Neonatal

hypoglycemia(Infant of
diabetic mother)
Presenter: Sharmadave
 INTRODUCTION
• Hypoglycemia develops in approximately 25-50% of
infants of diabetic mothers and 15-25% of infants of
mothers with gestational diabetes, but only a small
percentage of these infants become symptomatic.
 IN RELATION TO INFANT WITH
DIABETIC MOTHERS
Neonatal
EFFECTS
• In the first trimester and time of conception, maternal hyperglycemia can cause
diabetic embryopathy resulting in major birth defects
• Diabetic fetopathy occurs in the second and third trimesters, resulting in fetal
hyperglycemia, hyperinsulinemia, and macrosomia.

Cardiac – Cardiovascular malformations occur in 3 to 9 percent of diabetic pregnancies-include

transposition of the great arteries (TGA), double outlet right ventricle (DORV), ventricular septal defect
(VSD), truncus arteriosus, tricuspid atresia, and patent ductus arteriosus (PDA)

CNS – Anencephaly and spina bifida are 13 and 20 times more frequent, respectively, among Infants of
mothers with diabetes compared with infants of mothers without diabetes
Other anomalies include :
•Flexion contracture of the limbs.
•Vertebral anomalies.
•Cleft palate.
•Intestinal anomalies
 NORMAL TRANSITIONAL LOW GLUCOSE
LEVELS

• Transient low blood glucose concentrations in neonates are normal, as

the source of glucose at delivery changes from a continuous supply from
the mother intermittent supply from milk feeds.
• With loss of the continuous transplacental supply of glucose, plasma
glucose concentration in the healthy term newborn
• falls during the first two hours after delivery reaching a nadir that usually
is no lower than 40 mg/dL (2.2 mmol/L), and then
• stabilizes by four to six hours of age in the range of 45 to 80 mg/dL (2.5
to 4.4 mmol/L)
 NORMAL TRANSITIONAL LOW
GLUCOSE LEVELS
Immediately after birth, the plasma glucose concentration is maintained by
-> breakdown of hepatic glycogen (glycogenolysis) in response to
1. increased plasma epinephrine and glucagon concentrations
2. falling insulin levels

Glycogen stores are depleted during the first 8 to 12 hours of life.

Thereafter, plasma glucose levels are maintained by the synthesis of glucose from lactate,
glycerol, and amino acids (gluconeogenesis)

As feeds with adequate carbohydrate are established, maintenance of plasma glucose

concentrations is no longer solely dependent on gluconeogenesis
 NORMAL TRANSITIONAL LOW
GLUCOSE LEVELS
• However, if the first feeding is delayed for three to
six hours after birth, approximately 10 percent of
normal term newborns cannot maintain a plasma
glucose concentration above 30 mg/dL (1.7 mmol/L)
 PATHOPHYSIOLOGY

1. Glucose gets to fetal

Insulin resistance circulation for fetal At Seperation of
in maternal, nutrition and organ placenta at birth, flow
Placenta releases growth
Hypoglycemia
increase in Fetal hyperglycemia of glucose maternal
Human Placental 2. Maternal Beta cell
Lactogen (HPL)
glucose in hyperplasia to release and hyperinsulinemia interrupted with
hyperinsulinemia still
in neonates
maternal more insulin in response
circulation to HPL- maternal level in effect
glucose is normalised
 TARGET PLASMA GLUCOSE
LEVEL

• Plasma glucose level > 2.6mmol/L in a term or preterm infant

• For infants > 48 hours old, it is recommended to keep plasma glucose level
> 3.3mmol/L to be above the threshold for neuroglycopaenic symptoms

• For infants with suspected congenital hypoglycaemia disorder or

symptomatic infants, to keep plasma glucose > 3.9mmol/L.
A higher target level is chosen because of lack of alternative fuels and the risks
of undertreatment outweigh the risks of overtreatment.
 CLINICAL SIGNS OF
HYPOGLYCAEMIA
Neurogenic (autonomic) symptoms result from changes due to neural sympathetic
discharge triggered by hypoglycemia.
•Jitteriness/tremors
•Sweating
•Irritability
•Tachypnea
•Pallor

Neuroglycopenic symptoms are caused by brain dysfunction from impaired brain

energy metabolism due to a deficient glucose supply.
•Poor suck or poor feeding
•Weak or high-pitched cry
•Change in level of consciousness (lethargy, coma)
•Seizures
•Hypotonia
 MANAGEMENT OF
HYPOGLECEMIA
• Management of Hypoglycaemia
• Management of Persistent Hypoglycaemia
 MANAGEMENT OF HYPOGLYCAEMIA

• Infants should initiate feedings within 1 hr after birth.

• If necessary, supplement feeding until breastfeeding is established.

• Initial blood glucose should be done 30 minutes after the first feed
 Within the first 4 hours of life,
if blood glucose is 1.5 – 2.5 Set up IV Dextrose 10% drip
mmol/l and
• Asymptomatic:
1.Give supplementary feed (EBM or
formula) as soon as possible.
60ml/kg/day
2.If blood glucose remains < 2.6
mmol/l and infant refuses feeds,

re-check blood
IV 10% Dextrose 2-3 glucose
Symptomatic- every 30 minutes
ml/kg bolus
After 48 hours of life,
IV Dextrose10% drip
BG < 3.3 mmol/L
at 60-90 ml/kg/day

Start feeding when blood glucose Monitor hourly x 2,

remains stable and increase as Once blood glucose
tolerated. then 2 hourly X 2,
is above target
Reduce the IV Dextrose infusion then to 3-6 hourly level for 2 readings
rate 1 hour after the feeding
increment
pre feeding
 IF STILL HYPOGLYCAEMIA
AFTER REPEATING BG IN 30 MINUTES
AND DESPITE IV DEXTROSE 10%
INFUSION
If hypoglycaemia occurs in
infants with poor glycogen
Neonate stores as in IUGR,
is having Increase volume by most SGA babies, or in
30ml/kg/day If hypoglycaemia
Persiste adrenal insufficiency,
and/or increase still persists despite increase the glucose
nt dextrose glucose delivery > infusion rate to
Hypoglyc concentration 8-10 mg/kg/min, 12mg/kg/min.
aemia to 12.5% or 15%.
consider Glucagon
Concentrations > 0.5-1mg stat (iv, If hypoglycaemia persists
12.5% must be im, s/c) then 5- despite a glucose infusion
infused through a 10mcg/kg/ rate of > 12mg/kg/min, a
central line short course (1-2 days) of
IV hydrocortisone 1-2
mg/kg /dose bd or tds may
be considered.
 REFERENCES
• Hj Muhammad Ismail, H., Mohd Ibrahim, H., Hoong Phak, N. and Thomas,
T., 2018. Paediatric Protocols for Malaysian Hospitals. 4th ed. Kuala
Lumpur: Malaysian Paediatric Association.
• Robert, K., , Bonita., S., , Joseph W, S. and , Nina F., S., 2016. Nelson
textbook of pediatrics. 10th ed. Phialdelphia, PA: Elsevier.
• UpToDate 2019. Infants of women with diabetes. [ONLINE] Available at: 
https://www.uptodate.com/contents/infants-of-women-with-diabetes.
[Accessed 31 July 2019].
• UpToDate 2019. NEONATAL HYPOGLYCEMIA. [ONLINE] Available at: 
https://www.uptodate.com/contents/pathogenesis-screening-and-diagnosi
s-of-neonatal-hypoglycemia
. [Accessed 31 July 2019].
Thank you