NEONATAL HYPOGLYCEMIA : SUGAR THEM UP

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Neonatal hypoglycemia is a common disorder and in fact an emergency in neonates considering the devastating ill effects of hypoglycemia on neurological outcomes ranging from severe neurological dissability like seizure to social morbidity of scholastic backwardness. 

Even a single episode of asymptomatic hypoglycemia which might have been unnoticed may put the neoante at risk for developing long term neuro- developmental  sequelae and hence should be urgently treated. 
In a series of 151 infants with neonatal hypoglycemia followed  for 1-4 years the occurrence of seizures as part of the neonatal neurological syndrome was associated with  a clearly abnormal outcome in 50% and with transient neurological abnormalities an additional 12%.

Koivisto M, Dev Med Child Neurol. 1972; 14(5): 603-614.
A recent Indian study by Udani and co-workers has concluded that neonatal hypoglycemia is the most common etiology of remote symptomatic infantile onset epilepsy.

Udani V. Indian Pediatr 2009; 46: 127-131
During residency rotation in Neonatal ICU,s or Nurseries, one should know how to suspect neonatal hypoglycemia by identifying high risk babies, identify the possible symptoms in those symptomatic babies, and know by heart how, at what threshold should we treat them, for how long, and what all work up do we need to send to arrive to the diagnosis of hypoglycemia.

Neonatal hypoglycemia is amongst the most common dissorder encountered in NICU,s and therefore a detailed reading is recommended, besides its a high yield question in theory exam. Follow these links given in post where you can directly hit and download the study material for Neonatal hypoglycemia.

Very nice single slide for workup on Neonatal hypoglycemia here from st. Emlyns blog
hypoglycemia screening investigations

Signs and symptoms here

                    hypoglycemia signs


Management of Neonatal Hypoglycemia
Official guidelines from American association of pediatrics here
Year 2009-2010          ( http://pediatrics.aappublications.org/content/127/3/575.full.pdf )

Exhaustive review article by A.F. Williams for neonatal hypoglycemia, physiology explained nicely, glucose metabolism and much more. Find the full pdf article here 


Detailing every aspect of neonatal hypoglycemia, Here is Queensland Maternity and Neonatal Clinical Guideline on Newborn hypoglycaemia.
Here is the link

(http://www.health.qld.gov.au/qcg/documents/g_hypogly5-0.pdf)
Detailed charts on prevention and detection, management, hypoglycaemic screen and other investigations along with their interpretation. Pharmacological interventions for resistant and persistent hypoglycemia given in detail along with doses of drugs and finally discharge and follow up. Highly recommended for indepth read.

Both NNF and AIIMS protocol are good and almost same

NNF Clinical Practice Guidelines 

Topics under discussion are:

What is operational threshold for management 
How to screen for hypoglycemia 
How to measure  blood glucose 
How to manage asymptomatic hypoglycemia 
How to manage symptomatic hypoglycemia 
• Approach to diagnosis and evaluation of refractory and
   prolonged hypoglycemia 
What are the potential best practices for prevention of hypoglycemia 

AIIMS Protocol

IF YOU WANT TO DIG IN MORE
This is the most recent article , try to get a copy of NEOREVIEW 2014 , Here 
( Neonatal Hypoglycemia: Are Evidence-based Clinical Guidelines Achievable?NeoReviews Vol. 15 No. 3 March 1, 2014 )

Lastly few usefull maths for hypoglycemia
Infusion rate(mg/kg/min)  
             =     % of dextrose being infused x rate (mL/hr)
                                           body weight (in kg) x 6
   OR   
     
              =   0.007 x Fluid rate (ml/kg/day) x Dextrose %
As we already know what ml per kg per day fluid is going to the baby, so this makes it simpler.

All this simple stuff is based on this mother equation

GIR = IV Rate (mL/hr) * Dextrose Conc (g/dL) * 1000 (mg/g)
Weight (kg) * 60 (min/hr) * 100 (mL/dL)

Now while calculating GIR in babies on both IV fluid and Breast feed or any other feed 
Consider these

Breast milk sugar content   7.1 g / 100 ml
Term formula sugar content   7.1 g / 100 ml
Pre-term formula sugar content   8.5 g / 100 ml

GIR Calculation



Here is a nomogram to quickly see what Dextrose infusion rate you giving at % glucose fluid at perticular fluid rate or just know what is the desired % dextrose needed to achieve target GIR

(Interconversion of glucose infusion units. from Klaus MH, Fanaroff. AA, eds: Care of the High-Risk Neonate. 2nd edition. Philadelphia:WB Saunders, 1979:, 430.


After deciding what dextrose % you need in fluid, to target your DIR, you can use following simple formula to  achieve that % dextrose by mixing two fluid of different dextrose concentration.
Here, 

Desired conc - lowest conc  X 100 
Highest conc - lowest conc

This gives you volume of highest conc fliud in 100 ml rest will be the volume of lowest concentration fluid

Some ready made stuff


You can use following link to calculate GIR but "practising" will always be better for learning than shortcuts. The best thing is we can calculate the GIR of IVF along with Breast milk or Top milk, all together. 
Here is the link from nicutools.org

Glucomix is a android software, easy to use to calculate the combination of two fluids with different dextrose concentration right on your mobile, find details here
Happy studying.

WRITTEN BY:
Dr Ajay Agade is a pediatric critical care fellow pursuing FNB  from Kanchi Kamakoti Child Trust Hospital,  passionate about free online medical education, acute care and patient safety. He is editor of dnbpediatrics and criticalpediatrics blogs |  View Ajay Agade’s  posts
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