《Etiology of neonatal hypoglycemia.ppt》由会员分享，可在线阅读，更多相关《Etiology of neonatal hypoglycemia.ppt（39页珍藏版）》请在三一文库上搜索。
1、Neonatal Hypoglycemia,NICU Night Team Curriculum,1,Objectives,Define neonatal hypoglycemia Know the causes of neonatal hypoglycemia Know signs and symptoms of hypoglycemia Understand treatment,Case,39 wk F born by NSVD to a 22 y/o G1P0 mom with diet controlled GDM A1. Moms blood sugars throughout th
2、e pregnancy ranged from 120-160. Maternal serologies were negative, pregnancy otherwise unremarkable. APGARS were 8 and 9 at 1 and 5 minutes, respectively. BW was 4,000 g.,Physical Examination,VS: T 36.5 P 148 RR 80 BP 55/38 mmHg HC 34 cm (75%), Lt 50 cm (75%), BW 4,000 (97%) GA: Well appearing F, N
3、AD, no cyanosis HEENT: AF 2x2 cm, no cleft lip and palate Heart: RR, no murmur Lungs: Tachypneic breathing with even breath sounds throughout, no retractions, no flaring Abdomen: Soft ND, no hepatosplenomegaly Genitalia: Normal female genitalia Extremities: No deformities, MAEE,Labs,1 hour of life:
4、Hematocrit 56% Dexi 30 mg% Serum glucose 34 mg%,What is your primary concern in this patient?,Neonatal Hypoglycemia,Impaired glucose metabolism,Serum blood glucose 40 mg/dL OR Point of Care testing (accucheck, Dexi) 45,Why was a Dexi checked in this patient?,She is at risk for developing hypoglycemi
5、a,Definition: A plasma glucose of less than 40 mg/dl Plasma glucose is higher than whole blood glucose by 15%,Hypoglycemia,Fetal Glucose Metabolism Fetus does not produce glucose Maternal glucose is the only source of fetal glucose Baseline fetal blood glucose is 60-70% of maternal serum glucose,Phy
6、siology,Glucose metabolism after birth,Cessation of maternal glucose supply,Blood glucose Nadir ( 1-2 hrs after birth),Physiology,Glucose Metabolism After Birth,Cessation of maternal glucose supply,Surge in glucagon, catecholamine Decrease insulin,Gluconeogenesis: Hepatic glycogen, amino acid, fatty
7、 acid metabolism,Normal blood glucose,Etiology of neonatal hypoglycemia,Increased utilization (e.g.: hyperinsulinism) Decreased production/stores Increased utilization and/or decreased production,Increased Utilization,Diabetic mother Large for gestational age (LGA) infant Erythroblastosis Islet cell
8、s hyperplasia Beckwith-Wiedemann syndrome Insulin producing tumors Maternal tocolytic therapy with B-sympathomimetric agents Malposition of umbilical artery catheter,Decreased Production/Stores,Prematurity Intrauterine growth retardation(IUGR) Inadequate caloric intake Delayed onset of feeding,Incre
9、ased utilization AND Decreased production,Perinatal stress eg. shock, sepsis, asphyxia Enchange transfusion Defect in carbohydrate metabolism eg. glycogen storage disease Endocrne deficiency eg. adrenal insufficiency, hypopituitarism Defect in amino acid metabolism Polycythemia Maternal therapy with
10、 B-blocker,When do you screen?,Symptoms that could be due to hypoglycemia. At risk infants.,What are signs and symptoms of hypoglycemia?,Signs and Symptoms of Hypoglycemia,Symptoms are NON-SPECIFIC Jitteriness Apnea Irritability Grunting Lethargy Seizures,Who is at risk?,Infants of diabetic mothers
11、Maternal use of B-adrenergic agonist/ antagonist IUGR LGA Preterm Polycythemia Asphyxia Sick infant,When is the ideal time to screen high risk infants?,Screening,Blood glucose or point of care testing (POC) should be done in high risk infants within the first 1 to 2 hours after birth,Back to our cas
12、e:,Term LGA infant IDM with poor blood glucose control Tachypnea Hypoglycemia,Why do you think she developed hypoglycemia? Hyperinsulinism,Pathophysiology : infants of diabetic mothers,Feeding? IV therapy? Medication?,How do you treat this patient?,Management Oral Feeds,Can be used in asymptomatic i
13、nfants Only formula (never administer glucose water!) Follow up blood glucose within 1 hour of feeding. If the glucose level doesnt rise, a more aggressive therapy may be needed.,Management IV therapy,Indications: Inability to tolerate oral feeding Symptomatic infant Lack of response with oral feeds
14、 Glucose 25 mg/dL, regardless of patients symptoms,Management IV therapy,Urgent treatment Bolus 2 ml/kg of D10W Do not use 25% or 50% glucose ! Follow bolus with continuous dextrose fluid,Continuing IV fluid Start infusion of glucose at a rate of 6-8 mg/kg/min Glucose infusion rate formula (GIR):,GI
15、R = %IV fluid x rate(ml/hr) 6 x BW(kg),Management IV therapy,Management IV therapy,Re-check serum glucose 20-30 min after bolus and hourly until stable If glucose is normal and stable, feeding may be continued and glucose infusion tapered If glucose cant be maintained 50 mg/dL, increase GIR by 1-2 m
16、g/kg/hr If glucose cant be maintained 50 mg/dL, with a GIR 12 mg/kg/min, medication should be added.,Management Medication,Persistent hypoglycemia despite a GIR 12 mg/kg/min. Work up Critical Labs: Serum cortisol, insulin, growth hormone when glucose is low and prior to treatment DO NOT wait 5 minut
17、es for labs prior to treating hypoglycemia Medication Hydrocortisone Glucagon Diazoxide,Hydrocortisone,Dose: 10 mg/kg/day IV q 12 hrs Indication: Hypoglycemia despite GIR 12 mg/kg/min Send hormone level before starting hydrocortisone!,Glucagon,Dose: 0.025-0.3 mg/kg IM/IV (maximum 1 mg) Should cause
18、recovery of hypoglycemia May not work if Reduced glycogen stores Glycogen storage disease,Diazoxide,Dose: 2-5 mg/kg/dose PO q 8 hrs. Indication: Infants who have persistent hyperinsulinemia (e.g. Nesidioblastosis),Remember, he was tachypneic Urgent treatment:D10W 2 mL/kg IV bolus followed by continu
19、ous IV fluid,Back to our case: How would you treat our patient?,Board Question,A term infant was born to a pre-ecclamptic mother. BW was 2,000 g (10th%). Physical exam was normal. Blood glucose at 2 hour of age was 30 mg/dL What is your next step in management? a. D10W bolus of 4 mL b. D10W continuo
20、us IV infusion at 6.5 ml/hr c. 20 mL of oral glucose water d. 20 mL of infant formula,Board Question,A term infant was born to a pre-ecclamptic mother. BW was 2,000 g (10th%). Physical exam was normal. Blood glucose at 2 hour of age was 30 mg/dL What is your next step management? a. D10W bolus of 4 mL b. D10W continuous IV infusion at 6.5 ml/hr c. 20 mL of oral glucose water d. 20 mL of infant formula,Reference,Wilker RE. Hypoglycemia and hyperglycemia. In: Cloherty JP, Eichenwald EC, Stark AR, eds. Manual of Neonatal care. 5th ed. Lippincott Williams 51:703-723,