Our brains, especially that of a newborn, is dependent on glucose as the primary source of energy. Like most of their other bodily functions, glucose regulation is immature at birth. High glucose demand from rapid growth and high metabolic rates make newborns highly susceptible to neonatal hypoglycemia.
Low birthweight babies, preterm babies and babies born to moms with diabetes are at an increased risk for hypoglycemia. This is especially true during the transitional phase from womb to world.
We must treat prolonged or recurrent episodes of hypoglycemia immediately in neonates.
Our biggest concern is brain injury.
Specifically, edema and atrophy that can lead to permanent neurological damage which can manifest as cerebral palsy, epilepsy, deafness and blindness.
Here’s what you need to know about what drugs are needed, how to give them and 3 pitfalls to avoid.
Identifying Neonatal Hypoglycemia
We define neonatal hypoglycemia as a blood glucose of less than 40mg/dL. Hypoglycemia is always difficult recognize by symptoms. Nonspecific presentation in neonates ranges from poor feeding, tremors, twitching to seizures and coma.
We must also make the distinction between persistent hypoglycemia and normal fluctuations in blood glucose as the baby transitions out of the womb and establishes glucoregulaltion independent of mom.
Most newborn protocols will screen for hypoglycemia every 1-2 hours, increasing or decreasing surveillance frequency based on the presence or absence of signs and symptoms of hypoglycemia.
The treatment goal is to raise plasma glucose concentrations to 50-200mg/dL.
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How to Treat Neonatal Hypoglycemia
Dextrose administration is the foundation for correcting hypoglycemia in neonates. We will administer glucose via one of 2 routes depending on the severity and available route of administration.
1. Dextrose Gel
40% dextrose gel is indicated in mild cases of asymptomatic hypoglycemia. This is a baby who is able to feed, clinically stable and not is any distress.
How to Dose
We commonly refer to glucose gel as sweet cheeks.
Massage the gel into the buccal mucosa (the lining of the gums).
Prior to applying to the cheeks, dry the mouth with gauze and follow application of the gel with feeding (breast/bottle).
It is dosed at 0.2g/kg/dose or 0.5ml/kg/dose (see calculation below). Doses can be repeated up to 6 times in 48 hours.
2. Parenteral Dextrose
We use intravenous dextrose in babies who are:
- Asymptomatic with mild hypoglycemia but unable to receive oral treatment due to inability to feed or clinical instability like respiratory distress.
- Asymptomatic with severe hypoglycemia (plasma glucose <20mg/dL)
- Symptomatic
How to Dose
D10% (a 10% dextrose solution) to commonly used in neonates with hypoglycemia.
We give a bolus dose to babies who are symptomatic. The recommended dose is 0.2 grams/kg (note the similarity in dosing glucose gel: both are 0.2g/kg). You must be particularly careful with the units used in calculations for pediatric patients Because a 10% solution is 10g of dextrose per 100ml this equates to a 2ml/kg rate which is how it is commonly ordered. Administered the bolus over 1-2 minutes.
A continuous infusion using either 5% or 10% dextrose may follow at a rate of 5-8 mg/kg/minute of dextrose titrated to achieve target glucose levels of 50-200 mg/dL.
Repeat blood glucose concentrations after 20-30 minutes in symptomatic neonates. In asymptomatic patients it can repeated in an hour.
Discontinued intravenous dextrose when plasma glucose levels have been stabile for atleast 24 hours.
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Pitfalls to Avoid
1. Abrupt discontinuation of intravenous dextrose
Administration of intravenous dextrose induces a corresponding increase in insulin release from the pancreas. The body clears endogenous insulin from plasma in 4-6 minutes. When we abruptly discontinue IV dextrose the high ratio of insulin to glucose creates the potential for rebound hypoglycemia.
I explain the mechanism of rebound hypoglycemia in this video on TPN administration.
Reduce the rate of the dextrose infusion by 1-2mg/kg/min every 4-8 hours to prevent rebound neonatal hypoglycemia.
2. Concentration Confusion
We can safely administer dextrose 5%, 10% and 12% dextrose to a newborn.
We use D10 instead of D5 because of the difference in volume that we would administer. Because of their small body weight there is only so much volume a neonate can tolerate. Using D5 would require twice the volume of D10 to deliver the same milligram amount of dextrose.
We should never directly infuse higher concentration of dextrose like 25% and 50% in neonates. These concentrations have a high risk of vascular injury when administered via small veins. 12.5% is the maximum recommended concentration for peripheral administration.
3. Alligation
A provider might occasionally request a 12% dextrose solution when a neonate is not responding well enough to a D10 infusion. Though commercial preparations are available, in my experience it is not routinely stocked because it is not frequently used.
This is one scenario where knowing how to perform alligation calculations is important. Alligation uses a higher concentration of dextrose like D25% or D50% to compound a lower 12% solution.
I explain 2 ways to perform alligation:
How to Perform Alligation Calculations: Grid Method
Alligation Calculations Made Easy using Intuitive Equations
Discover which approach works best for you.
If this unit has been helpful, I would love to hear from you! Leave a question or comment below.
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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.