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Management and TREATMENT of neonatal HYPOGLYCEMIA — Transcript

by Tala Talks NICU · 6,040 words · 862 segments · language en · Watch on YouTube

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0:00what defines hypoglycemia and how do we
0:03manage it if you haven't watched the
0:05first video on what causes low sugars
0:08and its symptoms then go back and watch
0:10that first and remember if you want the
0:12PDF summary of this video then subscribe
0:15to our newsletter hello I'm Dr tala and
0:17I've been a neonatologist for about 16
0:20years now and I'm sure like a lot of you
0:22I don't think I've spent a single day in
0:25the unit where I don't have to correct
0:27somebody's low blood sugars so this is a
0:30very clinically important video also
0:33make sure that you watch until the end
0:34for your little homework assignment
0:36let's get straight into it one what
0:39defines
0:41hypoglycemia well this is the huge
0:44controversial question and depending on
0:47where you live you will get a different
0:49answer because different professional
0:51organizations in different countries
0:54have all determined that there are
0:56different levels of sugar that should be
0:58considered hypoglycemia which I always
1:00find very interesting because they're
1:02all looking at exactly the same studies
1:05and exactly the same research but coming
1:07up with slightly different algorithms
1:09and protocols in the references under
1:11the video we've included a brilliant
1:14article a review article where they
1:15basically go over all the different
1:18policies and recommendations from six
1:20different International professional
1:22organizations so the one from the US the
1:25AAP and Canada and then UK Australia and
1:30the uh endocrinological society as well
1:33so I would highly recommend that you
1:35look through that it summarizes
1:36everything so beautifully okay so back
1:39to the age-old question what do we
1:41consider to be a low glucose and I know
1:45that I've said something about this
1:46before but again in medicine we only
1:49care about an abnormal number if it is
1:52affecting the baby now or it is going to
1:55be affecting the baby in the future
1:57otherwise we don't really care what the
1:59number is so so logically if a baby has
2:01clinical symptoms of hypoglycemia so
2:04that means that it is affecting the baby
2:06right now then logically we should
2:09probably have a higher threshold to
2:11actually treat that hypoglycemia and all
2:14the professional organizations agree on
2:16this if a baby has clinical symptoms you
2:18are much more likely to treat that baby
2:21in the AAP report on postnatal glucose
2:24homeostasis which was published in 2011
2:27and it hasn't actually been reviewed
2:28since then but they recommended that if
2:31any baby has clinical symptoms of
2:33hypoglycemia and a blood glucose level
2:36of less than 40 milligrams per diler
2:39which is 2.2 Mill mes per liter then
2:42that baby should be treated with IV
2:45dextrose this was instituted before kind
2:48of glucose gels were used more regularly
2:50whereas other organizations use even
2:53slightly higher thresholds to
2:54automatically treat babies so 45 or 47
2:58migs per deciliter which which is 2.5 or
3:012.6 milles per liter I'm also just going
3:03to bring this up really quickly some
3:06countries use the unit of milligrams per
3:09deciliter for the glucose and other
3:11countries use Mill moles per liter
3:13basically the conversion is you multiply
3:16the mill moles times 18 to get the
3:18milligrams per deciliter because the
3:21molar weight of glucose is 180 remember
3:25C6 h126 and oxygen is 16 and carbon is
3:3012 or whatever not important and then
3:32you're also accounting for the fact that
3:33it's a deciliter and a liter so in
3:35summary multiply by 18 or divide by 18
3:39to get the millimoles now you
3:41know okay so that was the treatment of
3:44symptomatic infants what about
3:46asymptomatic infants with low blood
3:48glucoses well the first thing that you
3:50should know is that most professional
3:52organizations do not recommend routinely
3:56testing all babies for a glucose level
3:59so basically the only way that we're
4:01going to know if a baby does have a
4:03glucose level is if we are picking
4:05certain babies to screen for
4:08hypoglycemia on and logically these
4:11organizations all have recommendations
4:13in place for which babies we should be
4:15screening for example the AAP recommends
4:18that we screen at risk babies for
4:21hypoglycemia so who's at risk so pre-own
4:24babies if you're born less than 37 weeks
4:26sgaa babies small for gestational a age
4:29babies baby so your weight is less than
4:3110th percentile LGA baby so your birth
4:34weight is above 90th percentile or large
4:37for gestational age as well as infant of
4:40diabetic mothers they also recommend
4:42that if the baby is exhibiting very poor
4:44feeds or just subjectively the baby
4:47isn't feeding well at all then those are
4:49babies we should be checking as well and
4:52this goes without saying if a baby has
4:53any symptoms of hypoglycemia then
4:56obviously we should be checking the
4:57glucose level then as well now the
4:59question question is when do we check
5:01that first glucose level again every
5:03organization recommends something
5:05different some of them recommend before
5:07the second feed so kind of 2 to four
5:09hours of Life the AAP recommends
5:12checking the first blood glucose level
5:15about half an hour after the first feed
5:17which they recommend happening within
5:19the first hour or so so basically the
5:21AAP wants you to check that Sugar by the
5:23time the baby's about 2 hours old and
5:25then how long do you screen asymptomatic
5:28newborns for again again different
5:30policy statements everywhere somewhere
5:32between 6 to 24 hours so make sure that
5:36you familiarize yourself with a
5:38professional organization in your
5:40country as well as the individual
5:42hospital that you work in because they
5:44also may have interpreted those
5:46recommendations differently so everybody
5:49in your hospital should at least be
5:51treating low glucose levels in the same
5:53way okay so what should we consider
5:56hypoglycemia in an asymptomatic neonate
5:59so a baby that doesn't have any symptoms
6:02again almost impossible to pinpoint a
6:05number but if you are going to remember
6:07one number then remember 47 mg per
6:10deciliter or 2.6 mes per liter so if the
6:14baby's blood glucose level is
6:16consistently staying below 47 then
6:19according to the Canadian the UK and the
6:22Australian organizations that is their
6:24definition of hypoglycemia and by the
6:27way that seemingly very random
6:30specific number came from two studies in
6:32the 1980s the first one showed that if a
6:36baby had a blood sugar level of less
6:39than 47 for 3 days in a row then they
6:42had increased chance of Developmental
6:44delays and the other study use sensory
6:47evoked potentials like at different
6:49blood glucose levels to also make that
6:51same determination so old studies but
6:55we're saying 47 that's kind of when the
6:57baby's a little bit older because
7:00understand in the first few hours of
7:02Life the baby's blood sugar may be lower
7:05than that and still be acceptable like
7:07we said that a lot of babies their blood
7:10sugar can fall to 30 in 1 to two hours
7:13after birth before it starts naturally
7:15coming back up again so this is the
7:17algorithm recommended by AAP in the
7:20first few hours of life so a sugar in
7:23the first 4 hours of Life needs to be
7:25above 40 if it stays below 25 then the
7:28baby needs IV glucose after 4 hours
7:32we're looking for sugars above 45 but if
7:34it stays below 35 again the baby needs
7:37IV glucose again just to remind you all
7:40that this protocol was written before
7:42the huge availability of glucose gels in
7:44the UK the bapm recommended that there
7:47were three different levels of glucose
7:50that you needed to be aware of so that
7:52you could then escalate care whether
7:54that was escalate treatment or further
7:56evaluation or whatever and the three
7:58critical numbers for them was one any
8:01blood glucose below 1 m per liter or 18
8:05mg per deciliter two a blood glucose
8:08less than 45 or 2.5 in a baby with
8:12clinical signs and three a blood glucose
8:15of less than two or 36 on a repeat test
8:19with a baby with risk factors generally
8:22as we're managing the hypoglycemia we
8:24want those sugars to go up to the 40s
8:27and 50s and then again the different
8:29organizations have recommendations of
8:31How High the sugar should be for a baby
8:33to be able to be discharged to go home
8:35and depending on where you live those
8:38numbers for discharge can be anywhere
8:40between 45 and 70 the 70 number comes
8:44from the Pediatric endocrinological
8:46Society and that seems ridiculously high
8:50but they want a blood sugar consisteny
8:52of 70 in babies that are known to have
8:55risk factors for having hypoglycemia so
8:58this is like pfic istent hypoglycemia
9:00for a long period of time in babies that
9:03have some sort of congenital issue where
9:05we know that they are predisposed to get
9:07hypoglycemia so if a baby is healthy and
9:10they kind of gained weight we in their
9:12unit they're no longer pre-term or the
9:15insulin levels have normalized then even
9:17if the sugar drops a little bit they
9:18should have all the right Machinery in
9:20place to be able to get their sugars
9:22back up again but if we know that the
9:24infant has issues whether it's a organic
9:27acidemia or something then we want those
9:30sugars to stay at a higher level because
9:32those are the babies that the sugars can
9:33go from like 50 all the way down to zero
9:36and the baby isn't able to get it back
9:38up again two how do we manage
9:42hypoglycemia and you're going to be
9:44surprised or not at all a lot more
9:47greenness here as well so first of all
9:50let's go through all the different
9:52things we have to consider when we're
9:54choosing what treatment to give babies
9:56if any so these are all the things that
9:58you should consider as you're trying to
10:01decide how aggressively you should treat
10:02the baby one how old the baby is in
10:06hours so like we said the sugar soon
10:09after birth like less than 4 hours we
10:12expect it to be a little bit lower than
10:14after 4 hours and then after 24 hours
10:17and after 48 hours so definitely a 38 at
10:2248 Hours of life is pretty concerning
10:26whereas a 38 in the first four hours of
10:28life isn't as concerning so how old the
10:31baby is two is the baby feeding
10:34obviously if the baby is in the ncu and
10:36has a gastrosis and the baby's no then
10:39we're not going to increase the Sugar by
10:41giving the baby a feed we're not even
10:44going to give a glucose gel if we're
10:45really strictly trying to keep the baby
10:47NPO in this case we would have to give
10:49IV dextrose three does the baby have
10:52symptoms again if the baby has symptoms
10:56obviously you're more likely to treat
10:58but you're also more likely to treat
11:00with IV dextrose rather than with
11:02increased feeds or a glucose gel or
11:04whatever four how low is the number
11:07again the lower it is the more
11:09aggressive you're going to be in trying
11:11to get the sugar up if a baby's sugar is
11:1439 at 24 hours of life you're probably
11:17not going to start by admitting the baby
11:19to the unit and starting IV fluids
11:21whereas if it's less than 10 then you
11:23are going to admit that baby and give IV
11:25fluids how sick is the baby if the baby
11:28is septic or has hiie or is really
11:32acidotic we're already really worried
11:35about the status of the brain we
11:36definitely don't want to H add
11:38hypoglycemia on top of that so again
11:40we're probably going to make sure that
11:42we are treating that low glucose a
11:44little bit more aggressively what is
11:47causing the hypoglycemia and I really
11:49want to say a few words about this
11:51because it really can affect the baby's
11:52management and treatment strategies so
11:55for example let's say that you've got a
11:5736 weer a a baby that's in term nursery
12:02and the baby's sugars have just been
12:03borderline kind of low 40s high 30s they
12:07get a little bit better with the fees
12:08but then fall back down again how
12:11aggressively do we have to treat this
12:12baby well we can assume that the reason
12:16why this Baby's sugars are borderline is
12:18because the baby probably isn't eating
12:20great because it's late pre-term and
12:22also because the baby doesn't have as
12:23much stores because it's a late pre-own
12:26baby of the different substrates the
12:27glycogen or whatever and that's why the
12:30baby can't quite get its sugars just
12:32high enough so this is a baby that
12:34there's a good chance with a little bit
12:36of extra feeds whether that's
12:38encouragement or feeding more often or
12:40maybe even gavage feeds maybe even a
12:42glucose gel this Baby's sugars could be
12:45okay if this baby does end up going to
12:47the unit then it probably won't take a
12:50lot of IV glucose to get this Baby's
12:52sugars normalized because it's not like
12:54this baby has a huge demand for sugars
12:57it's just not quite getting enough now
13:00let's say that same baby is also
13:01hypothermic so the baby came from
13:03newborn nursery and the baby's cold or
13:04the baby's septic at that point the baby
13:07is going to need slightly more energy to
13:10help warm the baby up or to help the
13:12baby fight an infection so this is going
13:15to need a little bit more IV glucose or
13:17a higher giir then what about if we have
13:21an infant of a diabetic mother which
13:23like we already said these babies have
13:26high levels of insulin circulating
13:28around their bodies so what did we say
13:30that insulin does it basically sucks up
13:33all the glucose from the blood into the
13:35cells so it doesn't leave enough glucose
13:38circulating in the blood to reach the
13:40brain so if a baby in the term Nursery
13:43has a low sugar and the baby's mother
13:46was diabetic so it's an infant of a
13:48diabetic mother I'm thinking this baby
13:50is way more likely to need admission
13:52because even if this baby is eating
13:54enough the insulin in the body is
13:56sucking up that glucose and not leaving
13:59enough glucose in the blood often it's
14:01the IDM babies that we end up admitting
14:03to the niku and we have to carry on
14:05giving them higher and higher glucose
14:07concentration so we're creeping up on
14:09the G d10 d12.5 D15 whatever because all
14:14the glucose that we're giving is just
14:16being pulled into the cells really
14:18rapidly by the insulin obviously the
14:19same goes for other causes of
14:21hypoglycemia if the baby has a metabolic
14:25disorder then obviously that's going to
14:26be something that we treat differently
14:28for example if the baby has an error in
14:31breaking down fatty acids so the baby's
14:34lacking an enzyme and is unable to use
14:36the fatty acids as an energy source then
14:39those are babies that we don't want
14:41fasting at all so these are babies that
14:43we would be feeding really often to make
14:45sure that the glucose never plummets so
14:47obviously the cause of the hypoglycemia
14:50is going to determine your overall
14:52management and like we've been saying
14:54treatment is also going to depend on
14:56where you live because like we keep
14:58saying saying all these different
15:00professional organizations have slightly
15:02different protocols and algorithms for
15:04hypoglycemia and you should be following
15:07those in whatever hospital that you work
15:09in because as we all know consistency in
15:12the ncu is so important and a lot of
15:15those Hospital algorithms are going to
15:17depend on the hospital itself do you
15:19have gel available can you do an IV and
15:21the baby still stays with the mother is
15:23there a really high breastfeeding rate
15:25all these other things are going to kind
15:27of like influence what the hospitals end
15:30up doing in their own protocols but now
15:32let's go over all the different
15:34treatment options we have for babies
15:37with hypoglycemia not all of them I'm
15:39not going to go through all the organic
15:40acidemias and whatever else one good
15:43feeds obviously an important source of
15:46sugar so if the baby for example is 12
15:49hours old and literally never latched or
15:51has a very weak latch and baby hasn't
15:54really eaten anything at all then that
15:57baby is going to need help with feed
15:59hopefully there's a specialist that can
16:01kind of help with the breastfeeding
16:03itself or that baby needs to be
16:05supplemented with donut breast milk or
16:07formula if donut breast milk or whatever
16:09isn't available sometimes we even can
16:12gavage babies preferably when they're
16:14still with mommies just so that we don't
16:16have to separate them as we all know
16:19good feedings consistently good feedings
16:22every kind of 2 to 3 hours as well as
16:25keeping the baby warm are very good
16:27preventative strategies to to prevent
16:29the babies from actually developing
16:31hypoglycemia so hopefully your hospitals
16:33have lactation specialists in place or a
16:36team of nurses or a professional
16:37organization that can really help mother
16:40with the breastfeeding or just with
16:42feeding generally and just encourage her
16:45and remind her that this has to happen
16:47frequently in those first couple of days
16:49of life and let me just emphasize here
16:52that good feeds unless you have a super
16:55low glucose are always going to be the
16:57ideal treatment for babies with
17:00hypoglycemia it is the most natural way
17:02to get that glucose up and if you're
17:04just feeding the baby to increase the
17:06glucose then you're not going to be at
17:08risk of suddenly increasing that glucose
17:11like by a good amount and sudden
17:14increases in glucose have also been
17:16implicated with potentially bad outcomes
17:19in the future so obviously if we can go
17:22with feeds go with feeds two glucose
17:25gels and we've only started using
17:27glucose gels in like the last 5 to 10
17:30years and really we only use it in
17:32babies that are above 35 weeks glucose
17:35gels were initially introduced and
17:37tested upon and everything with the
17:39hopes that it would encourage the
17:41mothers to carry on breastfeeding the
17:43babies it wouldn't kind of interrupt
17:45that good breastfeeding by giving
17:47formula feeds or taking the babies to
17:49the unit or whatever and one study
17:52called the sugar babies what a perfect
17:54name for a study compared giving
17:56hypoglycemic babies a place ebo gel or a
17:59glucose gel and it found that the babies
18:01that got the glucose gel had fewer
18:04admissions to the niku it was also
18:06cost-saving and those babies were less
18:08likely to be on formula at 2 weeks of
18:10age having said that the followup of
18:13these sugar babies at 4 years of age
18:16showed no difference in developmental
18:18outcomes if anything the babies that had
18:21re received the glucose gel had slightly
18:24worse visual processing scores but they
18:27were taller and they weighed more
18:29the other things that we worry about
18:30when we give glucose gels are that one
18:33it may have additives in it that are not
18:35ideal and two that it may also alter the
18:39microbiota in the gut so as we've talked
18:42about before you know that in the gut
18:44there's a very careful balance of kind
18:46of good bacteria the commensal bacteria
18:49and the bad pathogenic bacteria and
18:52people are concerned that maybe by
18:54giving glucose gels we're encouraging
18:56the wrong type of development of
18:58bacteria and you're predisposing your
19:00gut to more of an inflammatory State
19:03having said that so far the small
19:05studies that have been done have been
19:07reassuring about that kind of Shifting
19:09microbiota anyway I'm sure a lot of you
19:12use glucose gels we use glucose gels and
19:15for us they have been very successful in
19:17keeping the babies with the mothers but
19:19just to let you know there's going to be
19:20a lot more to discuss on this topic
19:22moving forward but just so that you know
19:24these Basics about glucose gel generally
19:27we're using 40% % glucose gel and the
19:30dose is .5 milliliters per kilo which
19:34ends up with that percentage and
19:35everything being 200 mg per kilo and
19:39it's given into the bookl mosa into the
19:43mosa around the mouth so basically you
19:45should dry the Buckle mosa with some
19:47gauze and then you're giving 0.5
19:50milliliters that you're kind of
19:51massaging into the mosa so it's all
19:54being absorbed through that um until the
19:57full dose is being given gels should be
19:59given at least 30 minutes apart again
20:02that depends on what your hospital does
20:05and obviously if the sugar is really
20:07really low then the gel should only be
20:09given kind of as a bandage until you can
20:11get some good IV fluids going different
20:14hospitals allow different numbers of
20:16gels to be given on the floor before the
20:19baby's automatically admitted to the
20:20necu usually it's somewhere between
20:23three to six different gel doses three
20:27aex IV bolus so obviously a baby's going
20:32to need an IV for this sometimes you can
20:34do the IV on the floor most of the time
20:36a baby is being admitted to the ncu for
20:38an IV bolus dose and the standard dose
20:41of this if you are going to remember one
20:43dose in all of neonatology then this is
20:46what you should remember the standard
20:47dose is 2 milliliters per kilo which in
20:51a d10w IV ends up being 200 mix per Kake
20:56which is exactly the same dose that
20:58we're trying to get give when we give
20:59the glucose gels just as an aside other
21:01professional organizations can go up to
21:032.5 MLS per kilo remember that this
21:07really is just a Band-Aid if a baby has
21:09a low sugar and you just bolus them with
21:12a glucose gel or with a d10 bolus then
21:14what's going to happen to the baby
21:16immediately their insulin level might
21:18spike a little bit so if you don't do
21:21anything else apart from just give the
21:23bolus or just give the gel then that
21:25Sugar may end up being even lower
21:28afterwards
21:29so if you are giving the equivalent of a
21:31Bolis make sure that you're doing
21:33something else as well increasing the
21:35feeds or running IV fluids or whatever
21:38four IV dextrose infusion so for pretty
21:42much anytime you're giving this this
21:44baby is being taken to the ncu so the
21:46first thing that you have to realize is
21:48when you're starting the IV infusion
21:50then automatically you're separating the
21:52baby from his mother and you're
21:55increasing the mother's anxiety you're
21:57interrupting breast feing so that's why
22:00it's not like we want to rush towards
22:02this at all so usually we start IV
22:05dextrose in a baby where the sugars are
22:07staying really low or we've tried gels
22:10and increased feedings a few times and
22:12the sugars are still low so we'll admit
22:14them to the niku and start IV dextrose
22:17so usually we start with d10w running
22:21through a peripheral IV and usually we
22:24start at about 60 to 80 milliliters per
22:27kilo per day so with d10w that ends up
22:30being a g of between about 4.2 and 5.5
22:35if you can't remember what a g is then
22:37go back and watch the previous video
22:39that we made it really is critical that
22:41you understand what a g is when we're
22:43treating hypoglycemia if the sugars are
22:45staying low then you can start creeping
22:47up on the G so logically you can either
22:51go up on the rate or the total volume
22:54you're giving the baby so you can go up
22:55to 100 or 120 MLS per kilo per day
22:59remember you really don't want to fluid
23:00overload the baby especially in the
23:02beginning of the life that's not good at
23:04all either the other thing that you can
23:06do is go up on the concentration of the
23:08glucose so you can go 10 d10 d12.5 D15
23:12D20 or any number in between just
23:15remember though that many institutions
23:17max out the concentration of glucose
23:20that they're giving through a peripheral
23:22IV at
23:24d12.5 so if you in many hospitals if
23:27you're giving more than D2 12.5 then
23:29generally you're going to have to obtain
23:31Central Access whether it's an umbilical
23:33vein or a piic or a broviac or whatever
23:35by the way this d12.5 really isn't based
23:38on solid evidence so if anybody is
23:41looking for a very interesting and
23:43helpful research study then maybe add to
23:46the data that it would be acceptable to
23:48infuse D15 for example if you do have
23:52Central Access then you can carry on
23:54creeping up on the dextr concentration
23:56so to D15 or D20 some places will go up
24:00to d25 so obviously you can give a lot
24:04more sugar in a smaller volume if the
24:06concentration is higher which brings us
24:08to our next point if you are going up on
24:11the dextrose always calculate the G so
24:14you're actually comparing Apples to
24:16Apples if somebody comes and tells you
24:18oh my baby's not doing well he's on 100
24:20MLS per kilo per day that doesn't really
24:22mean a lot is it d10 is it D20 that's a
24:25huge difference in how much glucose that
24:28b is getting another important aspect of
24:30calculating the G is as that's going up
24:34then you should be more concerned that
24:36you are missing something or you should
24:38be starting additional therapies so
24:40really once the G is going above 8 migs
24:43per K per minute or 10 Mig per K per
24:45minute then maybe start thinking do I
24:48need to be doing something else the vast
24:50majority of the time when you're needing
24:51a really high GI it's because the baby
24:55has a high circulating level of insulin
24:57and what ever glucose we're giving the
24:59baby is getting sucked up into those
25:01cells almost immediately five what other
25:04therapies can we use and I'll list some
25:06other medications briefly because these
25:09are all things that we use in the unit
25:11but I'm not going to go into great
25:12detail about them the first one and a
25:15medication that I have come to love in
25:17just about all causes of hypoglycemia is
25:20glucagon so this can be given I am in
25:23fact one of the professional
25:24organizations recommends that if you
25:26can't get IV access and and the baby
25:29isn't feeding enough and the sugar is
25:30low you can give an IM dose of glucagon
25:33or more usually we're giving an IV bolus
25:36or in our institution we're normally
25:37giving an IV infusion glucagon like we
25:41said in the previous video is really
25:43good at making glucose so
25:45gluconeogenesis
25:46glycogenolysis and it's very good at
25:49increasing the glucose levels usually
25:51we're starting the glucagon infusion
25:53when the Gir is above about 10 migs per
25:57K per 10 mix per Kake per minute if a
26:00baby has high insulin levels and you've
26:03documented that the baby has high
26:04insulin levels then you could give
26:07dioxide this is a pottassium channel
26:10activator and it works directly to
26:13inhibit the pancreatic secretion of
26:16insulin so basically da oxide decreases
26:20insulin secretion this can be helpful in
26:22those IDM babies that have just that
26:25lingering ID fluids need so you can't
26:28get them off the glucose infusion for
26:30just days and days you just can't get
26:32them over the hump so dioxide is a good
26:35medication for those cases steroids are
26:37another medicine that is sometimes used
26:39and like we all know when we give
26:41steroids the sugars generally do go up
26:44it's very much a blanket treatment just
26:46like really all the times that we're
26:47giving steroids we don't really know
26:49what we're treating we're just making
26:51the numbers better whether that's better
26:53for the kids in the long run we don't
26:54know you could also use another
26:57medication which is is octreotide which
26:59is a somatostatin analog so like a
27:02man-made form of the somato Statin and
27:05basically that decreases really
27:07everything coming out of the pancreas
27:09including the insulin it's been shown
27:11that there this can be associated with
27:13an increased risk of neck and honestly
27:15if you're reaching otide you should
27:17definitely be doing this in conjunction
27:19with a pediatric endocrinologist it's
27:21not really recommended um in all babies
27:24for the sole purpose of treating
27:26hypoglycemia so in continu our general
27:29management guidelines at what point
27:32should we be investigating the
27:34hypoglycemia further like okay you've
27:36admitted a baby you've put them on a bit
27:38of IV fluids they're probably getting
27:40better then you probably don't need to
27:42investigate that further well when do
27:44you need to investigate it further so
27:46the first thing is is if you don't find
27:49any reason for why the baby has
27:50hypoglycemia so say you have a term a
27:53baby in the newborn Nursery the mother
27:56reports the baby's been eating really
27:57well so do the nurses but you can't seem
28:00to get the sugars out of the 20s that is
28:02concerning something else is going on
28:04that we're missing generally in these
28:06situations I start by going through the
28:08mother's chart are we missing something
28:11with her is she really a gestational
28:13diabetic or maybe she never got the
28:16diagnosis but she failed her 1hour
28:19glucose test but never ended up doing
28:21the three-hour glucose test maybe even
28:23though she didn't have the diagnosis all
28:25her sugars since admission had been
28:26really high Maybe she doesn't have the
28:28diagnosis but her last baby was 5 kilos
28:32also a little bit suspicious that she
28:33may have had gestational diabetes is
28:36there something else that we're missing
28:37does the mother have any prenatal
28:39infections does the mother have syphilis
28:41for example which notoriously produces
28:44low glucoses in babies or am I missing
28:46something with the baby is the baby sick
28:49does the baby have an infection does the
28:51baby have polycythemia so a really
28:53really high red blood cell count which
28:56can lower the glucose just cuz they're
28:58kind of gobbling up all that glucose and
29:01by the way anytime I end up admitting a
29:03baby with hypoglycemia to the NICU I
29:06will at least get a CBC in differential
29:10just to make sure I'm not missing an
29:12infection and I also want to check the
29:15hematocrit to make sure the baby doesn't
29:16have polycythemia once we go past kind
29:19of the initial more common things you
29:21have to start looking for zebras does
29:23the baby have any dysmorphic features
29:25are we missing a syndrome is it possible
29:27that the baby has some sort of metabolic
29:30disease clearly something is going on
29:32that we're missing here and it really
29:34does warrant further investigation two
29:36we also need to investigate further if
29:39the baby just doesn't seem to be getting
29:41better so for example the baby gets
29:43admitted with low sugars we have a
29:44reason for the low sugars but even after
29:47we have the baby on IV fluids we
29:50continue after giving the IV fluids for
29:52a lot longer than we think we would so
29:53days or we keep having to go up on the G
29:57and we don't really have a great
29:58explanation for it so one of the first
30:01things that we do when the amount of
30:04sugar that we're giving seems out of
30:05proportion to the baby's glucose levels
30:08is we will check hormone levels on the
30:09babies so we'll check TSH GH or thyroid
30:14stimulating hormone growth hormone and
30:16cortisol so all of those hormones should
30:19be involved with actually raising the
30:21baby's sugars so if the baby is
30:24deficient in any of those hormones we
30:26would expect the glucoses to be low
30:28ideally you want to check those hormones
30:31when the baby's glucose is at a low
30:33point so if the baby's glucose is less
30:35than 35 then we would definitely expect
30:39all those hormones to be elevated
30:41because they're reacting to the low
30:42sugar so it's kind of more sensitive to
30:45get all those lab levels when the baby's
30:47glucose is low so that would be a
30:49situation when you'd put in a
30:51conditional lab if the sugar Falls below
30:5335 then get these hormones you'd
30:56probably also want to check the insulin
30:58levels if the sugar is low then the
31:01insulin level should be really really
31:03low because the body doesn't want to
31:05make the sugar any lower so if the
31:07insulin is at all present or elevated
31:11then that is concerning for
31:13hyperinsulinism in the face of
31:15hypoglycemia so normal insulin levels in
31:18a newborn baby are about 10 but if
31:21they're about 10 when the sugar is 30
31:24then that is way too high really you
31:27want the insulin to to be unreadable
31:29when there is Hypoglycemia really if
31:31it's anywhere above one then probably
31:34this insulin is too high inappropriately
31:37high and you can label it
31:39hyperinsulinism if the level of insulin
31:41is really high so 15 20 50 then at that
31:45point you have to be concerned that
31:47maybe something is going on with a
31:49pancreas and it's just secreting a lot
31:51of insulin maybe there is a tumor or
31:52something there or some weird cause of
31:56really high trans
31:58hyperinsulinism this is an aside if
32:01anybody loves crime shows so when the
32:04body releases insulin a byproduct is
32:07also C peptide so if you happen to check
32:11the insulin level and it's really high
32:13and you also check the C peptide level
32:16but the C peptide is really low it means
32:18that it's not the baby that's actually
32:20producing the insulin it means that
32:22somebody's exogenously administering
32:25insulin so somebody is inappropriately
32:27giving this baby insulin making the
32:29sugars low hopefully none of us are ever
32:32going to see this but it's an
32:33interesting fact then in addition to
32:36those hormone studies if the baby
32:38appears sick then so many other things
32:40could be going on including like we keep
32:43saying an inborn era of metabolism and
32:45good screening test for that would be
32:47checking a gas so checking the metabolic
32:50acidosis of the baby maybe checking a
32:52lactate as well as checking an ammonia
32:55level and then obviously a bunch of
32:57other tests at that point you should
32:58probably be getting a metabolic
33:00specialist involved and really the third
33:02point of management is if the baby is
33:05getting better then how do we wean off
33:07the IV fluids and how do we send the
33:09baby home well for weaning normally what
33:12we do is we put some sort of weaning
33:14order in place so for example we would
33:17say if the blood glucose level is above
33:1960 or 65 then wean the IV fluids by 1 ml
33:23an hour until you're off different
33:25places will do it differently different
33:27provid will do it differently but really
33:29you want some sort of consistent plan so
33:32the baby slowly working to coming off
33:34the IV fluids once off the IV fluids or
33:37having not given glucose gel or whatever
33:39every different Professional
33:41Organization recommends a different
33:43number of normal glucose checks before
33:45the baby can go home for example the AP
33:48wants three normal glucose checks
33:51without obviously any fluids or any gels
33:54or anything being given before the baby
33:56can go normally when the baby is in the
33:58ncu normally we watch the baby for about
34:0024 hours off the ivu fluids before we
34:03send the baby home okay I think we're
34:05going to stop here there's so much
34:07information on hypoglycemia I really
34:10edited this out there was so much more I
34:11wanted to say but I really just wanted
34:13to include the really important points
34:15but here is your homework assignment for
34:17you one name three possible treatments
34:21for babies with
34:23hypoglycemia two name five possible
34:26tests that you you might want to get in
34:29a baby that you have in the NICU with
34:32hypoglycemia and three name three
34:35different ways in which the cause of
34:37hypoglycemia May then affect your
34:39management plans I hope you learned
34:41something from this video if you reach
34:43this far then please like it and
34:45subscribe to this channel if you're
34:47interested in neonatal education thank
34:50you so much for being here

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