Neonatal Hypoglycemia

Key considerations: Persistent hyperinsulinism (congenital), Inborn errors of metabolism, Adrenal insufficiency

Cannot miss

history: Maternal diabetes, gestational age, birth weight, feeding history, timing of symptoms; exam: Jitteriness, tone, feeding ability, respiratory status, temperature stability; labs: Point-of-care glucose (confirm with serum glucose); Critical sample at time of hypoglycemia: insulin, C-peptide, cortisol, GH, beta-hydroxybutyrate, free fatty acids, lactate, ammonia; imaging: Not typically indicated initially; bedside: Point-of-care glucose, continuous glucose monitoring if available

immediate: Symptomatic or glucose <40: D10W 2 mL/kg IV bolus then D10W infusion at GIR 6-8 mg/kg/min; Do NOT use D50W in neonates (too hyperosmolar — osmotic injury risk); general: Asymptomatic glucose 40-50: feed first (breast or formula), recheck in 30 min; If not improving: IV glucose; Target glucose >50 mg/dL first 48 hours per AAP; Glucagon 0.02 mg/kg IM if no IV access

admit: NICU for persistent or severe hypoglycemia; discharge: Term infants with resolved transitional hypoglycemia tolerating feeds; consults: Endocrinology if recurrent or requiring high glucose infusion rates, genetics if inborn error suspected

At-risk infants (IDM, LGA, SGA, preterm) should have glucose checked at 30 min, 1 hr, 2 hr, and before feeds for first 12 hours per AAP
D10W NOT D50W for neonates — D50W causes osmotic injury to neonatal veins
Persistent hypoglycemia requiring GIR >10 mg/kg/min suggests hyperinsulinism — get critical sample