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I. PROBLEM

An infant has a “low blood glucose level” on bedside glucose testing. The American Academy of Pediatrics (AAP) Committee on Fetus and Newborn states that the “absolute definition of hypoglycemia as a specific value or range cannot be given, as no evidence-based studies can define what clinically relevant neonatal hypoglycemia is.” Therefore, it is challenging to address treatment for hypoglycemia, as it is not possible to define a single blood glucose level that requires intervention in every newborn. Because blood glucose is lower in the first 12–24 hours after birth, some clinicians use a lower target number in the first 24 hours of life to define hypoglycemia. Treatment decisions depend on the clinical situation and infant characteristics. Note: Aggressive screening and treatment is recommended because hypoglycemia is linked to poor neurodevelopmental outcome. Incidence varies depending on many factors, including gestational age and cause, but is ∽15%.

  1. At-risk late preterm (34–36 6/7 weeks) and term infants (small for gestational age [SGA], infants of diabetic mothers [IDMs], large for gestational age [LGA]). AAP guidelines recommend treatment for low blood sugar in the following settings:

    1. Symptomatic infants at any age with a plasma glucose <40 mg/dL.

    2. Asymptomatic infants (birth to 4 hours) with a plasma glucose <40 mg/dL.

    3. Asymptomatic infants (4–24 hours) with a plasma glucose <45 mg/dL.

  2. AAP guidelines recommend a target plasma glucose of ≥45 mg/dL before routine feeding.

  3. Preterm infants <34 weeks. Plasma glucose <45 mg/dL (controversial; best to use your institutional guidelines). No guidelines have been established for premature infants with literature stating ranges 40–50 mg/dL.

  4. Infants with documented hyperinsulinemic states. Value of <60 mg/dL is considered hypoglycemic (controversial ).

II. IMMEDIATE QUESTIONS

  1. Has the value been repeated, and has a serum blood glucose sample been sent to the laboratory? Reagent strips can give incorrect values and be quite inaccurate in the low range (<40–50 mg/dL). Test strips can vary 10–20 mg/dL from the actual level of properly collected plasma glucose. Never diagnose or treat hypoglycemia based on these screening reagent strips alone. Always send a serum sample to the laboratory before starting treatment. Bedside glucose meters (use only FDA cleared for testing in neonates) are sufficiently accurate and precise for in-hospital use but only as screening devices. Remember, in infants with a high hematocrit a false low glucose may occur, and with galactosemia a false high glucose will occur. Note: Plasma glucose is 10–18% higher than serum glucose.

  2. Does the mother have any risk factors that would increase her infant's risk of hypoglycemia, such as gestational or insulin-dependent diabetes? Approximately 40% of IDMs have hypoglycemia. Throughout pregnancy, diabetic mothers can have episodes of hyperglycemia, resulting in fetal hyperglycemia. This fetal hyperglycemia induces pancreatic β cell hyperplasia, which in turn results in hyperinsulinism. After delivery, hyperinsulinism persists, and hypoglycemia results. An infant of an obese mother without glucose intolerance can also increase ...

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