Neonatal Hypoglycemia: Indian Academy of Pediatrics Guidelines

Hypoglycemia is low level of plasma or blood glucose in the neonate. In healthy term neonates, there is a transient, physiological fall in the blood glucose concentration with a nadir at 60–90 minutes after birth, without any symptoms later rising to levels above 60 mg/dL by 4 hours. ; Breastfed infants may tolerate lower blood sugar levels because of bioavailable alternate fuels like ketone bodies, thus facilitating adaptation during transition.

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Neonatal Hypoglycemia. The lead author for these guidelines on Neonatal Hypoglycemia is Dr VC Manoj along with co-author Dr Mamta Jajoo and Dr Nilesh Rao. The guidelines come Under the Auspices of the IAP Action Plan 2022,and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan and PT Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan

Following are the major recommendations of guidelines:

Clinical Manifestations of Hypoglycemia in Neonate:

Tachypnea, Tachycardia, Poor suck, Poor feeding, Pallor, Temperature instability, Sweating Neuroglycopenic, Lethargy and hypotonia, Apnea or irregular breathing efforts, Cyanosis, Seizures.

It is prudent to prevent recurrent and persistent hypoglycemia due to associations with seizures, poor visual motor, and executive function at 4–5 years of age, however there is no clear association between asymptomatic hypoglycemia, treatment for the same and poor neurodevelopmental.

Testing:

Testing is warranted only for at-risk neonates and is not needed for healthy term newborns.Point-of-care testing using reagent strips is rapid, bed side, convenient, and cost-effective.Blood glucose measured by strip is 15% lesser than plasma glucose. In case of low blood glucose, a laboratory sample for blood glucose estimation should be sent. A delay in testing of sample after collection can lead to a blood glucose reduction of up to 6 mg/dL/hour.

Etiology:

Decreased production/stores Prematurity, intrauterine growth restriction (IUGR), delayed feeding, growth hormone (GH) and cortisol deficiency, inborn errors of metabolism (IEM).Increased utilization, Infant of diabetic mother, large for gestational age (LGA), sepsis, asphyxia, hypothermia, polycythemia, hyperinsulinemia, maternal beta blockers, and oral hypoglycemic.

Management:

Gestation Age >35 Weeks;All infants:Skin-to-skin care, keep warm;Promote breastfeeding within first hour of birth;Infants should continue breastfeeding on cue;Not to give water or glucose water or formula may interfere with normal metabolic compensatory mechanisms;At risk infants: Symptomatic and blood glucose < 40 mg/dL: Start intravenous (IV) glucose Symptomatic with blood glucose < 25 mg/dL: Give bolus IV dextrose 10% 1–2 mL/kg followed by infusion at the rate of 5–8 mg/kg/min.

Target glucose > 50 mg/dL;Continue breastfeeding frequently;Recheck plasma glucose within 30 minutes Asymptomatic: 50 mg/dL;Recheck until three normal levels;Check glucose levels once at 24 hours of age in babies like small for gestational age (SGA)/ low birth weight (LBW)/preterm

Parenteral Therapy:

Rate of start of IV fluids: Use graded approach;IUGR: 5–7 mg/kg/min;Mother with infants of diabetic mothers (IDM)/LGA infants: 3–5 mg/kg/min;Infant with other risk group: 4–6 mg/kg/min;Glucose infusion >12 mg/kg/min: Consider for further interventions;Maximum dextrose concentration through peripheral IV cannula and central venous catheter is 12.5% and 25%, respectively.

Discharge Criteria:

Infant with persistent hypoglycemia for >72 hours or requiring IV therapy for symptomatic or asymptomatic low glucose levels should only be discharged if glucose level maintained above 70 mg/dL through several feed-fast cycles.

Neurodevelopmental Outcome:

Due to the potential deleterious effects on the neonatal brain, it is recommended to treat symptomatic hypoglycemia and prevent recurrent and persistent hypoglycemic episodes.In asymptomatic hypoglycemia, although there is not much evidence for adverse outcomes, there are concerns about poor literacy scores and lower visual motor, executive function with recurrent or severe hypoglycemia.In preterm neonates, associations have been reported between recurrent low sugars and lower bailey scores, developmental and cognitive delays. More research is needed in this group of neonates.

Reference: Adamkin DH, Polin RA. Imperfect Advice: Neonatal Hypoglycemia. J Pediatr. 2016; 176:195-6. ; Committee on Fetus and Newborn, Adamkin DH. Postnatal glucose homeostasis in late preterm and term infants. Pediatrics. 2011;127:575-9.Goode RH, Rettiganti M, Li J, Lyle RE, Whiteside-Mansell L, Barrett KW, et al. Developmental Outcomes of Preterm Infants with Neonatal Hypoglycemia. Pediatrics. 2016;138(6):e20161424.

McKinlay CJD, Alsweiler JM, Anstice NS, Burakevych N, Chakraborty A, Chase JG, et al. Association of Neonatal Glycemia with Neurodevelopmental Outcomes at 4.5 Years. JAMA Pediatr. 2017;171:972-83. Stanley CA, Rozance PJ, Thornton PS, De Leon DD, Harris D, Haymond MW, et al. Reevaluating "transitional neonatal hypoglycemia": mechanism and implications for management. J Pediatr. 2015;166:1520-5.e1.

Thornton PS, Stanley CA, De Leon DD, Harris D, Haymond MW, Hussain K, et al. Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children. J Pediatr. 2015;167: 238-45.

The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/