Neonatal Hypoglycemia (PES 2015)

Algorithm Steps

1. ▶

   Start

   Neonatal Hypoglycemia Risk Assessment

   Identify at-risk newborns

   1. ●

      Action

      Risk Factors for Neonatal Hypoglycemia

      Screen high-risk infants

      • HIGH RISK:
      • • Infant of diabetic mother (IDM)
      • • Large for gestational age (LGA)
      • • Small for gestational age (SGA)
      • • Preterm (<37 weeks)
      • • Perinatal stress (asphyxia, sepsis, hypothermia)
      • • Maternal beta-blockers, sulfonylureas
      • Screen glucose at 30-60 min of age if risk factors
      1. ●

         Action

         Treatment Thresholds

         When to treat (varies by guideline)

         • COMMON THRESHOLDS:
         • • <25 mg/dL (<1.4 mmol/L): Always treat
         • • 25-40 mg/dL: Treat if symptomatic, feed if asymptomatic
         • • <45-50 mg/dL after 4-24 hrs: Consider treatment
         • AAP: <25 mg/dL in first 4h, <35 mg/dL at 4-24h
         • PES: <50 mg/dL if symptomatic
         • GOAL: Maintain ≥45-50 mg/dL
         1. ◆

            Decision

            Symptomatic?

            Assess for symptoms of hypoglycemia

            • SYMPTOMS:
            • • Jitteriness, tremors
            • • Lethargy, hypotonia
            • • Poor feeding, weak cry
            • • Hypothermia
            • • Seizures, apnea
            • • Cyanosis
            1. ●

               Action

               Asymptomatic - Oral Feeding Trial

               Feed and recheck

               • Initiate feeding (breast or formula)
               • Feed 10-15 mL/kg
               • Recheck glucose 30-60 min after feed
               • If still low after feed:
               • • May give 40% dextrose gel 0.5 mL/kg buccal
               • • Recheck in 30 min
               • • If still low → IV dextrose
               1. ◆

                  Decision

                  Glucose Normalizing?

                  Monitor response to treatment

                  1. ●

                     Action

                     Wean IV Glucose

                     Transition to enteral feeding

                     • Wean GIR by 1-2 mg/kg/min q3-6h
                     • Increase enteral feeds simultaneously
                     • Monitor pre-feed glucose
                     • Discontinue IV when:
                     • • Taking full enteral feeds
                     • • Pre-feed glucose ≥50 mg/dL consistently
                  2. ●

                     Action

                     Increase GIR

                     Persistent hypoglycemia

                     • Increase GIR by 2 mg/kg/min increments
                     • May need GIR 10-15+ mg/kg/min
                     • If requiring GIR >12 mg/kg/min:
                     • • Consider hyperinsulinism
                     • • Send critical sample before correction:
                     • - Insulin, cortisol, GH, free fatty acids
                     • - Beta-hydroxybutyrate, lactate, ammonia
                     • Consult endocrinology if persistent
                     1. ⚠

                        Warning

                        Persistent Hypoglycemia Workup

                        If hypoglycemia persists >48-72h

                        • CONSIDER:
                        • • Hyperinsulinism (most common)
                        • • Hypopituitarism
                        • • Cortisol deficiency
                        • • Fatty acid oxidation defects
                        • • Glycogen storage disease
                        • Send critical sample during hypoglycemia
                        • MRI brain if hypopituitarism suspected
                        • Genetic testing may be indicated
            2. ●

               Action

               Symptomatic or Severe - IV Dextrose

               Immediate IV treatment

               • IV BOLUS:
               • D10W 2 mL/kg (200 mg/kg) over 5-10 min
               • THEN INFUSION:
               • D10W at glucose infusion rate (GIR) 5-8 mg/kg/min
               • GIR calculation:
               • GIR = (rate mL/kg/day × dextrose %) / 144
               • Recheck glucose q30-60 min
               • Titrate to maintain ≥50 mg/dL