neonatal hypogycemia.pptx imhportant for

hypoglycemia

1. ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCE DEPARTMENT OF NURSING AND MIDWIFERY POST GRADUATE PROGRAM SEMINAR PRESENTATION ABOUT NEONATAL HYPOGLYCEMIA BY: MULUGETA ABENEH 5/15/2024 1

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3. Neonatal hypoglycemia Objective At the end of this session we will able to know: introduction an understanding of hypoglycemia in the newborn . Identify neonates at risk for hypoglycemia during the immediate newborn period. Describe the signs and symptoms of hypoglycemia in the neonate. Identify the treatment for asymptomatic and symptomatic hypoglycemia in the neonate. 5/15/2024 3

4. N eonatal hypoglycemia Introduction: Hypoglycemia is a common metabolic problem in NICUs . This is because of abrupt cease in glucose supply following clamping of the umbilical cord at birth. Some neonates are symptomatic whereas most are asymptomatic despite very low blood glucose levels Due to this lengthy debate has occurred among investigators regarding the definition of hypoglycemia. Attempts have been made to define hypoglycemia by either a statistical approach or correlation of blood glucose concentration with clinical signs and symptoms 5/15/2024 4

5. NH…. Introduction… H ypoglycaemia could be defined as blood glucose level less than 40mg/dl within the first 4 hours and less than 45mg/dl within the 24 hours after birth The definition of hypoglycemia for preterm infants should not be any different from that for full-term infants. It should be described as transient or persistent, and in either or both of these cases, as symptomatic or asymptomatic. Overall incidence of symptomatic hypoglycemia is1– 3 per 1000 live births . 5/15/2024 5

6. NH…. Introduction … Transient hypoglycemia implies low glucose values that last only a short time(within 48 hrs. ) which is the most common . Persistent and recurrent hypoglycemia implies a form that requires prolonged management (glucose infusions for several days at high rates of infusion > 12mg/kg/min) or Persisting beyond 48 hours of life Several of these hypoglycemia syndromes may continue throughout infancy and childhood. 5/15/2024 6

7. NH Introduction …. Because of clinical manifestations of hypoglycemia are nonspecific and similar to those of many disorders in newborn, careful attention should be given to ensure that other associated disorders (e.g ., sepsis, asphyxia) are not missed. 5/15/2024 7

8. Causes of the two types of neonatal hypoglycemia Transient hypoglycemia Associated with changes in maternal metabolism Intrapartum administration of glucose Drug treatment( antidiabetic drugs tolbutamide and chlorpropamide ) Oral hypoglycemic agents Terbutaline , ritodrine, propranolol Diabetes in pregnancy: infant of diabetic mother 5/15/2024 8

9. Causes…. Transient hypoglycemia… Associated with neonatal problems Idiopathic condition or failure to adapt Intrauterine growth restriction Birth asphyxia Infection Hypothermia Erythroblastosis fetalis Congenital cardiac malformations 5/15/2024 9

10. Causes…. 2. Persistent or recurrent hypoglycemia Hyperinsulinism Congenital hyperinsulinism Beckwith- Wiedemann syndrome Endocrine disorders Pituitary insufficiency Cortisol deficiency Congenital glucagon deficiency Epinephrine deficiency 5/15/2024 10

11. Causes.… 5/15/2024 11 2. Persistent or recurrent hypoglycemia Inborn errors of metabolism Carbohydrate metabolism Galactosemia Hepatic glycogen storage diseases Fructose intolerance Amino acid metabolism Maple syrup urine disease Hereditary tyrosinemia Ethylmalonic-adipic aciduria Fatty acid metabolism Defects in carnitine metabolism Acyl-coenzyme dehydrogenase defects

12. Who is at risk? Limited glycogen stores(rapid depletion of stored glucose) Birth weight < 2 kg Small for gestational age (SGA) Intrauterine growth restriction (IURG ) Premature birth prior to timing of glucose storage during end of 3rd trimester Hyperinsulinemia( causes fetal insulin production) Neonates of IDM(1:1000 pregnant women ) Mothers with GDM(~ 2% of pregnant women ) Large for gestational age (LGA) > 4 kg 5/15/2024 12

13. At Risk… Who is at risk? By Increased glucose use are : • Hypoxia/Perinatal Asphyxia •Shock/Sepsis •Respiratory distress •Cardiac disease • Hypothermia Decreased glycogenolysis, gluconeogenesis, or use of alternate fuels Inborn errors of metabolism Adrenal insufficiency 5/15/2024 13

14. Pathophysiology Glucose Fetal storage of glucose occurs primarily in the 3 rd trimester in the form of glycogen ~ 70 – 80% of maternal glucose levels can be seen in fetus during pregnancy After birth Glycogen is broken down into glucose molecules which are released back into the blood stream to be used as energy Hormones which regulate glucose levels Insulin Glucagon 5/15/2024 14

15. Pathophysiology… Insulin is secreted after food intake to increase insulin levels Insulin stimulates liver to store glucose as glycogen When muscle/liver cells are saturated with glycogen extra glucose is stored as fat When glucose levels fall Glycogen is secreted to increase glucose levels through glycogenolysis Glycogenolysis releases glucose back into the blood 5/15/2024 15

16. Pathophysiology… After birth Serum glucose levels decline during the 1st 3 hours after birth then begin to stabilize Should reach nadir level ~ 1 hour after birth Glycogen stores in the liver rapidly deplete within 1st 12 hours of life. Glucose starts to increase spontaneously after 3 hours of life. Gluconeogenesis accounts for ~10% of glucose usage by the neonate by several hours of age . Glucose is the major fuel for brain functions/ metabolism which can lead to changes such as “brain cell softening swelling, necrosis, gyrus atrophy or white matter demyelination” 5/15/2024 16

17. Clinical symptoms and signs of hypoglycemia The clinical manifestations of neonatal hypoglycemia are non- specific and they may be confused with other disorders of the newborn Abnormal crying • Irritability • Apnea, cyanotic spells • Jitteriness, tremors • Feeding difficulty • Lethargy or stupor • Grunting, tachypnea • Seizures • Hypothermia • Sweating • Hypotonia limpness • Tachycardia 5/15/2024 17

18. Cont.… 5/15/2024 18 Maternal hyperglycemia Fetal hyperglycemia Fetal hyperinsulinemia D/Lung surfactant Polycythemia I/Fetal substrate uptake Hypoxemia ? Stillbirth I/Oxygen uptake Respiratory distress Macrosomia Erythropoietin

19. Cont.… Diagnosis is based on • Supportive perinatal history (risk factors). • Signs and symptoms of hypoglycemia. • Whole blood glucose less than 40 mg/dl. NB : Newborns with persistent or recurrent hypoglycemia need additional testing including hormone analysis and imaging studies . 5/15/2024 19

20. Management of neonatal hypoglycemia The overall management of neonatal hypoglycemia should include: 1. Anticipation and prevention in those who are at high risk. 2. Correction of hypoglycemia 3. Investigation and treatment of the cause of hypoglycemia, when it is possible to identify the cause. 5/15/2024 20

21. Management and treatment of NH… A .Treatment of asymptomatic hypoglycemia Feeding Feeding is the initial treatment in an asymptomatic term infants, • Immediately offer breast-feeding. • Check blood glucose 30 minutes after feeding to ensure normal glucose level before the next feeding. • If repeated blood glucose is > 40mg/dl continue to offer feedings at 2-3 hours interval. 5/15/2024 21

22. Management and treatment of NH… Indications of IV infusions in asymptomatic hypoglycemia (use same infusion as symptomatic hypoglycemia) • Blood glucose <25mg/dl. • Blood glucose remains < 40mg/dl after one attempt of feeding • If infant becomes symptomatic • If oral feeding is contraindicated 5/15/2024 22

23. CONT… B . Treatment of symptomatic hypoglycemia Many neonates have asymptomatic (chemical) hypoglycemia . T he incidence of symptomatic hypoglycemia is highest in small gestational age infants . The exact incidence of symptomatic hypoglycemia has been difficult to establish because many of the symptoms in neonates occur together with other conditions 5/15/2024 23

24. CONT… Immediate treatment Secure IV line, Give 2ml/kg of 10% glucose IV bolus over one minute . 10 % dextrose for IV bolus can be prepared using 40% dextrose, which is available in our country Continuous therapy Put on 10% glucose infusion at glucose infusion rate (GIR) of 6mg/kg/minutes (~ 90ml/kg/day) as maintenance. 5/15/2024 24

25. Cont.… Recheck blood glucose after 30 minutes and if it remains above 40 mg/dl frequency of checking can be decreased to one hourly then every six hourly. If blood glucose remains <40mg/dl, increase the GIR by 2mg/kg/minutes every 30 minutes until repeat values are above 40 mg/dl. Once the blood glucose values stabilize above 40mg/dl for 24 hours, the GIR can be tapered off at 2 ml/kg/min every six hours with proportional increment of oral feeds. 5/16/2024 25

26. Cont. If the neonate requires GIR > 12 mg/kg/minutes, persistent hypoglycemia should be considered . Glucose infusion rate (GIR) can be calculated using the following formula GIR in mg/kg/min= dextrose % () × total fluid ml/kg/ day ÷144 5/16/2024 26

27. Outcomes :Short and Long Term It is not known at exactly what level or for how long hypoglycemia must occur in order to affect the neonate’s developing brain. However , risk of adverse neurologic damage increases with severity and duration of hypoglycemia Infants are 2 – 3 times more likely to have issues with planning, memory, attention, problem-solving, and visual-motor coordination by 4 – 5 years of age Raising glucose levels too fast, too high has an even greater risk of brain damage 5/16/2024 27

28. PROGNOSIS Major long-term squeal include death and: Neurologic damage •Mental retardation • Recurrent seizure activity, epilepsy • Cerebral palsy • Developmental delay • Personality disorders Cardiovascular impairment • Myocardial ischemia Prolonged QT interval 5/16/2024 28

29. Reference 1 .Ethiopian ministry of health NICU management protocol 2024 2.Fanaroff and Martin’s neonatal perinatal Medicine 10 th edition volume one 3. Dr. Sharon Fassino, DNP, RN, NNP-BC Texas children hospital 2009 ppt. 5/16/2024 29

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