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Neonatal Hypoglycemia: Causes, Symptoms, PROGNOSIS — Transcript

by Tala Talks NICU · 3,524 words · 504 segments · language en · Watch on YouTube

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0:00even if you only work with newborns for
0:02one day you're going to end up seeing
0:05and having to deal with neonatal
0:08hypoglycemia in fact about 5 to 15% of
0:13all healthy newborns end up with a
0:16diagnosis of hypoglycemia and about 50%
0:20of at risk babies end up with a
0:22diagnosis of hypoglycemia hello I'm Dr
0:25tala and I've been a neonatologist for
0:28about 16 years now and today we're going
0:30to cover four topics the first one is
0:34why do we care about
0:36hypoglycemia the second one is what
0:38causes neonatal hypoglycemia three what
0:41are the symptoms of hypoglycemia and
0:44four how do we measure glucose levels
0:47our next video will be a bit more
0:49clinically relevant so make sure that
0:51you end up watching that one but in that
0:53one we'll talk about what actually
0:55defines or how do we diagnose
0:58hypoglycemia as well as the treatment
1:00and management of hypoglycemia make sure
1:03you stick around till the end of this
1:04video so that you can complete your
1:06little homework assignment and just a
1:08reminder if you do want the PDF summary
1:10of this video then make sure that you
1:12subscribe to our newsletter you'll have
1:14the details on the homepage let's get
1:16straight to it one why do we worry about
1:20hypoglycemia and I know that this is a
1:22bit of an unusual place to thought but
1:24if you think about it everything comes
1:26back to this in medicine we should only
1:29really care about an unusual value for a
1:32patient if it signifies something bad
1:35for the patient or if it's going to end
1:38up giving the patient a poor outcome in
1:40the future So based on that why do we
1:43care about whether the sugar is low in a
1:46baby let's divide the effect on babies
1:50into two groups the first one is kind of
1:53more acute symptoms and then we're also
1:56worried about chronic symptoms or really
1:58future outcomes based on neonatal
2:02hypoglycemia and I'm sure you've all
2:04seen the acute symptoms of hypoglycemia
2:07things like jiter apnea teyia
2:10tachicardia poor feedings leagy
2:14hypothermia basically these are all
2:17symptoms that can be explained by the
2:18body not having enough energy or they
2:22can be explained by the body's response
2:24in trying to create more energy so
2:27trying to create more glucose so
2:30basically the whole body is in that kind
2:31of flight or flight situation which is
2:35why you can end up with pic cardor into
2:37kipa when you've got hypoglycemia if the
2:40sugar stays really low like less than 10
2:42migs per deciliter for a really long
2:44time then the babies are at risk of
2:46developing seizures and becoming
2:49unresponsive so obviously all these
2:51symptoms can be very dangerous for
2:53babies more concerningly we have to
2:56worry about how low glucose affects the
2:58brain permanently
3:00and honestly this is what it's really
3:02all about the problem is is it's really
3:05difficult to figure out that exact level
3:07of glucose that we need to worry about
3:10so how low can the glucose go before we
3:13have to worry about the development in
3:14the future and how long does that low
3:17glucose have to last you can imagine how
3:20this is almost impossible to come up
3:22with one number for a period of time for
3:25every single baby and why should we even
3:28worry about it affecting the brain in
3:30the future well the issue is is that the
3:33brain primarily uses glucose as its
3:36energy source and because the brain is
3:40relatively larger in the baby as
3:42compared to older kids and adults
3:44relatively it has a really really high
3:47need for sugar continuous sugar so it's
3:51always been suspected that low glucoses
3:55can result with worse neurodevelopmental
3:57outcomes it's just being difficult to
4:00prove exactly how low that sugar should
4:03be one population study was done in
4:06Sweden and they basically looked at over
4:09a 100,000 kids that had had a low sugar
4:13less than 40 milligram per Dita in the
4:16newborn period and then they followed
4:18those kids up between the ages of two
4:21and six and what they found was that the
4:24babies that had had a transiently low
4:27glucose who were in the newborn Nursery
4:29by the way so less than 40 Mig per
4:32deciliter Which is less than 2.2 milles
4:35per liter then those babies had double
4:39the risk of having any developmental
4:41delay or a motor developmental delay and
4:45the adjusted risk of a cognitive
4:48developmental delay was almost triple
4:51another study that was done in New
4:53Zealand that was part of the glucose gel
4:55studies which included above a thousand
4:58babies show showed that if any baby had
5:01a sugar less than 47 mg per deciliter
5:05which is about 2.6 mes per liter then
5:09that baby had increased risk of
5:11neurodevelopmental impairment so that
5:14includes CP blindness deafness
5:17developmental delays this risk was even
5:20higher if the baby had recurrent
5:23episodes of hypoglycemia or the
5:26hypoglycemia was categorized as severe
5:29where which they defined as less than 36
5:32migr per deciliter so yes we know that
5:36having low sugars especially if they're
5:38really low especially if they're really
5:40persistent can affect developmental
5:43outcomes the problem is like we keep
5:45saying is we don't really know what that
5:47number is and where treating that number
5:50especially when it's borderline is it
5:52really going to make a difference but if
5:54you're going to take one thing home
5:56realize that the lower the number and
5:59the longer that the sugar is low for the
6:01worse the outcomes so if nothing else
6:04all this screening for hypoglycemia what
6:06we're really trying to do is prevent
6:08those babies that remain hypoglycemic
6:11for days two what causes neonatal
6:15hypoglycemia well as you know in utro
6:18the baby's getting a continuous glucose
6:20Supply from the mother and the glucose
6:24crosses the placenta if you're doing
6:26your boards via facilitated diffusion so
6:29the baby's glucose level is about 80% of
6:32the mother's glucose level also insulin
6:36in the baby basically just works as a
6:38growth factor after birth obviously the
6:41baby is cut off from the mother's
6:43glucose Supply and initially the baby's
6:46glucose can fall down steadily so in all
6:49babies it's very normal for the baby's
6:51sugar to get down to about 30 migs per
6:54deciliter in the first 1 to 2 hours
6:56after birth in a healthy newborn the
6:59baby will kickart ways to increase its
7:03glucose level in the blood so for
7:05example it will start secreting more
7:07glucagon glucagon will break down
7:10glycogen and basically start making more
7:13glucose for the baby the baby will also
7:15start secreting catac colomines like
7:17epinephrine which if you remember is the
7:20fight or flight hormone so obviously you
7:22need a lot of glucose's energy to either
7:25fight or flight another way that infants
7:28can actually increase their glucose
7:30level is by actually drinking the milk
7:32themselves they don't do it with a cup
7:34obviously um but as you all know in the
7:37first couple of days of life it's not
7:39like babies are really able to consume a
7:42lot of milk so basically whether a baby
7:45ends up with low glucose or not is going
7:47to depend on a balance it's going to
7:49depend on two things how much glucose is
7:52the baby able to produce whether that's
7:54by breaking down glycogen or any other
7:57stores and by drinking milk milk and
8:00also how much glucose is the baby
8:03actually using and needing So based on
8:05this you can see very easily where
8:07things start to go wrong if the baby's
8:09not eating enough then they're not going
8:11to have enough substrate and their sugar
8:12could end up low if the baby has for
8:15example low glycogen stores in the liver
8:17for example the baby is a late preey or
8:19the baby is sgaa then there's just less
8:23substrate to be able to break down to
8:25make into glucose or maybe they happen
8:28to be near a lot more sugar maybe they
8:30had a really stressful delivery and used
8:33a lot of sugar at the time of the
8:35immediate delivery period maybe they're
8:38still breathing really hard maybe
8:39they've got a fever maybe their heart
8:42rate's really fast all of these things
8:44are going to consume more sugar the
8:47other major category that makes a baby
8:50need more sugar is having a high insulin
8:53level so it's not so much that the
8:56insulin is using up all the sugar but
8:59what insulin does it it increases the
9:02uptake of the circulating glucose into
9:05cells so having a high insulin level
9:07will make different cells of the body so
9:10skeletal muscle fat cells liver cells
9:12suck up that Sugar from the blood so
9:15because it's all being taken up into the
9:17cells there's less sugar circulating in
9:20the blood and so less sugar that can
9:23actually reach the brain having a high
9:26insulin level is a major cause of hyp
9:29glycemia in babies especially when that
9:31hypoglycemia is persistent so it really
9:33is very important that you understand
9:35this point so why would a baby have too
9:38much insulin in its body well really
9:40there are two main reasons the first one
9:43is very rare and that is when the baby
9:46has some sort of insulin secreting tumor
9:49somewhere in the pancreas that is
9:51ignoring all messages and it just
9:53carries on secreting the insulin this
9:56can be this has to be treated with
9:58pretty aggressive medication sometimes
10:00the pancreas has to be cut out or
10:02reected and having some sort of
10:05insulinoma can be associated with
10:07syndromes for example Beckwith Weedman
10:09or sto syndrome the second reason is
10:12usually more transient and that is when
10:15for a small period of time the pancreas
10:17is ignoring the low sugars and Carries
10:20on Happily secreting its insulin the
10:23most common time that this happens is
10:25when it's an infant of a diabetic mother
10:29it's estimated that in about 6 to 7% of
10:32pregnancies the mothers have gestational
10:35diabetes or diabetes so this is a very
10:38common cause of hypoglycemia in babies I
10:41just want to spend a second explaining
10:43this if a mother has diabetes during
10:45pregnancy then her sugar levels are
10:47going to be high her insulin levels will
10:50also be high but the insulin cannot
10:52cross through the placenta like we said
10:54though if the mother has high sugar
10:56levels the baby's also going to have
10:58high sugar levels because it all crosses
11:00through the placenta through facilitated
11:02diffusion so if the baby has high sugar
11:05levels then the pancreas the baby's
11:07pancreas is going to start secreting
11:09more insulin so the baby relatively has
11:12a higher insulin level after the baby is
11:15born then the baby no longer is
11:18receiving those High sugars from the
11:19mother but the baby's insulin is still
11:22high and it normally takes a few days
11:24for that insulin level to start going
11:26down even though the baby sugar level is
11:30really low so that's why we worry
11:33especially about infant of diabetic
11:36mothers becoming hypoglycemic because of
11:39that lingering elevated insulin level in
11:42the babies insulin isn't the only
11:44hormone involved in Sugar control like
11:47we've already said catac colomines like
11:49norepinephrine and epinephrine also work
11:52to increase the sugar that the baby has
11:55like we keep saying the fal flight
11:57response other hormones that are
11:58involved involved in Sugar homeostasis a
12:01growth hormone thyroid stimulating
12:04hormone as well as steroid hormones so
12:07also if you have a deficiency in any of
12:09those hormones then the babies can
12:10present with
12:11hypoglycemia another massive group of
12:14diseases that can end up in low sugars
12:16are inborn eras of metabolism and this
12:20is very logical as well if the baby's
12:22body has run out of sugar then the next
12:25step is to break down other substances
12:27to try to produce that sugar
12:29but if there is a problem or a defect in
12:32the enzyme for example that breaks down
12:34fat or protein or glycogen or whatever
12:37then the body is unable to use those
12:40sources to make the sugar and the baby
12:42will become hypoglycemic so yes we have
12:45really common reasons for hypoglycemia
12:48babies aren't feeding enough babies are
12:50small and don't have enough glycogen but
12:52if the hypoglycemia is lasting longer or
12:55something feels off then we really
12:57should be investigating other causes and
12:59we'll talk about this more in the next
13:00video three let's cover symptoms of
13:03hypoglycemia I know we already went over
13:06it but I'm all about repetition for
13:08learning so let's cover them briefly
13:10again like so many diseases in newborn
13:13the signs and symptoms of hypoglycemic
13:15can be very non-specific I mean there's
13:18only a certain number of things that a
13:19baby can do right let's start with
13:22tremors or jitteriness and that is the
13:25high frequency shaking of the
13:27extremities it's not not jerking and
13:30it's much shallower than like a lot of
13:33the jerky movements that babies can make
13:35to differentiate a jitteriness from
13:38seizures you should be able to hold the
13:40extremities and the jitteriness will
13:42will stop if the baby is having seizures
13:45even when you hold the extremity then it
13:47will carry on jerking other symptoms are
13:50irritability I get pretty irritable when
13:53I'm hungry and my sugar is low so this
13:55is as my kids would say very relatable
13:59then apnea teyia Pala cyanosis poor
14:03feeds hypothermia and then obviously
14:06eventually seizures and leagy like we
14:09said earlier the symptoms are a
14:11combination of the baby's body
14:13desperately trying to increase its own
14:16energy Supply so increasing those stress
14:18hormones so that's the irritability and
14:20the jitteriness and the T tardar in the
14:23teyia and then the other set of symptoms
14:26are just when the body has run out of
14:28energy source is Al together so that's
14:30when you're ending up with the seizures
14:32and the floppiness and the leagy like we
14:34said that's when the baby's sugars are
14:37really low probably in the low teens or
14:39below 10 for a long period of time so
14:43again a lot of these signs and symptoms
14:45are really non-specific but just realize
14:49that if you do have any of these signs
14:51and symptoms then whatever work up
14:54you're doing even if you're working up
14:55the kid for sepsis or for hiie or
14:58whatever make sure that you are getting
15:00a glucose at some point to make sure
15:02that the baby isn't just hypoglycemic or
15:05isn't hypoglycemic on top of whatever
15:07else is going on four how do we actually
15:10measure glucose levels we kind of went
15:13back and forth with the even to include
15:15this and then we decided that it
15:17actually is a really important concept
15:19for all of us at bedside and the major
15:22concept you need to understand is the
15:24difference between testing the blood
15:26sugar in whole blood versus is checking
15:29the blood sugar in just plasma and if
15:32you remember plasma is just the liquid
15:34part of blood so without the blood cells
15:37and without all the proteins the way
15:39that machines test the glucose level in
15:42whole blood is by rupturing all the
15:45blood cells and so they end up with like
15:48all the liquid that was in the blood
15:49cells as well as all the liquid that was
15:51in the plasma when we're measuring the
15:54glucose at bedside it's normally the
15:56actual plasma glucose in most of the
15:59machines that we're using and because
16:02the whole blood cells don't really have
16:03a lot of fluid volume in them generally
16:07when the glucose is tested in whole
16:09blood then the glucose is lower in whole
16:12blood than it is in plasma in fact the
16:16glucose levels in the same sample from
16:19the same patient in plasma are about 10
16:22to 15% higher than the glucose levels in
16:25whole blood so when you're sending blood
16:28down to the lab and they are breaking
16:31down the cells and correctly testing the
16:34whole blood then often that sugar level
16:37is 10 to 15% lower than the level that
16:40you got at bedside which was the glucose
16:42level in plasma of course in practice we
16:45see so many variables in actually
16:48getting the glucose checks so for
16:51example if the baby's foot is cold or
16:54the baby has decreased perfusion or
16:56decreased blood pressure then by
16:59definition less blood is going to be
17:01going to that extremity so the cells in
17:04the foot or whatever are going to be
17:05sucking out a lot more of that glucose
17:08so if the baby's foot is cold or if it's
17:12blue or if the baby's blood pressure in
17:14low then that Sugar may be actually a
17:17lot lower than what's really circulating
17:20around the body so make sure that you
17:22always warm those heels before you're
17:25checking the glucose check on a heel
17:27prick another issue with those machines
17:29is they're basically made to check for
17:32much higher glucose levels and they're
17:34generally much less accurate at really
17:37low levels that's why sometimes in a
17:39warmed foot we check the sugar and it's
17:4122 and then we check it again like 3
17:43minutes later and it's 32 I mean that's
17:46a huge percentage difference in the
17:48actual sugar the baby's general
17:51hematocrite or the amount of red blood
17:53cells the baby has can also affect the
17:56blood glucose reading so generally if
17:58the baby is polycythemic the sugar
18:01anyway tends to be a bit lower but it
18:03may be even artificially lower than that
18:06when you check it on a bedside stick
18:08same thing with anemia the blood sugar
18:10level may be artificially higher than
18:12what is really being seen in the
18:14circulating blood volume also obviously
18:16it's going to depend where you actually
18:18get the sample from so an artery is
18:21going to have a higher blood glucose
18:23level than a vein because by the time
18:25the vein gets the blood all the cells
18:27have used up some of the sugars so also
18:29think about where you're getting your
18:31sample from when you're checking sugars
18:33it is always recommended that we send a
18:37blood sample down to the lab and we're
18:39not making major decisions on bedside
18:41sugar testing because the testing in the
18:44lab using different enzymes and machines
18:46is much more accurate than the bedside
18:49testing however another huge variable
18:52comes in and that is if you take the
18:54sample and then it takes hours for it to
18:57get down to the lab before it's actually
18:59being tested then there's a good chance
19:01that all the red blood cells in that
19:03sample have gobbled Up the sugar and it
19:05ends up being a lot lower than what the
19:07really sugar really is so if you are
19:10sending a blood sample down to the lab
19:12it should always be stacked if you're
19:14specifically doing it to check the sugar
19:17like we said though in the lab they're
19:18checking the whole blood sugar so often
19:21that is lower but like we said 10 to 15%
19:24lower if it's 50% the number that you
19:28got in the unit then something may be
19:30off either that's real and the plasma
19:33one is wrong or the blood was sitting
19:36down there for too long as an aside when
19:39we're getting the sugars on the blood
19:40gas machines the blood gas analyzers
19:43those are thought to be a lot more
19:45accurate based on the kind of enzymatic
19:47reactions that they're using than the
19:49regular glucometers so if you're unsure
19:52then that could be something that you do
19:53actually check the sugar on the blood
19:55gas analyzer the last thing I'll say
19:58about test is that just realize when
20:00you're checking a sugar it really is one
20:03moment in time and it's not like the
20:05baby's sugar is going like this
20:07continuously it's going to be going up
20:09and down right so ideally what would be
20:12really nice is if we had some sort of
20:15continuous glucose monitoring so we got
20:17like a really good average of what the
20:19baby does have eventually hopefully
20:21we'll get that I know that some
20:23companies are testing like transdermal
20:25continuous glucose monitoring so
20:27hopefully that will be something in the
20:28future whatever you're doing make sure
20:31that you always get a confirmatory test
20:33in the lab before you're making any huge
20:36decisions on glucoses okay your homework
20:39assignment for this video one name five
20:43potential symptoms of hypoglycemia two
20:46explain why infants of diabetic mothers
20:49have hypoglycemia and three explain why
20:52we worry about hypoglycemia and then
20:55just as a bonus go find out what type
20:58type of testing your unit does is it
21:01plasma or is it whole blood and what
21:04sort of enzymatic reactions are being
21:06used in your
21:07glucometer okay that was a lot but
21:10there's even more to come in the next
21:11video so go watch the next video on the
21:15definition of hypoglycemia and the
21:17management there's a lot of clinically
21:19applicable information in that if you've
21:22reached this far then please like this
21:23video and again thank you so much for
21:26being here

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