Newborn hypoglycemia is a frequent condition, although the parameters defining hypoglycemia remain ambiguous. Existing practices for prevention and management are chiefly based on practices and opinions rather than empirical practice guidelines. However, there is still a lack of knowledge in this area, especially what is deemed normal in neonates because transient hypoglycemia is expected in the first 48 hours of infancy.
In the study that Lucas et al conducted in 1988, they set the blood glucose level of 47mg/dL as the level that correlates neurodevelopmental problems in premature infants, and this is what was adopted for all the new borns. Although hypoglycemia is dangerous when its level is reduced to extremely low and can provoque seizes, status, and brain damaging, the outcome of short, non-symptomatic hypoglycaemia is not clear. The authors were unable to identify a specific glucose level below which adverse outcome can be predicted with certainty and acknowledge other factors that may influence the relationship between low glucose status and developmental problems.
Epidemiology
For this reason, the reported neonatal hypoglycemia rates differ as they depend on the population analysed, time and frequency of glucose assessment, methods of assessment and the definition of hypoglycaemia. In a cross-sectional study conducted in 2006 by Harris, et al, researchers assessed the incidence of hypoglycaemia (plasma glucose of less than 47 mg/dL) within 48 hours in infants born at or after 35 weeks of gestation who were deemed high risk based on the classification outlined in the AAP guidelines. The cross-sectional study revealed that 25% of neonates were assertively at risk and within this group 51% had at least one hypoglycaemic episode.
Anatomy
Pathophysiology
Glycogen Depletion: Newborns depend on glycogen deposited in the liver during last trimester of pregnancy. Low birth weight babies or growth retarded babies especially those born preterm have lower glycogen stores in their livers and thus have the tendency to develop hypoglycemia early in life after birth.
Inadequate Gluconeogenesis: Neonates’ ability to produced glucose from amino acids, lactates, and glycerol is very limited especially in preterm neonates because gluconeogensis enzymes are not well developed at birth.
Increased Insulin Sensitivity: Hyperinsulinemia such as in infants of diabetic mothers or congenital hyperinsulinism promotes the uptake of glucose by tissues and suppresses gluconeogenesis, resulting in hypoglycemia.
Etiology
Hyperinsulinism (PHHI): Hyperinsulinism of infancy (HI) is a condition characterized by recurrent severe hypoglycemia due to excessive insulin release from pancreatic beta-cells.
Limited Glycogen Stores: Such factors as prematurity or intrauterine growth restriction (IUGR) mean there is less glycogen stored and thus restricted glucose.
Increased Glucose Utilization: Conditions like hyperthermia, polycythemia, sepsis, or growth hormone deficiency cause the body to need more glucose resulting to hypoglycemia.
Impaired Glycogenolysis or Gluconeogenesis: Pathological states such as metabolic disorders, adrenal insufficiency or inborn errors of metabolism interfere with glycogen breakdown or glucose synthesis hence resulting in hypoglycemia.
Glycogen Depletion: It reduces glycogen stores through stress, asphyxia, or starvation but the store becomes useless in ketotic hypoglycemia where gluconeogenesis is less than sufficient to require fatty acid metabolism in glycogen deficit. Ketones which are an indication that the body is starved are commonly found in the urine.
Genetics
Prognostic Factors
Severity and Duration of Hypoglycemia: Severe hypoglycemia refers to blood glucose concentrations below 40 mg/dL, and infants with PPH, prolonged hypoglycemia, or hypoglycemia of any severity are at higher risk of adverse outcomes including, neurodevelopmental delay and cerebral injury.
Timing of Hypoglycemia: Hypoglycemia occurring within the first two days of life is usually mild and physiological Still, hypoglycemia developing after 48 hours of life is typically a more serious condition that can stem from other illnesses that may be present in the baby, and such cases usually have a poorer prognosis in most cases.
Gestational Age: As birth, preterm infants exhibit higher susceptibility to developing hypoglycemia because of immature metabolic pathways, lower levels of stored glycogen and hormonal feedback and control abilities. There is a general negative dose-response relationship between the gestational age at the time of exposure and the severity of adverse outcomes.
Birth Weight and Size for Gestational Age: Low birth weight infants which includes SGA and LGA are at higher risk of hypoglycemia. The SGA infants may have low glycogen reserve and the LGA infants: especially the babies of diabetic mothers are prone as they are hyperinsulinemic.
Underlying Conditions: In general, hypoglycemic encephalopathy due to congenital or inherited diseases or other non-traumatic chronic disorders, including persistent hyperinsulinemia hypoglycemia of infancy (PHHI), inborn errors of metabolism, or endocrine disease has a poorer prognosis because of its chronic or repeated nature.
Response to Treatment: This may include children who receive glucose feed or intravenous dextrose early and recover quickly are destined to have less complications compared with children who have refractory hypoglycemia and are harder to manage.
Clinical History
Age Group
Newborns (0-48 hours): The hypoglycemia mainly presents within the first hours to days of life with the majority occurring within the first 48 hours of life. This is the situation when glucose homeostasis is in a period of developmental transition from fetal to the postnatal period.
Preterm infants (<37 weeks gestation) and Term infants (>37 weeks gestation): It can occur to both preterm and term neonate but the preterm has high chances since their regulatory centre for glucose is not fully developed.
Physical Examination
General Appearance: Drowsiness, inappetence or anorexia, increased: irritability.
Neurological Signs: Muscle twitching, shaking, convulsions, hypotonia, or lethargy.
Cardiopulmonary Signs: Apnea, bradycardia, or tachypnea: Apnea is the complete cessation of breathing while bradycardia is a slow heart rate and tachypnea is a fast breathing rate.
Skin and Circulatory: Paleness, blueness or sweating, Sweating.
Gastrointestinal: Vomiting
Age group
Associated comorbidity
Infants of Diabetic Mothers (IDM): Hyperglycemia during pregnancy, whether gestational or pre-existing diabetes, leads to neonatal hyperinsulinism and subsequently hypoglycemia.
Intrauterine Growth Restriction (IUGR) or Small for Gestational Age (SGA): Most of these infants have reduced glycogen reserves leading to the high incidence of hypoglycemia.
Large for Gestational Age (LGA): Such infants are usually born to mothers with diabetes, and they may end up having high levels of insulin which may lead to hypoglycemia.
Preterm Birth: Preterm infants are at higher risk because of their low glycogen reserves and immature metabolic processes.
Perinatal Stress (Asphyxia, Birth Trauma): According to the levels of the birth stress, the glycogen stocks are burned through rapidly and hypoglycemia appears in the infants.
Sepsis: Neonatal infections are associated with increased blood sugar requirement for tissue maintenance and increased metabolic rate, thus resulting in hypoglycemia.
Associated activity
Acuity of presentation
Neonatal hypoglycemia is abrupt in its severity and typically manifests within the first two days of newborn’s life. The symptoms do not always come gradually, they range from moderate to severe and can appear at any first.
Symptoms:
Mild: Neglect or abuse, failure to be fed, tremors, hyperactivity, and lethargy, pale skin, or low muscle tone.
Moderate to Severe: Worse signs include muscle weakness which may feature conditions such as fatigue or coma if the disease progresses without adequate treatment.
Asymptomatic Hypoglycemia: Diabetic babies are some of the most challenging to diagnose because some of them, especially newborns, may present few or no symptoms and the test is done routinely on newborns- generally through monitoring of blood glucose.
Differential Diagnoses
Hyperinsulinemia
Adrenal Insufficiency
Congenital Hypopituitarism
Congenital Hypothyroidism
Infection
Prematurity:
Neonatal Stress
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Initial Assessment and Monitoring: A clinical assessment should be conducted to look for signs of hypoglycemia and the patient’s risk factors. Blood glucose levels should be constantly checked in high-risk infants or those with symptoms such as lethargy.
Immediate Management:
Feed the Infant: For the diagnosis of mild hypoglycemia (blood glucose level slightly below normal), initial management should involve the enteral route administration using breast milk or formula. It has been suggested that overloading the child can lead to the fluctuations of glucose levels, whereas their increased stabilization can be achieved through frequent feeding.
Intravenous Glucose: In cases of moderate to severe hypoglycemia or when the infant cannot feed, give intravenous dextrose to enhance the glucose level quickly.
Initial Dose: Orally, fluid resuscitation usually involves the use of 10% dextrose solution; for instance, 5-10 ml/kg.
Address Underlying Causes:
Hyperinsulinemia: In the case of PHHI, the patient should be given diazoxide or octreotide, or a surgical procedure can be performed in case of necessity.
Metabolic Disorders: Address other associated metabolic disorders with appropriate therapies including enzyme replacement or diet manipulation.
Endocrine Disorders: Treat diseases such as adrenal insufficiency with a proper hormonal replacement.
Preventive Measures and Long-Term Management:
Continuous Monitoring: Infants at high risk, or infants who have had recurrent hypoglycemic episodes, glucose monitoring may be necessary. Feeding Protocols: Implement measures such that hypoglycemia is not repeated especially in the high-risk infants including the small-for-gestational age and preterm infants.
Early and Frequent Feeding: Start on breastfeeding or bottle feeding immediately and thereafter feed the child with small quantities of food more often.
Frequent Monitoring: Self-monitored blood glucose measurement should be performed periodically and should be continuous in high-risk infants.
Feeding Protocols: They should modify their feeding timings by practicing more of a schedule feeding routine to avoid hypoglycemia.
Skin-to-Skin Contact: After the birth of the baby should be used kangaroo care to strengthen and stabilize the temperature of the child, as well as to support early feeding.
Temperature Regulation: Maintain the temperature of the infant to avoid hypoglycemia due to hypothermia.
Role of Anti-hypoglycemic Agents
Dextrose: It is used for the management of hypoglycemia in newborns and is the first line of treatment in this condition. If given orally, it is rapidly absorbed through the intestinal wall, and it will thus cause a rapid rise in blood glucose levels. In cases of infants of diabetic mothers with transient neonatal hyperinsulinemia, dextrose should be administered intravenously and until the condition persists. This may at times need caution to ensure one does not get hypersensitive, this leads to the production of insulin which in turn leads to a drop in blood sugar, hypoglycemia.
Diazoxide: It increases blood glucose by suppressing secretion of insulin in pancreas and, perhaps, through other mechanisms. It starts to function after an hour, and it is observable that it remains effective within a period of eight hours in those people with sound kidney. It is used mostly in SGA infants and those developing maternal toxemia or perinatal asphyxia.
Octreotide: It is a peptide drug belonging to somatostatin analogs and it may be used in short term treatment of hypoglycemia by inhibiting insulin release.
Glucagon: It is given in the management of hypoglycemia due to hyperinsulinemia especially where intravenous line has not been established. It is provided in a concentration of 1 mg (1 U) per mL in vials. Using IV, glucose concentrations are at their optimum within 5 to 20 minutes while IM administration, the glucose concentrations take about 30 minutes to reach the peak.
Intravenous Glucose Administration: Introduce an IV catheter and perform the bolus administration of a dextrose solution (e.g. 10% dextrose) to quickly raise blood glucose levels. Used to correct severe hypoglycemia in infants and helps to ameliorate fluctuating glucose levels in susceptible infants.
Intramuscular Glucagon Injection: If the IV access is not achievable or there is a problem with glucose infusion then glucagon is to be given IM. Raises blood glucose levels by glycogenolysis meaning the breakdown of stored glycogen to glucose in the liver to be useful in emergency times. Gastric Tube Feeding: Perform nasogastric (NG) intubation if a patient can’t eat an adequate amount of food, or if he or she only takes small portions of food at a time. Useful for determining sufficient glucose intake in poorly nourished infants, thus preventing and treating hypoglycemia.
Initial Assessment and Stabilization: Immediately recognize hypoglycemia and give glucose orally, if the condition is mild; or intravenously, if severe, to restore blood glucose level as quickly as possible.
Underlying Cause Evaluation and Management: Hypoglycemia must be accrued and treated according to the primary cause such as metabolic or endocrine disorders.
Monitoring and Ongoing Care: Promoting blood glucose level checks, setting feeding regimen and supportive care to ensure appropriate levels of glucose are maintained.
Preventive Measures and Long-Term Management: Carefully plan the feeding of the child, provide information to the parents and arrange for subsequent appointments to avoid relapse and improve the child’s health and well-being.
Newborn hypoglycemia is a frequent condition, although the parameters defining hypoglycemia remain ambiguous. Existing practices for prevention and management are chiefly based on practices and opinions rather than empirical practice guidelines. However, there is still a lack of knowledge in this area, especially what is deemed normal in neonates because transient hypoglycemia is expected in the first 48 hours of infancy.
In the study that Lucas et al conducted in 1988, they set the blood glucose level of 47mg/dL as the level that correlates neurodevelopmental problems in premature infants, and this is what was adopted for all the new borns. Although hypoglycemia is dangerous when its level is reduced to extremely low and can provoque seizes, status, and brain damaging, the outcome of short, non-symptomatic hypoglycaemia is not clear. The authors were unable to identify a specific glucose level below which adverse outcome can be predicted with certainty and acknowledge other factors that may influence the relationship between low glucose status and developmental problems.
For this reason, the reported neonatal hypoglycemia rates differ as they depend on the population analysed, time and frequency of glucose assessment, methods of assessment and the definition of hypoglycaemia. In a cross-sectional study conducted in 2006 by Harris, et al, researchers assessed the incidence of hypoglycaemia (plasma glucose of less than 47 mg/dL) within 48 hours in infants born at or after 35 weeks of gestation who were deemed high risk based on the classification outlined in the AAP guidelines. The cross-sectional study revealed that 25% of neonates were assertively at risk and within this group 51% had at least one hypoglycaemic episode.
Glycogen Depletion: Newborns depend on glycogen deposited in the liver during last trimester of pregnancy. Low birth weight babies or growth retarded babies especially those born preterm have lower glycogen stores in their livers and thus have the tendency to develop hypoglycemia early in life after birth.
Inadequate Gluconeogenesis: Neonates’ ability to produced glucose from amino acids, lactates, and glycerol is very limited especially in preterm neonates because gluconeogensis enzymes are not well developed at birth.
Increased Insulin Sensitivity: Hyperinsulinemia such as in infants of diabetic mothers or congenital hyperinsulinism promotes the uptake of glucose by tissues and suppresses gluconeogenesis, resulting in hypoglycemia.
Hyperinsulinism (PHHI): Hyperinsulinism of infancy (HI) is a condition characterized by recurrent severe hypoglycemia due to excessive insulin release from pancreatic beta-cells.
Limited Glycogen Stores: Such factors as prematurity or intrauterine growth restriction (IUGR) mean there is less glycogen stored and thus restricted glucose.
Increased Glucose Utilization: Conditions like hyperthermia, polycythemia, sepsis, or growth hormone deficiency cause the body to need more glucose resulting to hypoglycemia.
Impaired Glycogenolysis or Gluconeogenesis: Pathological states such as metabolic disorders, adrenal insufficiency or inborn errors of metabolism interfere with glycogen breakdown or glucose synthesis hence resulting in hypoglycemia.
Glycogen Depletion: It reduces glycogen stores through stress, asphyxia, or starvation but the store becomes useless in ketotic hypoglycemia where gluconeogenesis is less than sufficient to require fatty acid metabolism in glycogen deficit. Ketones which are an indication that the body is starved are commonly found in the urine.
Severity and Duration of Hypoglycemia: Severe hypoglycemia refers to blood glucose concentrations below 40 mg/dL, and infants with PPH, prolonged hypoglycemia, or hypoglycemia of any severity are at higher risk of adverse outcomes including, neurodevelopmental delay and cerebral injury.
Timing of Hypoglycemia: Hypoglycemia occurring within the first two days of life is usually mild and physiological Still, hypoglycemia developing after 48 hours of life is typically a more serious condition that can stem from other illnesses that may be present in the baby, and such cases usually have a poorer prognosis in most cases.
Gestational Age: As birth, preterm infants exhibit higher susceptibility to developing hypoglycemia because of immature metabolic pathways, lower levels of stored glycogen and hormonal feedback and control abilities. There is a general negative dose-response relationship between the gestational age at the time of exposure and the severity of adverse outcomes.
Birth Weight and Size for Gestational Age: Low birth weight infants which includes SGA and LGA are at higher risk of hypoglycemia. The SGA infants may have low glycogen reserve and the LGA infants: especially the babies of diabetic mothers are prone as they are hyperinsulinemic.
Underlying Conditions: In general, hypoglycemic encephalopathy due to congenital or inherited diseases or other non-traumatic chronic disorders, including persistent hyperinsulinemia hypoglycemia of infancy (PHHI), inborn errors of metabolism, or endocrine disease has a poorer prognosis because of its chronic or repeated nature.
Response to Treatment: This may include children who receive glucose feed or intravenous dextrose early and recover quickly are destined to have less complications compared with children who have refractory hypoglycemia and are harder to manage.
Age Group
Newborns (0-48 hours): The hypoglycemia mainly presents within the first hours to days of life with the majority occurring within the first 48 hours of life. This is the situation when glucose homeostasis is in a period of developmental transition from fetal to the postnatal period.
Preterm infants (<37 weeks gestation) and Term infants (>37 weeks gestation): It can occur to both preterm and term neonate but the preterm has high chances since their regulatory centre for glucose is not fully developed.
General Appearance: Drowsiness, inappetence or anorexia, increased: irritability.
Neurological Signs: Muscle twitching, shaking, convulsions, hypotonia, or lethargy.
Cardiopulmonary Signs: Apnea, bradycardia, or tachypnea: Apnea is the complete cessation of breathing while bradycardia is a slow heart rate and tachypnea is a fast breathing rate.
Skin and Circulatory: Paleness, blueness or sweating, Sweating.
Gastrointestinal: Vomiting
Infants of Diabetic Mothers (IDM): Hyperglycemia during pregnancy, whether gestational or pre-existing diabetes, leads to neonatal hyperinsulinism and subsequently hypoglycemia.
Intrauterine Growth Restriction (IUGR) or Small for Gestational Age (SGA): Most of these infants have reduced glycogen reserves leading to the high incidence of hypoglycemia.
Large for Gestational Age (LGA): Such infants are usually born to mothers with diabetes, and they may end up having high levels of insulin which may lead to hypoglycemia.
Preterm Birth: Preterm infants are at higher risk because of their low glycogen reserves and immature metabolic processes.
Perinatal Stress (Asphyxia, Birth Trauma): According to the levels of the birth stress, the glycogen stocks are burned through rapidly and hypoglycemia appears in the infants.
Sepsis: Neonatal infections are associated with increased blood sugar requirement for tissue maintenance and increased metabolic rate, thus resulting in hypoglycemia.
Neonatal hypoglycemia is abrupt in its severity and typically manifests within the first two days of newborn’s life. The symptoms do not always come gradually, they range from moderate to severe and can appear at any first.
Symptoms:
Mild: Neglect or abuse, failure to be fed, tremors, hyperactivity, and lethargy, pale skin, or low muscle tone.
Moderate to Severe: Worse signs include muscle weakness which may feature conditions such as fatigue or coma if the disease progresses without adequate treatment.
Asymptomatic Hypoglycemia: Diabetic babies are some of the most challenging to diagnose because some of them, especially newborns, may present few or no symptoms and the test is done routinely on newborns- generally through monitoring of blood glucose.
Hyperinsulinemia
Adrenal Insufficiency
Congenital Hypopituitarism
Congenital Hypothyroidism
Infection
Prematurity:
Neonatal Stress
Initial Assessment and Monitoring: A clinical assessment should be conducted to look for signs of hypoglycemia and the patient’s risk factors. Blood glucose levels should be constantly checked in high-risk infants or those with symptoms such as lethargy.
Immediate Management:
Feed the Infant: For the diagnosis of mild hypoglycemia (blood glucose level slightly below normal), initial management should involve the enteral route administration using breast milk or formula. It has been suggested that overloading the child can lead to the fluctuations of glucose levels, whereas their increased stabilization can be achieved through frequent feeding.
Intravenous Glucose: In cases of moderate to severe hypoglycemia or when the infant cannot feed, give intravenous dextrose to enhance the glucose level quickly.
Initial Dose: Orally, fluid resuscitation usually involves the use of 10% dextrose solution; for instance, 5-10 ml/kg.
Address Underlying Causes:
Hyperinsulinemia: In the case of PHHI, the patient should be given diazoxide or octreotide, or a surgical procedure can be performed in case of necessity.
Metabolic Disorders: Address other associated metabolic disorders with appropriate therapies including enzyme replacement or diet manipulation.
Endocrine Disorders: Treat diseases such as adrenal insufficiency with a proper hormonal replacement.
Preventive Measures and Long-Term Management:
Continuous Monitoring: Infants at high risk, or infants who have had recurrent hypoglycemic episodes, glucose monitoring may be necessary. Feeding Protocols: Implement measures such that hypoglycemia is not repeated especially in the high-risk infants including the small-for-gestational age and preterm infants.
Endocrinology, Metabolism
Early and Frequent Feeding: Start on breastfeeding or bottle feeding immediately and thereafter feed the child with small quantities of food more often.
Frequent Monitoring: Self-monitored blood glucose measurement should be performed periodically and should be continuous in high-risk infants.
Feeding Protocols: They should modify their feeding timings by practicing more of a schedule feeding routine to avoid hypoglycemia.
Skin-to-Skin Contact: After the birth of the baby should be used kangaroo care to strengthen and stabilize the temperature of the child, as well as to support early feeding.
Temperature Regulation: Maintain the temperature of the infant to avoid hypoglycemia due to hypothermia.
Endocrinology, Metabolism
Dextrose: It is used for the management of hypoglycemia in newborns and is the first line of treatment in this condition. If given orally, it is rapidly absorbed through the intestinal wall, and it will thus cause a rapid rise in blood glucose levels. In cases of infants of diabetic mothers with transient neonatal hyperinsulinemia, dextrose should be administered intravenously and until the condition persists. This may at times need caution to ensure one does not get hypersensitive, this leads to the production of insulin which in turn leads to a drop in blood sugar, hypoglycemia.
Diazoxide: It increases blood glucose by suppressing secretion of insulin in pancreas and, perhaps, through other mechanisms. It starts to function after an hour, and it is observable that it remains effective within a period of eight hours in those people with sound kidney. It is used mostly in SGA infants and those developing maternal toxemia or perinatal asphyxia.
Octreotide: It is a peptide drug belonging to somatostatin analogs and it may be used in short term treatment of hypoglycemia by inhibiting insulin release.
Glucagon: It is given in the management of hypoglycemia due to hyperinsulinemia especially where intravenous line has not been established. It is provided in a concentration of 1 mg (1 U) per mL in vials. Using IV, glucose concentrations are at their optimum within 5 to 20 minutes while IM administration, the glucose concentrations take about 30 minutes to reach the peak.
Endocrinology, Metabolism
Intravenous Glucose Administration: Introduce an IV catheter and perform the bolus administration of a dextrose solution (e.g. 10% dextrose) to quickly raise blood glucose levels. Used to correct severe hypoglycemia in infants and helps to ameliorate fluctuating glucose levels in susceptible infants.
Intramuscular Glucagon Injection: If the IV access is not achievable or there is a problem with glucose infusion then glucagon is to be given IM. Raises blood glucose levels by glycogenolysis meaning the breakdown of stored glycogen to glucose in the liver to be useful in emergency times. Gastric Tube Feeding: Perform nasogastric (NG) intubation if a patient can’t eat an adequate amount of food, or if he or she only takes small portions of food at a time. Useful for determining sufficient glucose intake in poorly nourished infants, thus preventing and treating hypoglycemia.
Newborn hypoglycemia is a frequent condition, although the parameters defining hypoglycemia remain ambiguous. Existing practices for prevention and management are chiefly based on practices and opinions rather than empirical practice guidelines. However, there is still a lack of knowledge in this area, especially what is deemed normal in neonates because transient hypoglycemia is expected in the first 48 hours of infancy.
In the study that Lucas et al conducted in 1988, they set the blood glucose level of 47mg/dL as the level that correlates neurodevelopmental problems in premature infants, and this is what was adopted for all the new borns. Although hypoglycemia is dangerous when its level is reduced to extremely low and can provoque seizes, status, and brain damaging, the outcome of short, non-symptomatic hypoglycaemia is not clear. The authors were unable to identify a specific glucose level below which adverse outcome can be predicted with certainty and acknowledge other factors that may influence the relationship between low glucose status and developmental problems.
For this reason, the reported neonatal hypoglycemia rates differ as they depend on the population analysed, time and frequency of glucose assessment, methods of assessment and the definition of hypoglycaemia. In a cross-sectional study conducted in 2006 by Harris, et al, researchers assessed the incidence of hypoglycaemia (plasma glucose of less than 47 mg/dL) within 48 hours in infants born at or after 35 weeks of gestation who were deemed high risk based on the classification outlined in the AAP guidelines. The cross-sectional study revealed that 25% of neonates were assertively at risk and within this group 51% had at least one hypoglycaemic episode.
Glycogen Depletion: Newborns depend on glycogen deposited in the liver during last trimester of pregnancy. Low birth weight babies or growth retarded babies especially those born preterm have lower glycogen stores in their livers and thus have the tendency to develop hypoglycemia early in life after birth.
Inadequate Gluconeogenesis: Neonates’ ability to produced glucose from amino acids, lactates, and glycerol is very limited especially in preterm neonates because gluconeogensis enzymes are not well developed at birth.
Increased Insulin Sensitivity: Hyperinsulinemia such as in infants of diabetic mothers or congenital hyperinsulinism promotes the uptake of glucose by tissues and suppresses gluconeogenesis, resulting in hypoglycemia.
Hyperinsulinism (PHHI): Hyperinsulinism of infancy (HI) is a condition characterized by recurrent severe hypoglycemia due to excessive insulin release from pancreatic beta-cells.
Limited Glycogen Stores: Such factors as prematurity or intrauterine growth restriction (IUGR) mean there is less glycogen stored and thus restricted glucose.
Increased Glucose Utilization: Conditions like hyperthermia, polycythemia, sepsis, or growth hormone deficiency cause the body to need more glucose resulting to hypoglycemia.
Impaired Glycogenolysis or Gluconeogenesis: Pathological states such as metabolic disorders, adrenal insufficiency or inborn errors of metabolism interfere with glycogen breakdown or glucose synthesis hence resulting in hypoglycemia.
Glycogen Depletion: It reduces glycogen stores through stress, asphyxia, or starvation but the store becomes useless in ketotic hypoglycemia where gluconeogenesis is less than sufficient to require fatty acid metabolism in glycogen deficit. Ketones which are an indication that the body is starved are commonly found in the urine.
Severity and Duration of Hypoglycemia: Severe hypoglycemia refers to blood glucose concentrations below 40 mg/dL, and infants with PPH, prolonged hypoglycemia, or hypoglycemia of any severity are at higher risk of adverse outcomes including, neurodevelopmental delay and cerebral injury.
Timing of Hypoglycemia: Hypoglycemia occurring within the first two days of life is usually mild and physiological Still, hypoglycemia developing after 48 hours of life is typically a more serious condition that can stem from other illnesses that may be present in the baby, and such cases usually have a poorer prognosis in most cases.
Gestational Age: As birth, preterm infants exhibit higher susceptibility to developing hypoglycemia because of immature metabolic pathways, lower levels of stored glycogen and hormonal feedback and control abilities. There is a general negative dose-response relationship between the gestational age at the time of exposure and the severity of adverse outcomes.
Birth Weight and Size for Gestational Age: Low birth weight infants which includes SGA and LGA are at higher risk of hypoglycemia. The SGA infants may have low glycogen reserve and the LGA infants: especially the babies of diabetic mothers are prone as they are hyperinsulinemic.
Underlying Conditions: In general, hypoglycemic encephalopathy due to congenital or inherited diseases or other non-traumatic chronic disorders, including persistent hyperinsulinemia hypoglycemia of infancy (PHHI), inborn errors of metabolism, or endocrine disease has a poorer prognosis because of its chronic or repeated nature.
Response to Treatment: This may include children who receive glucose feed or intravenous dextrose early and recover quickly are destined to have less complications compared with children who have refractory hypoglycemia and are harder to manage.
Age Group
Newborns (0-48 hours): The hypoglycemia mainly presents within the first hours to days of life with the majority occurring within the first 48 hours of life. This is the situation when glucose homeostasis is in a period of developmental transition from fetal to the postnatal period.
Preterm infants (<37 weeks gestation) and Term infants (>37 weeks gestation): It can occur to both preterm and term neonate but the preterm has high chances since their regulatory centre for glucose is not fully developed.
General Appearance: Drowsiness, inappetence or anorexia, increased: irritability.
Neurological Signs: Muscle twitching, shaking, convulsions, hypotonia, or lethargy.
Cardiopulmonary Signs: Apnea, bradycardia, or tachypnea: Apnea is the complete cessation of breathing while bradycardia is a slow heart rate and tachypnea is a fast breathing rate.
Skin and Circulatory: Paleness, blueness or sweating, Sweating.
Gastrointestinal: Vomiting
Infants of Diabetic Mothers (IDM): Hyperglycemia during pregnancy, whether gestational or pre-existing diabetes, leads to neonatal hyperinsulinism and subsequently hypoglycemia.
Intrauterine Growth Restriction (IUGR) or Small for Gestational Age (SGA): Most of these infants have reduced glycogen reserves leading to the high incidence of hypoglycemia.
Large for Gestational Age (LGA): Such infants are usually born to mothers with diabetes, and they may end up having high levels of insulin which may lead to hypoglycemia.
Preterm Birth: Preterm infants are at higher risk because of their low glycogen reserves and immature metabolic processes.
Perinatal Stress (Asphyxia, Birth Trauma): According to the levels of the birth stress, the glycogen stocks are burned through rapidly and hypoglycemia appears in the infants.
Sepsis: Neonatal infections are associated with increased blood sugar requirement for tissue maintenance and increased metabolic rate, thus resulting in hypoglycemia.
Neonatal hypoglycemia is abrupt in its severity and typically manifests within the first two days of newborn’s life. The symptoms do not always come gradually, they range from moderate to severe and can appear at any first.
Symptoms:
Mild: Neglect or abuse, failure to be fed, tremors, hyperactivity, and lethargy, pale skin, or low muscle tone.
Moderate to Severe: Worse signs include muscle weakness which may feature conditions such as fatigue or coma if the disease progresses without adequate treatment.
Asymptomatic Hypoglycemia: Diabetic babies are some of the most challenging to diagnose because some of them, especially newborns, may present few or no symptoms and the test is done routinely on newborns- generally through monitoring of blood glucose.
Hyperinsulinemia
Adrenal Insufficiency
Congenital Hypopituitarism
Congenital Hypothyroidism
Infection
Prematurity:
Neonatal Stress
Initial Assessment and Monitoring: A clinical assessment should be conducted to look for signs of hypoglycemia and the patient’s risk factors. Blood glucose levels should be constantly checked in high-risk infants or those with symptoms such as lethargy.
Immediate Management:
Feed the Infant: For the diagnosis of mild hypoglycemia (blood glucose level slightly below normal), initial management should involve the enteral route administration using breast milk or formula. It has been suggested that overloading the child can lead to the fluctuations of glucose levels, whereas their increased stabilization can be achieved through frequent feeding.
Intravenous Glucose: In cases of moderate to severe hypoglycemia or when the infant cannot feed, give intravenous dextrose to enhance the glucose level quickly.
Initial Dose: Orally, fluid resuscitation usually involves the use of 10% dextrose solution; for instance, 5-10 ml/kg.
Address Underlying Causes:
Hyperinsulinemia: In the case of PHHI, the patient should be given diazoxide or octreotide, or a surgical procedure can be performed in case of necessity.
Metabolic Disorders: Address other associated metabolic disorders with appropriate therapies including enzyme replacement or diet manipulation.
Endocrine Disorders: Treat diseases such as adrenal insufficiency with a proper hormonal replacement.
Preventive Measures and Long-Term Management:
Continuous Monitoring: Infants at high risk, or infants who have had recurrent hypoglycemic episodes, glucose monitoring may be necessary. Feeding Protocols: Implement measures such that hypoglycemia is not repeated especially in the high-risk infants including the small-for-gestational age and preterm infants.
Endocrinology, Metabolism
Early and Frequent Feeding: Start on breastfeeding or bottle feeding immediately and thereafter feed the child with small quantities of food more often.
Frequent Monitoring: Self-monitored blood glucose measurement should be performed periodically and should be continuous in high-risk infants.
Feeding Protocols: They should modify their feeding timings by practicing more of a schedule feeding routine to avoid hypoglycemia.
Skin-to-Skin Contact: After the birth of the baby should be used kangaroo care to strengthen and stabilize the temperature of the child, as well as to support early feeding.
Temperature Regulation: Maintain the temperature of the infant to avoid hypoglycemia due to hypothermia.
Endocrinology, Metabolism
Dextrose: It is used for the management of hypoglycemia in newborns and is the first line of treatment in this condition. If given orally, it is rapidly absorbed through the intestinal wall, and it will thus cause a rapid rise in blood glucose levels. In cases of infants of diabetic mothers with transient neonatal hyperinsulinemia, dextrose should be administered intravenously and until the condition persists. This may at times need caution to ensure one does not get hypersensitive, this leads to the production of insulin which in turn leads to a drop in blood sugar, hypoglycemia.
Diazoxide: It increases blood glucose by suppressing secretion of insulin in pancreas and, perhaps, through other mechanisms. It starts to function after an hour, and it is observable that it remains effective within a period of eight hours in those people with sound kidney. It is used mostly in SGA infants and those developing maternal toxemia or perinatal asphyxia.
Octreotide: It is a peptide drug belonging to somatostatin analogs and it may be used in short term treatment of hypoglycemia by inhibiting insulin release.
Glucagon: It is given in the management of hypoglycemia due to hyperinsulinemia especially where intravenous line has not been established. It is provided in a concentration of 1 mg (1 U) per mL in vials. Using IV, glucose concentrations are at their optimum within 5 to 20 minutes while IM administration, the glucose concentrations take about 30 minutes to reach the peak.
Endocrinology, Metabolism
Intravenous Glucose Administration: Introduce an IV catheter and perform the bolus administration of a dextrose solution (e.g. 10% dextrose) to quickly raise blood glucose levels. Used to correct severe hypoglycemia in infants and helps to ameliorate fluctuating glucose levels in susceptible infants.
Intramuscular Glucagon Injection: If the IV access is not achievable or there is a problem with glucose infusion then glucagon is to be given IM. Raises blood glucose levels by glycogenolysis meaning the breakdown of stored glycogen to glucose in the liver to be useful in emergency times. Gastric Tube Feeding: Perform nasogastric (NG) intubation if a patient can’t eat an adequate amount of food, or if he or she only takes small portions of food at a time. Useful for determining sufficient glucose intake in poorly nourished infants, thus preventing and treating hypoglycemia.
Endocrinology, Metabolism
Initial Assessment and Stabilization: Immediately recognize hypoglycemia and give glucose orally, if the condition is mild; or intravenously, if severe, to restore blood glucose level as quickly as possible.
Underlying Cause Evaluation and Management: Hypoglycemia must be accrued and treated according to the primary cause such as metabolic or endocrine disorders.
Monitoring and Ongoing Care: Promoting blood glucose level checks, setting feeding regimen and supportive care to ensure appropriate levels of glucose are maintained.
Preventive Measures and Long-Term Management: Carefully plan the feeding of the child, provide information to the parents and arrange for subsequent appointments to avoid relapse and improve the child’s health and well-being.
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