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Key Features

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Essentials of Diagnosis
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  • Blood glucose < 40 mg/dL at birth to 4 h, or < 45 mg/dL at 4–24 h of age

  • Large or small for gestational age (LGA/SGA), preterm, and stressed infants at risk

  • May be asymptomatic

  • Infants can present with lethargy, poor feeding, irritability, or seizures

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General Considerations
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  • Blood glucose concentration in the fetus is approximately 15 mg/dL less than maternal glucose concentration

  • Glucose concentration decreases in the immediate postnatal period, to as low as 30 mg/dL in many healthy infants at 1–2 hours after birth

  • Concentrations below 40 mg/dL after the first feeding are considered hypoglycemic

  • By 3 hours, the glucose concentration in normal full-term infants stabilizes at 45 mg/dL or greater

  • Two groups of full-term newborn infants at highest risk for hypoglycemia

    • Infants of diabetic mothers (IDMs)

      • Have abundant glucose stores in the form of glycogen and fat

      • Hypoglycemia develops because of hyperinsulinemia induced by maternal and fetal hyperglycemia

    • Intrauterine growth restricted (IUGR) infants

      • Has reduced glucose stores in the form of glycogen and body fat

      • Marked hyperglycemia and a transient diabetes mellitus–like syndrome occasionally develops, particularly in the very premature infant

  • Other causes

    • Disorders with islet cell hyperplasia, including Beckwith-Wiedemann syndrome, nesidioblastosis, and genetic forms of hyperinsulinism

    • Certain inborn errors of metabolism, such as glycogen storage disease and galactosemia

    • Adrenal insufficiency and hypopituitarism

    • Birth asphyxia, hypoxia, and bacterial or viral sepsis

    • Prematurity

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Clinical Findings

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  • Lethargy, poor feeding

  • Irritability

  • Tremors, jitteriness

  • Apnea

  • Seizures

  • Cardiac failure may occur in severe cases

  • Hypoglycemia in hyperinsulinemic states can develop within the first 30–60 minutes of life

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Diagnosis

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  • Blood glucose can be measured by heelstick using a bedside glucometer

  • All low or borderline values should be confirmed by laboratory measurement of blood glucose concentration

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Treatment

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  • Therapy is based on the provision of enteral or parenteral glucose

  • After initial correction with a bolus of 10% dextrose in water (D10W; 2 mL/kg), glucose infusion should be increased gradually as needed from a starting rate of 6 mg/kg/min, and weaned slowly when normoglycemic

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Outcome

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Follow-Up
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  • Infants with hypoglycemia requiring intravenous glucose infusions for more than 5 days should be evaluated for less common disorders, including

    • Inborn errors of metabolism

    • Hyperinsulinemic states

    • Deficiencies of counterregulatory hormones

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Prognosis
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  • Good if therapy is prompt

  • CNS sequelae are more common in infants with hypoglycemic seizures and in neonates with persistent hyperinsulinemic hypoglycemia

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References

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Adamkin  DH; Committee on Fetus and Newborn: Clinical report—postnatal glucose homeostasis in late preterm and term infants. Pediatrics 2011;127:575 21357346. 
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Hay  WW Jr: Care of the infant of the diabetic mother. CurrDiab Rep 2012;12(1):4–15 22094826.
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Rozance  PJ, Hay  WW Jr: Neonatal hypoglycemia. NeoReviews 2010;11:e681.

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