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Troubles métaboliques du nouveau- né - Pr. Amrani Rim fac de médecine oujda morocco — Transcript

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0:18I'm going to continue with this because
0:20we've already talked about hypoglycemia
0:22, and I wanted to take the opportunity
0:24to discuss it as well so you have a
0:25consistent thread in the videos. So, I
0:29will start just with neonatal
0:31hypoglycemia, and we will leave the
0:33rest for general hypoglycemia. So,
0:35there are some general points.
0:36Prevention and systematic screening in
0:38at-risk newborns are essential. When I
0:41say at-risk newborn, I mean a premature
0:43baby, a growth-restricted infant, a
0:45baby of a diabetic mother, a baby with
0:48perinatal hypoxic-ischemic distress, or
0:50an infected baby. Therefore, every
0:53abnormal situation can predispose a
0:55baby to neonatal hypoglycemia and
0:57should push the pediatrician, or even
0:59the general practitioner or the student
1:01, to at least perform a finger-stick
1:03test to see what is happening.
1:06Prolonged or repeated hypoglycemia is
1:08known to be detrimental to the central
1:10nervous system, especially if it is
1:12symptomatic. For example, hypoglycemia
1:15that goes unnoticed is not very serious
1:17at that point, but hypoglycemia that
1:19reaches the point where the child has
1:21convulsions means there could be
1:22lasting damage to the central nervous
1:24system. So, we cannot make a prognosis
1:26for this type of baby. For instance,
1:28when that happens and a mother asks me,
1:30"Will this child have any sequelae?""
1:32Ma'am, I cannot tell you." And in any
1:34case, what happened is serious and
1:36grave. Okay? It is often resolved by
1:40simple measures. That is exactly what
1:43is a shame, that we can fight this
1:45hypoglycemia ourselves, and it's easy.
1:49So normally, any one of us can treat it
1:51easily. Right away, dry sugar water,
1:56and you can give it to them. And I'll
1:58tell you one thing, a baby who is
1:59convulsing is having hypoglycemia, for
2:01example, if I'm outside and don't have
2:03my kit with me. There's no need to
2:04overcomplicate things. In the hospital,
2:06if they are convulsing, it's
2:08hypoglycemia. Don't overcomplicate it:
2:10they've had a seizure, I have an easy
2:12solution. If I give glucose, okay?
2:15There is no hyperglycemia that causes
2:17convulsions, whereas hypoglycemia can
2:19do so. The reflex: a diabetic, a
2:23convulsion, is a problem. Because
2:28hypoglycemia can kill, hyperglycemia
2:30won't kill, it will take its time, no
2:32worries, okay? Okay? So, often resolved
2:34by simple measures. If it is severe or
2:36persistent, then we must move to
2:38intravenous treatment, but we should
2:39already do the maximum while on the
2:41scene. An etiological assessment is
2:43necessary, especially if you suspect
2:45hyperinsulinism, metabolic diseases, or
2:48growth hormone deficiency. This is
2:50because there are certain pathologies
2:51that can lead to hypoglycemia that is
2:53not merely transient. In such cases, it
2:55must be investigated as appropriate. To
2:57define hypoglycemia, let's look at
2:59full-term or near-term infants.
3:01Normally, everything depends on
3:03postnatal age and the type of feeding.
3:06And you will see that there are figures
3:07to keep in mind and not forget. The
3:10risk is less significant if you have a
3:12breastfed newborn. That is why when we
3:14say breastfeeding, it is very important
3:16because it helps maintain constant
3:18blood glucose levels. It is very, very
3:20important. Regarding hypoglycemia. So,
3:27for the postnatal period, I have
3:28provided this table here. Yes, it is
3:30for indicative purposes: less than 2
3:32hours, less than 0.8 g/l, it is a blood
3:35glucose level below the 5th percentile.
3:37Between 3 and 47 hours, less than 0.7 g
3:39/l, and beyond 48 hours, it is less
3:41than 0.8 g/l. But I would ask you to
3:43remember the numbers in red. For a
3:47newborn with a pathology—when I say
3:50with pathology, whether hypotrophic,
3:52premature, infected, from a diabetic
3:54mother, or presenting with neonatal
3:56respiratory distress—regardless of
3:58gestational age, type of feeding, or
4:01postnatal age, hypoglycemia is
4:02considered if you have a blood glucose
4:05level below 0.45 g/l. From the moment
4:09it is pathological, if its blood
4:12glucose drops below 0.45 g/l, it is
4:14hypoglycemia. Now, we can only speak of
4:16severe hypoglycemia requiring urgent
4:18intravenous treatment when you have a
4:20blood glucose level that is less than
4:22or equal to 0.22 g/l. Less than or
4:24equal to 0.22 g/l, the infant will
4:27convulse. It will burn out all its
4:28neurons without debate. So, at 0.2 g/l,
4:30we don't argue; we admit the infant,
4:33place an intravenous line, and do the
4:35maximum. If there is no venous access,
4:37it's an umbilical catheter or even a
4:39central line. You really must do the
4:40maximum. And in the meantime, don't
4:43panic; you can administer the
4:44equivalent via the gastric route,
4:46either by syringe or however you like,
4:48while waiting to establish access.
4:51Regardless of postnatal age, and I put
4:54this in red on purpose, any symptomatic
4:56child with a blood glucose level below
4:590.4 g/l must receive urgent treatment.
5:01Because from the moment the child is
5:03symptomatic, whether they are
5:04convulsing, hypotonic, or not doing
5:06well, it means this is a blood glucose
5:08level that is problematic. To measure
5:12capillary blood glucose, you must have
5:14an adapted device, and be aware that
5:16just any diabetic monitor won't give
5:17you the same reading. They have to be
5:20devices specifically designed for
5:22newborns. In fact, even here, we don't
5:24work with ordinary blood glucose
5:26monitors. These are special newborn
5:29monitors calibrated for newborn blood.
5:33And so, you must know that polycythemia
5:35lowers the result. When you have a baby
5:37with polycythemia, it is possible to
5:39find a low blood glucose level when it
5:41actually isn't low. It is simply
5:43because the child has polycythemia. No
5:45skin disinfection with alcohol because
5:47that will also lead to a low figure. So
5:50when you want to disinfect, generally
5:52use chlorhexidine, not alcohol, for a
5:54newborn. It also risks lowering the
5:56result. For venous blood glucose
5:59measurement, and this is new, even with
6:01alcohol, when you disinfect with
6:03alcohol, you lower the result. When
6:07measuring venous blood glucose, the
6:09sample must be sent to the lab without
6:11delay, because when you delay, there is
6:13glucose remaining that gets consumed,
6:15and so we will also have a lower result
6:17. So when you perform a blood glucose
6:20test, it must be sent as quickly as
6:22possible. The sample inevitably, you
6:26will have a blood glucose level that is
6:27abnormally low when it is not the case.
6:31Newborns at risk, no indication. For a:
6:34you have a baby who is full-term,
6:36eutrophic, has a good, perfectly normal
6:38weight, who is healthy in the maternity
6:40ward, whose birth was normal, there is
6:42nothing to report. Actually, we look
6:43for nothing, we won't overcomplicate
6:45things. A hypothermic newborn, yes,
6:48there is an increased risk of
6:49hypoglycemia. He is in hypothermia, he
6:52is also at risk of hypoglycemia. That
6:54is why we insist on transfers: when you
6:56have a newborn who is to be transferred
6:58from a hospital facility, we insist on
7:00warming; if it is not a transport
7:02incubator, at least the kangaroo method
7:04I told you about, skin-to-skin, and
7:06then of course either an IV line or, if
7:08we cannot get one, at least have them
7:10accompanied by someone who will give 10
7:12%glucose serum throughout the transport
7:14, because the risk of hypoglycemia is
7:16even greater. A newborn to develop
7:22hypoglycemia, especially when the
7:24weight is above the 97th percentile and
7:26especially when it is disharmonious
7:28macrosomia. So, you have a head
7:31circumference and height that are
7:33completely preserved, just an increased
7:35weight. Because sometimes macrosomia is
7:39harmonious, the head circumference is
7:41large, the height is large, and so the
7:43baby is like a three-month-old baby,
7:45not a newborn, given how significant
7:47the measurements are. But sometimes,
7:49only the weight is high, while the head
7:51circumference and height are completely
7:53normal. Hypoglycemia in this case, the
7:58baby is cushingoid, because regardless
8:00of the weight, head circumference, or
8:02height, you have a normal head
8:04circumference and height, but he looks
8:06small in stature yet puffy. So for
8:11hypoglycemia, it's the 97th percentile
8:13for weight according to age, which is
8:15what we call the Intergrowth-21st
8:17curves, which are the most recent ones
8:19we use, and it also depends on
8:21gestational age and sex. For a girl,
8:27you will see that she will be
8:28considered macrosomic at a weight
8:30slightly lower than a boy, because boys
8:32are generally known to have a higher
8:34weight than girls from a very early age
8:35. And so, as age progresses, the figure
8:40increases to define whether or not it
8:42is macrosomia. For example, a baby born
8:45at 40 weeks weighing 4.2 kg, we are not
8:47concerned. 4 kg at 37 weeks is a
8:49significant macrosome. So, 4 kg. Do you
8:53understand? Newborns of diabetic
8:57mothers treated with insulin, we just
8:59talked about them. Regardless of the
9:02type of diabetes, whether
9:04insulin-dependent or not, you must
9:06systematically monitor diabetes if the
9:08mother is treated with insulin, but no,
9:10if she is treated by diet alone, it is
9:12not necessary. A mother who has
9:16gestational diabetes managed by diet
9:18alone doesn't have a baby predisposed
9:20to hyperinsulinism, because the baby
9:22isn't receiving insulin while in the
9:23mother's womb. Right? When you have a
9:27fetus that has no growth abnormalities,
9:29you do nothing. Now, you have a mother
9:31who has been on insulin and is a known
9:32pre-existing diabetic. Whether
9:34insulin-dependent or not. The baby is
9:36predisposed to having problems. A
9:38premature newborn in the maternity ward
9:40should have blood drawn or be checked
9:42at least three times. And also
9:44growth-restricted newborns because they
9:46are predisposed to having hypoglycemia
9:48problems. Newborns of mothers on
9:51treatments like Depakine—incidentally
9:53, I don't know if you're aware, but
9:55Depakine is now normally
9:57contraindicated for girls of
9:58childbearing age, women in general, and
10:00girls from the age of puberty, starting
10:03at 14. Why? Because they found that it
10:06causes malformations. It is teratogenic
10:08for the baby. I don't know if you're
10:10aware, but it's very recent. So for
10:13sodium valproate, for moms who are
10:15epileptic, we offer them many other
10:17products, not Depakine. They should be
10:21warned about it. Because beta-blockers
10:26will cause this blood sugar to drop in
10:28the baby, because when the mom is on a
10:30beta-blocker like Ablocarde. This
10:33transition must cause a drop in blood
10:34sugar. Bronchodilators, especially
10:38beta-mimetics—and for the older
10:40schools, when a mom presented with
10:41threatened premature labor, we used to
10:43offer her beta-mimetics as treatment,
10:45which would cause both tachycardia in
10:47the mom and a risk of hypoglycemia in
10:49the baby. Now, there are other
10:54medications offered, like
10:55antihypertensives, antidiabetics like
10:58Glucophage, metformin or Daonil, and
11:00sulfonylureas; these, too, can cause
11:02recurring hypoglycemia in the baby. So,
11:06the newborn...there's a third, not
11:08hypothermia; the newborn in a context
11:10of moderate perinatal hypoxia. So any
11:12situation of distress, whether it's
11:14hypotrophy, macrosomia, fetal distress,
11:16infection, polycythemia, or neonatal
11:19respiratory distress, will predispose
11:21this baby to developing hypoglycemia.
11:23Clinical sign: most often this baby is
11:25asymptomatic, and that is what's
11:27serious, because being asymptomatic
11:29means we might...When it is symptomatic
11:34, we have clinical signs that are
11:35telling. The child will move on to...
11:38will show neurological signs, be
11:40lethargic, hypotonic, have a weak
11:42sucking reflex, a really very weak cry,
11:44and sometimes it can go straight to
11:46convulsions, tremors, irritability, and
11:49more; there are feeding difficulties.
11:56Cyanotic spells and...be careful, the
11:58warning signs are not very specific,
11:59meaning it's a baby that can give the
12:01false impression of being completely
12:03normal. From the moment you have one of
12:07the criteria you should be flagged on,
12:09I'd say whether it's infection,
12:11distress, hypotrophy, or macrosomia,
12:13you must evaluate these babies, at
12:15least do a blood glucose check—a
12:17check won't kill them. If you have
12:18clinical manifestations of hypoglycemia
12:20, a capillary blood glucose check must
12:22be done in the minutes that follow.
12:23That is to say, you correct it, and
12:25then you see if their blood sugar will
12:26rise or not. If the hypoglycemia is
12:28symptomatic, management should be
12:30carried out as an emergency. And it's
12:32no longer the oral route; it's strictly
12:34the intravenous route because it is
12:35already symptomatic, meaning the brain
12:37has already been affected. To prevent
12:40hypoglycemia in the delivery room, one
12:42must first maintain normothermia.
12:44Earlier, we mentioned that hypothermia
12:46will aggravate hypoglycemia. So, you
12:47must keep the baby at a temperature of
12:5037 plus or minus 0.3 degrees. The first
12:52feeding should be early, and if you
12:54recall when we covered breastfeeding,
12:55we said they should be breastfed within
12:5730 minutes of birth. Especially if it
13:00is a mother who delivered vaginally:
13:01offer the breast within the following
13:0330 minutes. Subsequently, if it is
13:05breastfeeding, the feedings should be
13:07frequent at first, every 2 to 3 hours.
13:09Honestly, for the first week, certainly
13:11the first three days, for her to have a
13:13good supply, it is given on demand,
13:15madam. Every time they wake up, you
13:17give them the breast; if they don't
13:18wake up, you wake them after 2 or 3
13:20hours maximum, and you give them the
13:22breast because these babies sometimes
13:24have an inverted circadian rhythm; they
13:26sleep more during the day and wake up
13:27at night. You must not wait for them to
13:30wake up and ask for it. Sometimes, they
13:32enter hypoglycemia, they become
13:34lethargic, and the mother thinks they
13:36are fine. Whereas when we take them and
13:38perform a blood glucose test, we end up
13:39with levels that are really very, very
13:41low. If this baby is not breastfed,
13:45they must be fed at least 8 times a day
13:49. If they are hypoglycemic, it must be
13:52offered every 3 hours if not every 2
13:54hours. So it will depend on the
13:57indication. If the oral route is
14:06impossible, one must switch to the
14:07intravenous route. When I say
14:09impossibility of the oral route, for
14:10example enterocolitis, a baby we are
14:12preparing for potential surgery, they
14:14must be kept fasting, they might become
14:15hypoglycemic, so we must switch to the
14:17intravenous route without question. The
14:19first blood glucose test should be done
14:21before the second meal, generally
14:23around 3 or 4 hours after birth, to see
14:24if we are on the right track or not.
14:28Blood glucose should be checked every
14:30other meal, meaning every 4 to 6 hours,
14:32until there are three satisfactory
14:34readings. Then we stop monitoring. You
14:38have three normal readings with checks
14:40done every other meal, which is our
14:42standard procedure. We will then
14:44discontinue this monitoring. Monitoring
14:46and therapeutic management after the
14:47delivery room. This is an emergency;
14:49I'm marking it in red. When you have
14:54hypoglycemia that is below 0.2 g/L,
14:56this is a baby at risk of convulsing at
14:58any moment. If they haven't already,
15:00sometimes these babies do convulse.
15:05They choke, then you check the blood
15:07sugar, and you find it's below 0.2. A
15:10symptomatic newborn with hypoglycemia
15:12of less than 0.4 g/L, but in this case,
15:15they are symptomatic. Therefore, this
15:17is an indication for an intravenous
15:19line. If they weren't symptomatic, we
15:21would have just used the oral route, or
15:23for a newborn with underlying pathology
15:25and blood glucose below 0.45 g/L. Now,
15:27we shouldn't wait for the levels to
15:29drop even further. We should offer the
15:31intravenous route right away. The goal
15:34of intravenous treatment, regardless of
15:37postnatal age, is to achieve blood
15:39glucose greater than or equal to 0.45 g
15:41/L. You've noticed I've only been
15:44speaking in grams per liter because
15:45that's the unit we use most frequently.
15:49Any intravenous treatment justifies a
15:51transfer for monitoring and etiological
15:53and therapeutic management in a
15:54neonatology unit. That is our
16:02monitoring protocol. And when I say
16:03intravenous route, we rarely just set
16:05up an ordinary IV drip and leave it
16:07like that for a newborn. It is risky to
16:09use a standard IV drip bag. Honestly,
16:11we never do that; it is inadmissible
16:13and unacceptable. Because what is the
16:15risk? It's a small mass, a small volume
16:19that will pass, close to 500 mL; you
16:21turn your head, the product infuses
16:23rapidly, and hello trouble. So,
16:27normally, under the best conditions,
16:29you should use a syringe pump, which is
16:31ideal. That's what we do in neonatal
16:34units. If we don't have these syringe
16:36pumps and we have to set up a 500 mL
16:38drip, yes, we give the required amount.
16:40Why am I giving you these messages?
16:42Because one day you will find yourself
16:44in the emergency room as interns or as
16:46general practitioners somewhere, and
16:47these are reflexes to keep in mind. I
16:52only provide the necessary amount so
16:54that, in case of human error—since we
16:56never know what might happen—we won't
16:58harm the baby. So, make it a habit to
17:01give the right amount and keep only
17:03what is strictly necessary. Ideally,
17:05use a syringe pump in neonatal units,
17:07of course. Now, if you are in a
17:09maternity ward and need to administer
17:11this, just keep the required amount on
17:13hand. That way, even if the entire
17:14amount is administered, there is no
17:16risk of complications. Establishing
17:19venous access is very important. You
17:21cannot treat a If you're struggling,
17:25what can you do? You are searching for
17:29a vein, but you shouldn't just leave
17:30the baby without providing something to
17:32compensate for the deficiency. We will
17:35administer it orally. We will give 2 to
17:383 cc per kilo, either by syringe or
17:40directly via a gastric tube, while we
17:43establish an IV line. Honestly, when it
17:46comes to the oral route, I go straight
17:48to 3 cc per kilo if venous access is
17:50difficult, especially with a macrosomic
17:53baby, because in chubby babies, veins
17:55are not visible and with a continuous
18:12feeding, we ensure a stable intake, so
18:14it should be enriched. I have included
18:19a table at the end for you to see how
18:20it works. After establishing venous
18:24access, inject 2 to 3 cc per kilo of 10
18:27%glucose solution as a bolus. Remember
18:302 cc per kilo, or a maximum of 3 cc per
18:33kilo over about 5 minutes. So it must
18:35be administered quickly to correct low
18:37levels, especially those below 0.2,
18:39then followed by a continuous infusion.
18:42This is why we use a syringe pump with
18:4410%glucose. 2 to 3 cc per kilo, and we
18:47will increase or decrease it based on
18:49our blood glucose readings. So, either
18:53we get three consecutive normal blood
18:55glucose readings and we can gradually
18:57switch back to oral feeding only, or
18:59the glucose levels won't rise and we
19:01are forced to increase the dose. We can
19:03go up to 4 cc per kilo, but be aware
19:05that the higher the concentration, the
19:08less effective a peripheral venous line
19:10becomes. Therefore, if you increase the
19:12concentration through a peripheral vein
19:14, you will burn the veins of this
19:15newborn. So ideally, use a central
19:18venous line. The flow rate should be
19:20increased if there is an indication for
19:22an IV, especially if you have
19:24refractory hypoglycemia. Check the
19:26capillary blood glucose 30 to 60
19:28minutes after the IV injection. It is
19:32normalizing and you have a blood
19:34glucose level that reaches the desired
19:36figure, which is above 0.45. At that
19:38point, you must continue the venous
19:40access and transfer the child. I have
19:41insisted, I have insisted a lot on
19:43hypoglycemia because we see babies, you
19:45will see babies who are disabled in
19:47strollers or in wheelchairs because of
19:49hypoglycemia. It might seem trivial to
19:51you, but it is not trivial at all. A
19:52baby who has remained in hypoglycemia
19:54for a long time without being noticed
19:56risks having lifelong cerebral palsy.
19:59And so this is serious; it weighs on
20:01our conscience. If there is no
20:05normalization while waiting for the
20:07transfer, you must repeat our dose via
20:09the IV route and then increase the flow
20:11rate, which can reach 4 cc/kg, then
20:13check the blood glucose; beyond that,
20:15switch to a central line. I repeat,
20:18beyond 4 cc/kg, you risk burning the
20:20veins; it no longer works. Switch to a
20:23central line for the patient.
20:24Fortunately, you always have the
20:26umbilical catheter, which is possible
20:27especially when they arrive in the
20:29first few days before the cord dries or
20:31falls off. So, ideally, place it
20:32immediately; all the babies I have in
20:34the ward have an umbilical venous
20:36catheter placed upon arrival. You never
20:38know if they are coming for a simple
20:39infection or jaundice; it could turn
20:41out to be a urinary tract infection. So
20:43, if they have pyelonephritis, it is a
20:45minimum of 10 to 14 days of treatment.
20:46Imagine 10 to 14 days peripherally; we
20:49would kill this baby. Avoid any
20:52administration of 30%glucose solution.
20:56High concentrations should not be given
20:58, nor should any 10%glucose solution be
21:00administered in isolation without
21:02continuous support. That is, generally,
21:05G10 with calcium for the first 48 hours
21:08. Beyond 48 hours, ensure that it is
21:13well established and that they are
21:15producing urine correctly. I have some
21:22reactive hypoglycemia, because when you
21:24switch from 30%, it causes such a
21:25significant negative feedback that they
21:28risk developing reactive hypoglycemia
21:30when you give it without continuous
21:31support. There too, you risk the same
21:35thing of hypoglycemia, asymptomatic or
21:41close to it. I have placed them in the
21:46maternity ward, meaning from the moment
21:48they are not symptomatic, we can leave
21:49them with their mother but manage their
21:51hypoglycemia. In all cases,
21:53skin-to-skin contact is safe because
21:54hypothermia must be avoided. You place
21:56them skin-to-skin. This is the kangaroo
21:58method. So, you are already avoiding
22:00hypothermia. So, first of all, you
22:02reduce the risk of hypoglycemia.
22:03Keeping the mother close to her child
22:0524/7, especially if she's breastfeeding
22:07, the baby needs to be with her. You
22:09don't want to put him elsewhere, making
22:11her go back and forth, especially with
22:13C-sections. I don't think that's going
22:15to make things any better. Support the
22:16start of lactation, especially if it's
22:18breastfeeding. Distinguish between
22:21exclusive breastfeeding and other
22:23feeding. No. If it's exclusive, the
22:26mother must feed the baby frequently.
22:29If it's partial or if the baby isn't
22:31breastfed, it's up to us to offer the
22:33right solution and even fortify it.
22:35Don't waste time when the child is
22:37unable to feed. I mean, recently I had
22:41a child who had severe hypoglycemia,
22:43and the mother told me: "The
22:44pediatrician..." but it's not a diverse
22:54case, an older child who’s picky and
22:57"never ate." But a newborn doesn't know
23:01that, they don't get that; they are
23:03here, and they must be fed. He isn't
23:05taking it? It means he’s hypotonic;
23:07don't overthink it. And ultimately, we
23:12end up with a baby having seizures just
23:14because we waited for him to be...to be
23:16hungry and to latch. So that’s not
23:18logical. We need to be careful with
23:20what we do; avoid forced oral feeding
23:22at all costs. If he can't latch, he
23:24can't latch. If he's hypotonic, he
23:26doesn't have a good reflex; he just
23:27doesn't. So, in the beginning, you have
23:29hypoglycemia, you must treat the
23:31hypoglycemia. We don't care about what
23:33happens afterward. Turn to intravenous
23:34intake, or possibly continuous enteral
23:36route if it's difficult to get venous
23:38access. I mean, we always have the
23:42fallback of using a gastric tube when
23:44you can't get an IV. It's simple: place
23:47a gastric tube and give him what he
23:49needs directly into his stomach. But
23:51the sucking reflex, he can't...Four
23:55levels of care will follow each other.
23:59Continued monitoring before each
24:00feeding as long as the blood sugar is
24:02abnormal. Every time you find an
24:05abnormal blood sugar, you must check it
24:07again before the next feeding. The goal
24:09is to normalize blood glucose levels
24:11and reach a figure above 0.45. And
24:13these are just stages, just so you have
24:15an idea. It's not about memorizing this
24:17. So what I would like you to learn is,
24:20first, knowing at what level to treat.
24:23For a pathological baby, it's 0.45. For
24:26a normal asymptomatic baby, it's 0.40.
24:29When it's below 0.2, it's intravenous.
24:31So, the indications for intravenous.
24:33What can we give orally? You should
24:35remember 2 to 3 cc per kilo orally.
24:37What can we give intravenously? 2 to 3
24:40cc intravenously in 5 minutes, and if
24:43we can't do it, it's glucagon. If we
24:45can't do that, it's the gastric tube.
24:47If you at least remember that, that is
24:49the essential part for me. The stages
24:52are just so you have a complete lesson,
24:54and you will see that it differs
24:56depending on whether the child is
24:58exclusively breastfed, not breastfed,
24:59or partially breastfed. And I will
25:03leave the other part for the next
25:05lesson. Thank you for your attention.

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