How to Manage Hypoglycaemia or Hyperglycaemia in NYI (Chapter 11)

Learning Objectives

After completion of this chapter the participant should be able to:

• Define hypoglycaemia.
• Perform a glucose test.
• Identify NYI at risk of hypoglycaemia.
• Identify signs and symptoms of hypoglycaemia.
• Describe the treatment of hypoglycaemia in a symptomatic and asymptomatic NYI.
• Describe assessment and management of a neonate with hyperglycaemia in NYI.

• How to make up a 10% dextrose solution when you only have 50% dextrose
• To make up a bag of 10% dextrose solution

Hypoglycaemia is common in LBW and very sick NYI and should always be considered early in management. 20% of infants below seven days of age have hypoglycaemia. It is important to identify hypoglycaemia as there is an increased association with convulsions, permanent brain injury, and mortality

COIN defines hypoglycaemia as blood glucose of < 45 mg/dl (2.5 mmol/L) for NYI. Blood glucose levels can be checked using a glucometer.

Newborns at risk of hypoglycaemia
Any baby who has:

• Seizures
• Reduced consciousness
• Lethargy

Also:

• Small for dates
• Low birth weight
• Infant of diabetic mothers
• Following asphyxia or prolonged resuscitation
• Unable to feed
• Jittery babies

E 9 Glucometer

Assessment of blood glucose with a glucometer should be conducted as part of routine assessment for all infants on admission.

Glucometers should also be used during continuing management for all sick or at-risk patients. Hypoglycaemia may present as:

• Jitteriness
• Irritability
• Hypotonia
• Lethargy
• Reduced level of consciousness
• Failure to feed or poor feeding
• Seizures
• Hypothermia
• Apnoea or irregular breathing

Identifying and Managing a NYI with Hypoglycaemia

Chart A: Identify a NYI with Hypoglycaemia
Chart B: Management if not symptomatic
Chart C: Management if symptomatic

Chart A

Identify a NYI with Hypoglycaemia

Chart B

Management of a baby with blood glucose of less than < 45 mg/dl (2.5 mmol/l) and NOT symptomatic

Chart C

Management of a baby with blood glucose of less than < 45 mg/dl (2.5 mmol/l) and symptomatic

How to make up a 10% dextrose solution when you only have 50% dextrose:

To make up a bag of 10% dextrose solution:

Empty fluid out of a litre bag of IV normal saline until there is only 200mls left (4 parts) and then add 50mls of 50% dextrose (1 part) to make up 250mls of a 10% dextrose solution.

GIVING 50% GLUCOSE IS NO LONGER RECOMMENDED

• There have been case reports of dextrose overdose resulting in convulsions and death (hyperosmolar brain injury).
• In newborns it has been suggested that use of 50% glucose increases the risk of brain damage due to asphyxia.
• 10% glucose solutions work just as well and are safer.

Maintenance Therapy

After a bolus of glucose a plan must be made to continue providing a glucose supply as:

• IV fluids with glucose and electrolytes or
• Nasal gastric or oral feed

Hypergylcaemia

Neonatal hyperglycaemia is defined as a blood glucose of more than 145mg/dl (8mmol/L) regardless of body weight, gestational or postnatal age. Hyperglycaemia may be seen in any baby but is more common in low birth infants.

In settings where a neonate is on IV fluids the most common cause is infusion of inappropriately high amounts of glucose as IV fluids. In our setting, where IV infusions are less frequently given, hyperglycaemia is most commonly due to stress, usually from an intercurrent sickness such as sepsis, dehydration and HIE. This is because of raised cortisol levels in response to the stressful situation. Adequate treatment of the underlying illness will often result in resolution of the hyperglycaemia and improvement of baby’s overall condition. Rarely patients may have insulin resistance or neonatal insulin dependent diabetes mellitus and such patient need discussion and care at a tertiary level facility.

What should be done when a neonate has a high glucose reading?

1. Repeat the test to confirm if it is accurate (You may want to use a different glucometer).
2. Review the patient fully by performing a physical examination and monitoring their vital signs. Often hyperglycaemia is asymptomatic but you may find signs of the underlying cause. Also look for signs of dehydration, fever, acidosis and monitor the weight. Treat the underlying problem, if identified.
3. If on IV fluids confirm that the fluids were correctly prepared and administered and ensure that the infusion rate is appropriate for the age and weight (see infusion rates on the feeding charts).
4. If the blood glucose is above 180mg/dl (10mmol/L), this should be discussed with a referral facility who will provide additional guidance.
5. Monitor the baby and the blood sugar 2-4 hourly.