Management of neonatal hypoglycemia ppt

what are hypoglycemia, its causes, types, and its management

1. MANAGEMENT OF NEONATAL HYPOGLYCEMIA MRS Niyati Das Professor cum vice Principal Kalinga Institute of Nursing Sciences KIIT Deemed To Be University

2. OUTLINES OF PRESENTATION What is Hypoglycaemia? What are the aetiology ? Discuss the pathophysiology. Classify its’ clinical types and their - management. Treatment Monitors blood glucose level , screening and when to stop monitoring Prevention Nursing management

3. INTRODUCTION Glucose is the major energy source for fetus and neonate. The newborn brain depends upon glucose almost exclusively. Up to 90% of total glucose used is consumed by the brain. Alternate fuels ( e.g., ketones, lactate) are produced in very low quantities. The usual rate of glucose utilization is 4-8 mg/kg/min. Glucose regulatory mechanisms are sluggish at birth. Thus, the infant is susceptible to hypoglycemia when glucose demands are increased or when exogenous or endogenous glucose supply is limited. Severe or prolonged hypoglycemia may result in long term neurologic damage

4. Neonatal hypoglycemia Statistics Neonatal hypoglycemia can affect as many as 5-15% of healthy infants . The risk of hypoglycemia may be as high as 72% in certain at-risk infants such as small for gestational age infants . There is currently not enough evidence to define a specific glucose value that results in long-term neurodevelopmental sequela.Sep 19, 20 The prevalence of hypoglycaemia is approximately 10%- in full term neonates 6.5% in appropriate for gestational age(AGA) 8% in large for gestational age(LGA) 15% in small for gestational age(SGA) 15.5% in late preterm infants

5. Why do neonates get hypoglycaemia? Glucagon helps regulate gluconeogenesis and glycogenolysis within the liver as a counter regulatory agent to insulin. Exaggerated insulin secretion from beta-cells can occur during the first few hours to days of life, resulting in hyperinsulinemia, which is the leading cause of hypoglycaemia in neonates

6. What is Hypoglycemia Hypo means low and glycemia is the term used for blood sugar level

7. ETIOLOGY OF NEONATAL HYPOGLYCEMIA Decreased substrate availability Hyperinsulinemia: Other endocrine abnormalities: Increased glucose utilization Miscellaneous conditions

8. E tiology 1. Decreased substrate availability : •Intra-uterine growth retardation •Glycogen storage disease •Inborn errors ( e.g., fructose intolerance) • Prematurity •Prolonged fasting without IV glucose 2. Hyperinsulinemia : •Infant of diabetic mother •Islet cell hyperplasia •Erythroblastosis fetalis •Exchange transfusion •Beckwith-Wiedemann Syndrome •Maternal ß-mimetic tocolytic agents •”High” umbilical arterial catheter •Abrupt cessation of IV glucose

9. Other endocrine abnormalities : •Pan-hypopituitarism •Hypothyroidism •Adrenal insufficiency 4. Increased glucose utilization: •Cold stress •Increased work of breathing •Sepsis •Perinatal asphyxia 5. Miscellaneous conditions: •Polycythemia •Congenital heart disease •CNS abnormalities

10. SIGNS AND SYMPTOMS OF NEONATAL HYPOGLYCEMIA ` Bluish-coloured skin ( cyanosis )  or  pale skin Breathing problems , such as rapid breathing ( tachypnea ), pauses in breathing ( apnea ), or a  grunting sound Irritability or listlessness Loose or floppy muscles ( hypotonia ) Vomiting or poor feeding Weak or high pitched cry Tremors, shakiness, sweating, or seizures

11. CLASSIFICATION OF NEONATAL HYPOGLYCEMIA TRANSIENT HYPOGLYCEMIA PERSISTENT HYPOGLYCEMIA

12. TRANSIENT HYPOGLYCEMIA Perinatal asphyxia Polycythemia Maternal beta blockers Rh isoimmunization 18times higher risk of ND Hypoglycemia multiplies injury

13. MANAGEMENT OF TRANSIENT HYPOGLYCEMIA

14. Hypoglycemia persisting beyond 48 hours of life or appearing for the first time after 48 hours of life is more likely due to underlying metabolic or endocrine disorders and requires more aggressive approach. Refractory or persistent hypoglycemia should be suspected and investigated if the glucose infusion requirement is >12 mg/kg/min or the hypoglycemia persists >5-7 days, respectively . Congenital conditions such as Beckwith-Wiedemann, Mosaic Turner syndrome, and Costello syndromes have also been linked to hyperinsulinemia and subsequent hypoglycemia. These patients may experience a more prolonged hyperinsulinism lasting from several days to week . PERSISTENT HYPOGLYCEMIA

15. Requirement of a dextrose infusion rate or more than 12 mg/ kg/min suggests resistant hypoglycemia. • One should rule out hyperinsulinemic state or inborn errors of metabolism. • Increase the DIR to 12–15 mg/kg/min , keeping in mind that more than 12.5% dextrose should not be given through a peripheral vein and a central venous catheterization is require d MANAGEMENT OF PERSISTENT HYPOGLYCEMIA

16. DIAGNOSIS OF NEONATAL HYPOGLYCEMIA Plasma serum level Serum insulin Urine sugar Metabolic error

17. Specimens for measurement of glucose should be obtained from Heel stick, venipuncture, or from an indwelling catheter that does not have glucose infusing in it. SCREENING OF AT RISK INFANTS: Infants at risk for hypoglycemia should be screened by measuring blood sugar by Glucometer at ages 1, 2, 4, 6, 9 and 12h. Less frequent measurements are appropriate if blood glucose is stable. However continued surveillance and more frequent measurements may be needed until blood glucose is stable >40 mg/dL or >50 mg/dL in very preterm infants.

18. Differential diagnosis. The symptoms mentioned due to many other causes with or without associated hypoglycemia . If symptoms persist after the glucose concentration is in the normal range, other etiologies should be considered. Some of these are as follows: a . Sepsis,CNS disease, Toxic exposure, Metabolic abnormalities i . Hypocalcemia ii. Hyponatremia or hypernatremia iii. Hypomagnesemia iv. Pyridoxine defi ciency e. Adrenal insuffi ciency f. Heart failure g. Renal failure h. Liver failure

19. MANAGEMENT OF HYPOGLYCEMIA Glucometer reading >40 mg/dL and infant is feeding normally: follow usual nursery protocol. • Glucometer reading 20-40 mg/dL, infant is term and is able to feed: -Draw blood for stat blood glucose. -Feed 5 mL/kg of D5W. -Repeat blood glucose or Glucometer 20 min after feeding.

20. Glucometer reading: (a) <20 mg/dL or (b) <40 mg/dL and NPO or preterm or (c) <40 mg/dL after feeding or (d) <40 mg/dL and symptomatic -Draw blood for stat glucose measurement. -Give IV bolus of 2-3 mL/kg of D10W. -Begin continuous infusion of D10W at 4-6 mg/kg/min. -If infant of diabetic mother, begin D10W at 8-10 mg/kg/min (100-125 cc/kg/d). -Repeat blood glucose in 20 min and pursue treatment until blood sugar >40 mg/dL.

21. Do not use D25W or D50W IV or large IV volume boluses as this creates rebound •If hypoglycemia is not controlled with above measures: Obtain Endocrine Consult to guide further diagnostic evaluation and management. While awaiting consult, send blood (while bloodsugar is low) for glucose, plasma cortisol, growth hormone and insulin concentrations. Further management may include glucocorticoids, diazoxide, somatostatin or pancreatectomy. • Weaning IV dextrose infusion: When blood glucose has been stable for 12-24 h, begin decreasing IV infusion by 1-2 mL/ hr q3-4 hours if blood glucose remains ≥60 mg/dL.

22. T r e a tme n t To raise the blood sugar value to normal range, give 200 mg/kg of dextrose i.e. 2 ml /kg of 10% dextrose as bolus slowly over 3-5 minutes and start maintenance fluids with a dextrose infusion rate (DIR) of 6 – 8 mg/kg/min. The maximum strength of dextrose that can be given through a peripheral vein is 12.5%. Repeat Dextrostix after 15-30 minutes, if still low, repeat bolus and increase (DIR) by 1 – 2 mg/kg/min or the maintenance fluids by 10 – 20 ml/kg/day .

23. How to monitor blood glucose in hypoglycemia In asymptomatic babies measure blood glucose within 2 hrs of birth, preferably before feeds. Frequency & duration depends on clinical features and glucose value, initial frequency may be 2 hrly , and later 4 hrly and finally 8 - 12 hrly . Monitoring is usually done for 72 hrs after birth in at risk newborns or till glucose levels remain normal for 48 – 72 hrs. Symptomatic babies : may require more frequent monitoring. Maintain the same DIR till the blood glucose is stable for at least 6 – 8hrs and then decrease the DIR by not greater than 1 – 2 mg/kg/min every 2 hours with adequate monitoring.

24. Resistant or Persistent Hypoglycaemia: Requirement of a dextrose infusion rate or more than 12 mg/ kg/min suggests resistant hypoglycemia. Any hypoglycemia persisting beyond one week despite adequate management suggests persistent hypoglycemia. One should rule out hyperinsulinemia state or inborn errors of metabolism. Increase the DIR to 12–15 mg/kg/min, ( keeping in mind that more than 12.5% dextrose should not be given through a peripheral vein and a central venous catheterization is required.)

25. COMPLICATIONS Developmental delay Brain damage CNS dysfunction Seizures Heart failure

26. Indication for Routine Blood Glucose Screening Infants <2000grams. Infants <_35 weeks. Small for Gestational Age. Large for Gestational Age. Infant of Diabetic Mother. Infants with Rh Hemolytic disease. Mothers receiving therapy with Terbutaline/ Propanolol / Lebatolol /Oral Hypoglycemic agents IUGR. Any sick neonate (Perinatal a s p h y x ia/ Pol y c y themia /Sepsis/S h oc k ) Infants on Parenteral Nutrition.

27. GENERAL TREATMENTS If IV dextrose isn’t an option for a baby with NH, glucagon can be used as a treatment and administered subcutaneously or intramuscularly. Glucagon can be used to treat babies who experience severe hypoglycemia and may not have dextrose available to them. Babies who have experienced NH and are not being treated with dextrose or glucagon should be fed within the first hour of life . These feedings should be done at two to three hour intervals, and blood glucose concentrations should be monitored frequently within 20 to 30 minutes after being fed.

28. PREVENTION OF HYPOGLYCEMIA

29. Supporting the Mother Giving birth to an infant who develops hypoglycemia is of concern to both the mother and family and thus may jeopardize the establishment of breastfeeding . Mothers should be explicitly reassured that there is nothing wrong with their milk and that supplementation is usually temporary. Having the mother hand-express or pump milk 

30. MANEGEMENT OF SEVERE HYPOGLYCEMIA Whenever possible continue the breastfeed to the infant

31. NURSING MANAGEMENT

32. Nursing care management The biggest nursing concern for a neonate experiencing hypoglycemia is the physical assessment to potentially find the cause. [1]  It is also essential to prevent environmental factors such as cold stress that may predispose the newborn for further decreasing blood sugar. [1]  Within the physical assessment, comorbidities of hypoglycemia should also be assessed such as intolerance of feeding, or respiratory distress. [1]  Another important nursing intervention is assisting the mother in successful breastfeeding as this can prevent and treat hypoglycemia. [1] If an IV infusion of 10% dextrose in water is initiated then the nurse must monitor for: •Circulatory overload [1] •Hyperglycemia [1] •Glycosuria [1] •Intracellular dehydration [1]

33. Recommendations for Future Research 1. Well-planned, well-controlled studies are needed that look at plasma glucose concentrations, clinical signs, and long-term sequelae to determine what levels of blood glucose are the minimum safe levels. 2. The development and implementation of more reliable bedside testing methods would increase the efficiency of diagnosis and treatment of significant glucose abnormalities . 3. Studies to determine a clearer understanding of the role of other glucose-sparing fuels and the methods to measure them in a clinically meaningful way and time frame are required to aid in understanding which babies are truly at risk of neurologic sequelae and thus must be treated. 4. For those infants who do become hypoglycemic , research into how much enteral glucose, and in what form, is necessary to raise blood glucose to acceptable levels is important for clinical management. 5.  Randomized controlled studies of prenatal colostrum expression and storage for mothers with infants at risk of hypoglycemia are important to determine if this is a practical and safe treatment modality.

34. THANK YOU