Chapter 62

### 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 the risk in the infant. Infants born to mothers who had preeclampsia, or received glucose infusion during delivery, or were on oral terbutaline are also at increased risk.

3. Is the infant at risk for hypoglycemia?...

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