. Hypoglycaemia may produce long term neurological injury and
the level at which it occurs is controversial.

(i) Identify all high-risk neonates

Prematurity Small for gestational age

Hypothermia Birth Asphyxia / Perinatal Stress
Sepsis Infant of Diabetic Mother
Infant > 4 kg. Polycythaemia
Rhesus disease

(ii) Check glucometer/dextrostix on admission

(iii) Immediate feeding for all well babies who are at risk.
If hypoglycaemic on admission, repeat glucometer 1 hour later after feeding.
Continue monitoring at 2 hours and 4 hours later. (i.e. O,1,2, 4 hours)
If normoglycaemic on admission feed and monitor 6-8 hourly till past stage of
hypoglycaemic risk

(iv) Unwell babies (e.g. birth asphyxia or premature): set up a 10% dextrose drip.
Monitor blood sugar Hourly X 2
Then 2 hourly X 2
Then 4 → 6 → 8 hourly until stable

(v) Clinical features are:

Symptoms are non-specific. For example: apathy, hypotonia, apnoea, poor

sucking, cyanosis, abnormal cry, jitteriness, seizure, lethargy and temperature
instability.

C. If Hypoglycaemia is detected

1. Repeat the glucometer test. Send RBS stat for confirmation.

(Note: monitoring using reagent strip measurement is quick, cheap and easy
but not a precise method)
Check expiry date of test stick!

2. Is the infant symptomatic?

3. When was the last feed given? Is the intravenous drip adequate and running
well? (i.e. not disconnected or extravasated)
D. Asymptomatic Hypoglycaemia

 Feed early or bring forward next feed due.

 Feed 3 hourly.
 Recheck glucometer after 1 hour.
 If glucometer still < 2.6 mmol/L and child asymptomatic, can increase
feeds if child can tolerate. Otherwise,
Set up IV D 10% and give at least 72 ml/kg/day
(5 mg/kg/min of glucose)

 Continue enteral feeds as tolerated.

 Recheck glucometer hourly until stable and then 4-6 hourly.

E. Symptomatic Hypoglycaemia (Glucometer level immaterial)

Give a bolus of 2 ml/kg of IV Dextrose 10% slowly .

Follow-up by an infusion of glucose at 4-6 mg/kg/min (72ml/kg/day
D10%)
Keep nil by mouth
Repeat glucometer after 1/2 to 1 hour and increase the infusion as necessary
to 6-8 mg/kg/min (90 ml/kg/day D10%)

If infection is suspected or there is no alternative explanation for

hypoglycaemia take Blood C&S and treat as sepsis.

Once the blood glucose normalised, feeds can be reintroduced gradually and
infusion tailed off

F. If Hypoglycaemia persists

Take Blood C&S and treat as sepsis if not done yet.

Increase the rate of dextrose infusion if possible (i.e. do not increase beyond
daily requirement).

Increase the concentration of dextrose. Concentrations of 12.5% to 15% may

be needed. If concentration of  12.5% is used, a central line is required

If glucose infusion rates of more than 12mg/kg/min are required,

hyperinsulinism should be seriously considered and investigated accordingly.

Refer specialist

Consider
1. Glucagon 0.2 mg/kg IV (IM) bolus
2. Hydrocortisone 2.5 -5 mg/kg/dose bd IV
3. Diazoxide 5 mg bd orally
4. Adrenaline 500 ng/kg/min IV infusion
5. Somatostatin 1 - 4 microgram SC.

Also need to consider metabolic (See Approach to Hypoglycaemia under

Metabolic section) and endocrine workup.
Key points:
A. Serial blood glucose should be routinely monitored in infants who have risk factors for
hypoglycaemia

B Bolus injections of large volumes of hypertonic glucose solutions should be

avoided - dangerous to neurological function and may be followed by a rebound
hypoglycaemia, cerebral oedema and is caustic to neonatal veins.

C Milk formula provide more energy/ml than 10% dextrose and supply important non-
glucose fuels, which have a glucose sparing role in neurological function.
(Energy content of formula milk is 2750 kJ/l while that of 10% D is 1600 kJ/l). It
promotes ketogenesis and gut maturation.
Breast-feeding should be encouraged as it is more ketogenic.

D. Milk feeds must not be discontinued or reduced when intravenous fluids are given
unless the child develops NEC or other causes of feeding intolerance. The
recommended practice is to feed the baby with as much milk as is tolerated and
to infuse glucose at a rate sufficient to prevent hypoglycaemia. The IV glucose is
then reduced slowly while milk feeds is maintained or increased. May need to
continue over a few days.

E. Ensure volume of intravenous fluid is appropriate for patient, taking into consideration
concomitant problems like cardiac failure, cerebral oedema and renal failure. If unable
to increase volume further, concentration of dextrose to be increased.

Glucose requirement (mg/kg/min) = % of dextrose x rate (ml/hr) x 0.167

-------------------------------------------------------
wt (kg)

F. Plasma glucose is 13-18% higher than whole blood glucose. Arterial blood has higher
glucose concentration than venous blood. Capillary sampling can be unreliable in the
presence of poor peripheral circulation.

G. Requirement of >9mg/kg/min suggests hyperinsulinism. Truly hyperinsulinaemic babies

may require 15-20 mg/kg/min

References
Koh G Aynsley-Green A 1988a Neonatal hypoglycaemia- the controversy definition. Arch Dis
Childhood;63:1386-1398
Koh G Aynsley-Green A Tarbit A Etre J 1988b Neural dysfunction during hypoglycaemia. Arch Dis
Childhood;63:1353-1358
DK Pal et al 2000 Neonatal hypoglycaemia in Nepal. Prevalence and risk factors Arch Dis
Childhood;82:F46-52
AA M Moris et al 1996 Evaluation of fast for investigating hypoglycaemia or suspected metabolic disease
Arch Dis Childhood;75:115-119
th
Gomella, Cunningham ,Eyal and Zenk: Neonatalogy 4 edition Lange