NEONATAL

HYPOGLYCEMIA

SEPTEMBER 2022
 SESSION OBJECTIVES
• Define neonatal hypoglycemia

• Describe the transition of the fetus to extrauterine life in terms of glucose regulation.

• Discuss risk factors, symptoms, and management of hypoglycemia

• Explain the clinical features of neonatal hypoglycemia.

• Discuss the nursing management with emphasis on breast feeding

 DEFINITION
Hypoglycemia is present when the newborn’s blood glucose concentration is lower than the body’s requirement for
cellular energy and metabolism.

Definitive glucose levels

• The normal blood glucose level in a newborn baby is 2.5 - 6 mmol/l (45-108mg/dl).

• Hypoglycaemia is when the blood glucose level below 2.5 mmol / l (45mg/dl)

• Severe hypoglycemia is a blood glucose level of < 1.5 mmol / l (25mg/dl)

(Essential Maternal and Newborn Clinical Care Guidelines for Uganda 2021)
Over view of fetal transition to extrauterine life in terms of
glucose regulation.

• Fetal glucose homeostasis predominately depends on the constant maternal

supply of glucose.
• During the third trimester, the fetus prepares for extrauterine survival by
increasing energy stores and developing metabolic processes for rapid glucose
production and utilization. Key metabolic processes which influence glucose
homeostasis are:
 fetal transition to extrauterine life in
terms of glucose regulation cont,
• Glycolysis – the conversion of glucose to lactate and pyruvate resulting in
adenosine triphosphate (ATP) storage

• Glycogenesis – the release of glycogen from the liver to form glucose

• Gluconeogenesis – the production of glucose by the liver and kidneys

from non-carbohydrate substrates like fatty acids and amino acids
 fetal transition to extrauterine life in
terms of glucose regulation cont,
• Low blood glucose concentrations cause a surge of insulin and other hormones (including
catecholamines, glucagon, and corticosteroids) that stimulate glucose production via
gluconeogenesis and glycogenolysis and enhance fatty acid oxidation.

• endogenous source of glucose and other energy substrates necessary to sustain its metabolism the
result is the gradual rise of blood glucose levels over the next several hours to days is thus provided

• Any mechanism that disrupts this sequence of physiologic changes puts the infant at risk of more
severe or prolonged periods of low glucose. The risk for hypoglycemia is greatest in the first hours
after birth
 Transition cont,
• The transition from intrauterine to extrauterine life involves many physiologic changes.
The fetus receives a constant supply of glucose from the mother across the placenta
• Healthy infants experience an expected drop in blood glucose concentrations
immediately following birth as a part of the normal physiologic transition to extrauterine
life.
• Abruptly clamping the umbilical cord at birth disrupts the infant's connection to the
placenta, upon which it relied to supply glucose and other metabolites necessary to meet
its energy needs in utero

• At delivery, termination of the maternal glucose supply results in a decrease in neonatal

blood glucose values, which reach a nadir at one to three hours post-delivery
 Transition cont,
• During the normal transition to extrauterine life, blood glucose concentration in the healthy term newborn
falls during the first one to two hours after delivery, reaching a lowest point with a median concentration
of approximately 55 mg/dL.

• For most healthy infants, this transitional neonatal hypoglycemia is brief, transient and most often
asymptomatic

• It is important to differentiate this normal physiologic transitional response from disorders that result in
persistent or recurrent hypoglycemia, which if left untreated may lead to significant neurologic and
developmental sequelae
 Risk factors for neonatal hypoglycaemia
• The most common causes of neonatal hypoglycaemia are deficient glycogen stores,
delayed feeding, and hyperinsulinemia.
• There are numerous risk factors associated with neonatal hypoglycemia
• They commonly include maternal conditions, such as
• obesity, diabetes, hypertension
• medications (eg, intravenous glucose, beta-blockers, and beta-agonist tocolytics)
substance use, pre-eclampsia, and gestational diabetes.
• cesarean delivery, discordant twins, polycythemia, inborn error of metabolism (IEM)
• genetic syndromes, endocrine abnormalities, respiratory distress, and other perinatal
complications (including a 5-min Apgar score
 Risk factors cont,
• infants of diabetic mothers (IDM) and large for gestational age infants experience fetal
hyperinsulinism and increased peripheral glucose utilization, putting them at risk for
hypoglycemia in the immediate postnatal period
• The placenta supplies the fetus with a direct source of glucose via facilitated diffusion,
such that fetal glucose concentrations are proportional to maternal levels. Prolonged
elevations in maternal glucose concentrations result in fetal hyperglycemia and
pancreatic overstimulation to increase endogenous fetal insulin production.
• ]These elevated levels of fetal insulin persist after birth and, in the absence of a
continuous exogenous glucose source, result in increased glucose utilization and lower
blood glucose concentrations
• IDM have a decreased ability to mobilize glycogen stores after birth and experience a
relative adrenal insufficiency with decreased levels of catecholamines, further
contributing to the risk of low blood glucose levels
 Risk factors cont..,
• Intrauterine growth restriction or small compared to gestational age infants .Late-
preterm infants (34 to 36.6 weeks gestational age)
• Preterm, intrauterine growth restricted and small for gestational age infants are at risk
for hypoglycemia because they are born with decreased glycogen stores, decreased
adipose tissue and experience increased metabolic demands because of their
relatively large brain size
• In very low birth weight (<1000 g) preterm infants, the enzymes involved in
gluconeogenesis are expressed at low levels; thus their ability to produce
endogenous glucose is poor, contributing to their risk of severe or prolonged low
glucose concentrations
 Clinical presentation of neonatal hypoglycemia
• The clinical presentation of neonatal hypoglycemia is variable. An otherwise healthy infant may remain asymptomatic despite
extremely low blood glucose levels during the period of transitional hypoglycemia.
• Many infants remain asymptomatic.
Prolonged or severe hypoglycemia causes both adrenergic and neuroglycopenic signs.
• Adrenergic signs include diaphoresis include
-tachycardia,
-lethargy or weakness, and shakiness.
• Neuroglycopenic signs include
-seizure, coma,
-cyanotic episodes,
-apnea,
-bradycardia or respiratory distress,
- hypothermia.
-Listlessness, poor feeding, hypotonia, and tachypnea may occur
 Diagnosis of Neonatal Hypoglycemia
• Bedside glucose check
• All signs are nonspecific and also occur in neonates who have asphyxia, sepsis or
hypocalcemia,
• Neonates with or without these signs require an immediate bedside blood glucose check
from a capillary sample. Abnormally low levels are confirmed by a venous sample.

• Measure blood glucose every six hours:

-If the blood glucose is less than 45 mg/dl (2.6 mmol/l), treat for low blood glucose

-If the blood glucose is more than 105 mg/dl (6 mmol/l ) ( hyperglycaemia) on two consecutive
readings : - Change to a 5% glucose solution, if possible;
- Measure blood glucose again in three hours.
 Differential diagnosis
• . The symptoms mentioned can be due to many other causes with or without associated
hypoglycemia.
• If symptoms persist after the glucose concentration is in the normal range, other etiologies
should be considered. Such as
Sepsis
-CNS disease oxic exposure
-Metabolic abnormalities
-Hypocalcemia
-Hyponatremia or hypernatremia
-Hypomagnesemia
-Pyridoxine deficiency
-Adrenal insufficiency
 Management
The goals of managing neonatal hypoglycemia are:
• To correct blood glucose levels in symptomatic neonates
• To prevent symptomatic hypoglycemia in at-risk patients
• To avoid unnecessary treatment of infants with physiologic low blood glucose
during the transition to extrauterine life, which will self-resolve without
intervention
• To identify newborns with a serious underlying hypoglycemic disorder
• Prevent long-term neurologic sequelae of neonatal hypoglycemia
IV therapy Medical Management
• a. Indications i. Inability to tolerate oral feeding
• ii. Symptoms
• iii. Oral feedings do not maintain normal glucose levels
• iv. Glucose levels less than 25 mg/dL
b. Urgent treatment
i. 200 mg/kg of glucose over 1 minute, to be followed by continuing therapy discussed
subsequently
ii. This initial treatment is equivalent to 2 mL/kg of dextrose 10% in water (10% D/W) infused
intravenously
c. Continuing therapy i. Infusion of glucose at a rate of 6 to 8 mg of glucose/kg per minute ii.
10% D/W at a rate of 86.4 mL/kg per day or 3.6 mL/kg per hour gives 6 mg/kg per minute of
 Nursing Management
• Nurses providing ongoing care at the bedside are often the first to identify an infant at risk
for developing hypoglycemia. Prophylactic care for any infant assessed to be at risk for
hypoglycemia includes (Narvey & Marks, 2019):
• Early enteral feeding,
• Difficulties with infant latching, poor feeding, and low volumes of breast-milk may interfere
with the successful establishment of early breastfeeding in the first hours of life.should be
addressed

• Maintenance of a neutral thermal environment Skin-to-skin contact between mother and

newborn to prevent cold stress and use of glucose stores
• Correction or treatment of other problems that increase energy requirements
• When a newborn arrives in the nursery, a protocol that includes head-to-toe assessment and
gestational age assessment of predisposing risk factors should be followed.
 Breast feeding for management of
hypoglycemia
• Early initiation of breastfeeding is crucial for all infants. The best intervention
for asymptomatic hypoglycemia is to increase feeding frequency.

• Breastfeeding eight to twelve times per day

• Feeding in response to readiness cries, not on a schedule
• Not letting the newborn get to the point of crying (i.e., crying depletes
glycogen stores rapidly and can contribute to a steep decline in blood sugar
levels)
• Pump or hand expressing colostrum into a spoon or cup for the newborn that
is reluctant to suckle at the breast and feed the newborn colostrum several
times per hour until he can feed adequately at the breast
 Measures to promote breastfeeding :
• Giving the baby to the mother for breastfeeding shortly after birth
• promoting breastfeeding on demand, 24 hours a day
• promoting rooming-in (mother and baby are together 24 hours a day)
• informing mothers about the benefits of breastfeeding and dangers of artificial
feeding
• showing mothers how to breastfeed and inform them about the problems that may
arise
• avoiding any use of breast-milk substitutes and bottle-feeding
• avoiding hospital routines that may interfere with breastfeeding.
 Measures to promote breastfeeding comt,
• Assist mother with positioning for feeding
- Head and body in a straight line
- Face opposite nipple
-Neck not flexed
- Whole body supported
• Provide advice about signs that a baby is adquately fed.
- softening of the breast with feeding
- swallowing sounds heard during feeding
-feeds every 2-4 hours (8-12 times per day)
-baby sleeps well between feedings
 Measures to promote breastfeeding cont,

Advise mother about Signs of good attachment

• Signs of good attachment
- mouth wide open
- lower lip turned downward
- chin touching breast
- most of dark portion of the nipple in the mouth
-swallowing sounds heard during feeding
-feeds every 2-4 hours (8-12 times per day) - baby sleeps well between feedings
• Signs of poor attachment
- only nipple in mouth
- baby pulls on nipple
Advise mothers about how to improve flow of milk

• Apply warm compresses

• Massage the back and neck
• Massage the breasts and nipples To improve supply of milk
• Increase maternal fluid intake
• Increase frequency of feedings
 Feeding sick neonates
• FEEDING THE BABY USING AN ALTERNATIVE FEEDING METHOD
• Teach the mother how to express breast milk, if necessary.
• Encourage the mother to express breast milk at least eight times in 24 hours.
• Assess feeding ability twice daily, and encourage and support the mother to
begin breastfeeding as soon as the baby shows signs of readiness to suckle
unless treatment of the baby’s illness prevents breastfeeding (e.g. the baby is
receiving oxygen).
• Record the following each time the baby is fed time of feeding;
 Calculation of milk requirements

Amount and kind of milk

given (e.g. expressed breast
milk or breastmilk
substitute);any feeding
difficulty.
Calculate the volume of
milk required according to
the baby’s age
• Feed the baby immediately after the milk is expressed, if possible. If the baby
does not consume all of the milk, store the remaining milk according to the
guidelines on for expressed breast milk.
• Have the mother feed the baby unless she is not available. The mother should:
• measure the volume of breast milk in the cup, ensuring that it meets the required volume
according to the baby’s age
• hold the baby sitting semi-upright on her lap;
• rest the cup (or paladai or spoon) lightly on the baby’s lower lip and touch the outer part of
the baby’s upper lip with the edge of the cup;
• tip the cup (or paladai or spoon) so the milk just reaches the baby’s lips;
• allow the baby to take the milk; do not pour the milk into the baby’s mouth;
• end the feeding when the baby closes her/his mouth and is no longer interested in feeding.
FEEDING EXPRESSED BREAST MILK BY GASTRIC TUBE

• Ensure that the mother can properly express breast milk Insert a gastric tube if one is not
already in place.
• Confirm that the tube is properly positioned before each feeding.
• Encourage the mother to hold the baby and participate in feedings.
• Determine the required volume of milk for the feed according to the baby’s age
• (Remove the plunger of a high-level disinfected or sterile syringe (of a size large
enough to hold the required volume of milk) and connect the barrel of the syringe to the
end of the gastric tube:
• If a high-level disinfected or sterile syringe is not available, use a clean (washed, boiled or rinsed
with boiled water, and air-dried) syringe;
• If a suitable syringe is not available, use any other suitable, clean funnel that connects snugly to the
gastric tube.
F eeding expressed breast milk by gastric
tube cont,
• Pour the required volume of milk for the feed into the syringe with the
“tip” of the syringe pointed downward.

• Have the mother hold the syringe 5 to 10 cm above the baby or suspend
the tube above the baby and allow the milk to run down the tube by
gravity. Do not force milk through the tube using the plunger of the
syringe.
 Education needs

Education for family members regarding hypoglycaemia is an important aspect of the neonate’s
holistic care.
• Education may include:
• Risk factors and causes of neonatal hypoglycaemia

• Clinical manifestations of neonatal hypoglycaemia

• Investigations of neonatal hypoglycaemia
• Basic nursing management to prevent and manage of neonatal hypoglycaemia
• Medical management of neonatal hypoglycaemia
• Family-centered care must always be upheld during clinical concerns of the neonate.
Communication of a hypoglycaemic event, investigations taken and subsequent results should
be discussed with the family when appropriate. Communication with the family can be
documented progress notes
 APPLICATION EXERCISE
• During clinical practicum , inquire about neonatal hypoglycaemia, incidences and
how neonatal hypoglycemia is prevented/ managed
• What policies encourage early and exclusive breastfeeding?
• Who helps new mothers with breastfeeding?
• Are there any local practices that interfere with exclusive breastfeeding

• What care is given to sick neonates unable to breast feed? Emphasis on IPC?
• Explain what you appreciated most or what would do differently in the
prevention and management of neonatal hypoglycaemia
 References
Ministry of Health Uganda , (2021) Essential Maternal and Newborn
Clinical Care Guidelines for Uganda

Manual of neonatal care / editors, John P. Cloherty ... [et al.]. — 7th ed.

Wong’s nursing care of infants and children / [edited by] Marilyn J.

Hockenberry, David Wilson.—10th edition