neonatal hypoglycemia- approach, diagnosis and management

Comprehensive slides on neonatal hypoglycemia

1. HYPOGLYCEMIC BRAIN INJURY IN NEONATES -Dr .Sanjeev .I

2. Introduction Defining hypoglycemia is highly complex and must be individualized according to the infant’s clinical situation. But its been found that neurological symptoms occurs when the blood glucose value is <47mg/dL or 2.6 mmol for 3 consecutive days

3. Factors to consider Vulnerability of specific cells and regions in the brain The status of brain energy reserves Hepatic glycogen reserves Gluconeogenic capacity GA of the infant Status of intrauterine nutrition, Prior or concomitant hypoxic-ischemic insults Seizures

4. ENERGY SOURCES FOR BRAIN METABOLISM Glucose is the primary fuel for brain metabolism Reason Respiratory quotient Cerebral Oxygen uptake Effect of hypoglycaemia on CNS

5. Alternative sources for energy Lactate Ketones Fatty acids Amino acids Glycerol

6. Biochemical aspects of Hypoglycemia Initial effects Increased CBF Increase glycogenolysis Sharp decline in CMR of glucose ↓ Amino acids, ↑ ammonia

7. Dissociation of Impaired Brain Function and Energy Metabolism The evolution with hypoglycemia of clinical changes from an alert state to a depressed level of consciousness (and even to seizures) and of EEG changes from normal activity to slowing (and even to burst-suppression patterns and seizure discharges) occurs with no definite change in ATP levels in the whole brain or the cerebral cortex and several other brain regions

8. Later effects Decrease in ATP Increased intracellular Calcium and extracellular potassium Excitotoxic neuronal death ( Gluatamate ) Glutathione depletion

9. NEUROPATHOLOGY Injures Neuron and glial cells Discordance of topography Can cause neuronal injury at subthreshold level if associated with other factors

10. Most prone areas for insult Parieto occipital cortex ( dendritic arborization and synaptogenesis ) Outer cortical layers (Contact with CSF) Periventricular leukomalacia

11. Clinical categorization Early transient adaptive hypoglycemia Hypoglycemia Associated With Impaired Metabolic Adaptation Neonatal Hypoglycemia Associated With Intrauterine Growth Restriction Severe Recurrent Hypoglycemia

12. Early transient adaptive hypoglycemia Preterm asphyxiated neonates Failure of glycogenolysis and gluconeogenesis

13. • Infant of diabetic mother • Preterm infants • Large for gestational age infant • Intrauterine growth restriction • Perinatal hypoxia-ischemia Hypoglycemia Associated With Impaired Metabolic Adaptation

14. Severe recurrent hypoglycemia Hyperinsulinemic hypoglycemia of infancy Congenital hyperinsulinism.

15. CLINICAL FEATURES • Changes in level of consciousness - Irritability ,Lethargy ,Stupor • Jitteriness/tremor • Seizures • Apnea and other respiratory abnormalities • Feeding poorly • Hypotonia

16. Brain imaging

17. Adverse outcomes Developmental delay/mental retardation Seizures Visual impairment Microcephaly

18. Management Prevention : Identification of the high-risk infant Minimization of excessive caloric expenditures by maintenance of temperature in the normal range Implementation of oral feedings (breast-feeds when possible) as soon as possible after birth Careful surveillance for clinical symptoms Determination of blood glucose level before the first feeding and subsequently according to the clinical setting

19. Recent advances

20. Important slide of ALL There is no specific single value for categorizing Hypoglcemia Diagnosis should be individualized Metabolic triangle should be addressed early PREVENTION IS BETTER THAN CURE

21. Reference