Treatment of neonatal hypoglycemia

this ppt contains some easy formula to calculate GIR, how to increase GIR by 1, tables for fluid and treatment,

1. Treatment of Neonatal Hypoglycemia DR MANDAR HAVAL DCH.DNB. FELLOW IN NEONATOLOGY (NNF)

2. NEONATAL HYPOGLYCEMIA IS A METABOLIC DISORDER AND OPERATIONAL THRESHOLD VALUE OF BLOOD GLUCOSE <40MG/DL (PLASMA GLUCOSE < 45MG/DL) SHOULD BE USED TO GUIDE MANAGEMENT What should be the operational threshold for management of neonatal hypoglycemia

3. Why should hypoglycemia in new born should manage aggressively Glucose is a predominant fuel of a neonatal brain Low blood glucose in new born period in isolation as well as associated with other morbidities predispose to long term neurological output

4. Which neonate should be screen for hypoglycemia All at risk neonate and sick infant should be screen Eg preterm infants /Small for gestation / Large for gestation Infant of diabetic mother Post exchange blood transfusion On intravenous fluid and parenteral nutrition Mother on Beta blocker, OHA, intrapartam dextrose infusion

5. Schedule of blood glucose monitoring Category of infants Time schedule 1 At risk neonates (SN 1-8 in Table 1) 2 , 6, 12, 24, 48, and 72 hrs Sick infants (Infants with sepsis, asphyxia , shock during active phase of illness. Once the underlying condition is under control , frequency of screening can be reduced or omitted) Every 6-8 hrs (individualize as needed) Stable VLBW infants on parenteral nutrition Initial 72 h: every 6 to 8 hrs After 72 hr: once a day Infants exhibiting signs compatible with hypoglycemia at any time also need to be investigated.

6. How should blood glucose be tested in neonate Glucose reagent strip are use to screen for hypoglycemia. If values are low , a blood sample should be sent to a lab for confirmation by glucose oxidase or glucose electrode method Treatment should be commenced on the basis of screening test and should not be delayed till lab results

7. Neonate with asymptomatic hypoglycemia management

8. IV Glucose infusion should be started in babies with asymptomatic hypoglycemia BSL< 25mg/dl BSL< 40mg/dl despite of one attempt of feeding breast milk Enteral feeding is contraindicated Baby became symptomatic

9. How to mix various solution for creating a desired concentration of glucose in IV infusate 100ml of fluid of desired dextrose concentration by using 5% and 25% dextrose is as follows 5X – 25 = Y (X- required percentage of dextrose , Y – amount of 25%D to be made up with 5% D to make a total of 100ml)

10. Eg . To prepare 100ml 0f 25% D Formula – 5X – 25 =Y ( X – 12.5) 5 * 12.5 – 25 = 37.5 (Y) Thus 37.5ml of 25%D is to be added in 62.5ml (100-37.5) of 5%D to get 100ml of 12.5% D

11. Calculation of GIR GIR = %D being infused X rate of infusion Body Wt X 6 GIR = Rate of IV fluids (ml/kg/day) X % of dextrose infused 144

12. 3. GIR = Rate of IV fluid (ml/kg/day) X % of dextrose infused X 0.007

13. Note - 10%D – 100mg/ml 5% D – 50mg/ml 7.5% D – 75mg/ml 12.5% D – 125mg/ml

14. Simple method to calculate GIR Desired fluid intake (ml/kg/day) eg-80ml/kg/day Convert it into ml/kg/min by dividing the figure by 1440 ( 24hr – 1440min) i.e 80/1440 = 0.055 If 10% D is used then multiply the above fig by 100 (as 10% D has 100mg) i.e 0.055 X 100= 5.5mg/kg/min

15. How to increase GIR by 1mg/kg/min Add 2ml/kg of 25% D to the volume of the fluid infused over 8 hr . Explanation – i ) 25% D has 250mg/ml of D(2ml = 500mg) ii) 8hr period has 8 X 60min = 480 min iii) so 2ml/kg of 25%D over 8 hr will increase the GIR by 500/480 = 1mg/kg/min(roughly)

16. Daily fluid volume ( mL /kg/d) Glucose infusion rate (GIR) 6 mg/kg/min 8 mg/kg/min 10 mg/kg/min D10 D25 D10 D25 D10 D25 60 42 18 24 36 5 55 75 68 7 49 26 30 45 90 90 - 74 16 55 35 105 85 * - 99 6 80 25 120 100 * - 120 - 97 18 Achieving appropriate glucose infusion rate at different daily fluid intakes

17. How to covert mg/dl to mmol / L To convert mmol /L to mg/dl multiply by 18 1mmol = 1 X (18) mg/dl Similarly divide by 18 if converting into mg/dl from mmol /L

18. How to calculate GIR in an infant on oral feed along with simultaneously intravenous infusion of glucose GIR = IV rate (ml/hr) X Dextrose conc (g/dl) X 0.0167/wt(kg) Feed rate(ml/hr) X Dextrose conc *(gm/dl) X 0.0167/wt(kg) Amount of dextrose in milk: breast milk 7.1gm/dl, Term formula 7.1gm/dl preterm formula 8.5gm/dl

19. How should be refractory and prolong hypoglycemia be evaluated GIR requiring more than 12mg/kg/min for more than 24 hr OR Blood glucose level remain unstable beyond 5 to 7 days respectively

20. Investigation to be done Sr insulin, cortisol (adrenal insufficiency), TSH Ammonia, Lactate urine for ketone and reducing substance for Metabolic disorder ( galactosemia , glycogen storage disease, organic acidemia and mitochondrial disorder) Rarely 17 OHP, GALT assay, TMS, Growth harmone , glucagon level

21. Note Persistent hyperinsulinemia (PHHI) is diagnosed if there is hyper insulinemia plasma insulin > 2uU/ml, in presence of documented lab hypoglycemia

22. Note.. Drugs like hydrocortisone, diazoxide , octreotide , nifedipin , or glucagon may be prescribed only in consultation with pediatric endocrinologist

23. Hydrocortisone 5 mg/kg/day IV or PO in two divided doses for 24 to 48 hrs Diazoxide can be given orally 10-25 mg/kg/day in three divided doses . Diazoxide acts by keeping the KATP channels of the Beta-cells of the pancreas open, thereby reducing the secretion of insulin. It is therefore useful in states of unregulated insulin secretion like in insulinomas . Glucagon 100 u g /kg subcutaneous or intramuscular (max 300 ug ) – maximum of three doses. Glucagon acts by mobilizing hepatic glycogen stores, enhancing gluconeogenesis and promoting ketogenesis . These effects are not consistently seen in small-for-gestational age infants. Side effects of glucagon include vomiting, diarrhea and hypokalemia and at high doses it may stimulate insulin release. Octreotide (synthetic somatostatin in dose of 2-10 μg /kg/day subcutaneously two to three times a day.

24. Best practice for prevention of neonatal hypoglycemia Support and prompt early exclusive breast feeding ( sucrose fortified milk 5gm of sucrose in 100ml milk is shown to raise blood glucose level to prevent hypoglycemia*) Prevent hypothermia Do not feed 5%,10% or 25% D as a substitue for breast feeding (risk of rebound hypoglycemia is more) * However risk of contamination cannot be ruled out