<prompt> In a neonate with asymptomatic hypoglycemia immediate Rx should include which of the following?100 mgkg 10 Dextrose2 mlkg 10 Dextrose2 mlkg 25 Dextrose4 mlkg 25 Dextrose  <response>: Ans. B 2 mlkg 10 Dextrose Ref. OP Ghai 7thpg. 155, Reference : Neonatal Hypoglycemia: A blood glucose value of 40 mgdL plasma glucose 45 mgdL. Hypoglycemia in first 18-36 hrs is usually due to transient neonatal hypoglycemia and after 36 hrs metabolic and other causes are likely. Persistentrecurrent hypoglycemia is defined as requiring either parenteral glucose for 7 days or high IV glucose infusion rates 12-16 mgkgmin. Etiopathogenesis: High risk factors of hypoglycemia include: 1 Infants of diabetic mothers many of whom are LGA, 2 All macrosomic LGA infants mothers may have occult diabetes, 3 SGA, i.e., intrauterine stressed infants, 4 Stressed infants i.e., difficult delivery, low Apgar 7 at five minutes, 5 Infants of mothers on tocolytics terbutaline, ritodrine, oral hypoglycemics or propranolol within 72 hrs before delivery, 6 Premature infants 37 weeks gestational age, 7 Postmature infants 42 weeks gestational age. A Transient hypoglycemia: 1. Maternal conditions causing transient hypoglycemia: a. Intrapartum glucose given at too high a rate to the mother. b. Drug Rx terbutaline, ritodrine, propranolol, oral hypoglycemics. c. Intrauterine growth retardation IUGR: placental insufficiency resulting in SGA infant. d. Diabetes in pregnancy hyperinsulinism. 2. Neonatal conditions causing transient hypoglycemia: a. Failure to adapt extrauterine life b. Birth asphyxia c. Infectionsepsis d. Hyperviscosity e. Congenital heart disease f. Erythroblastosis fetalis g. Hypothermia. h. Inadequate calories. i. Other iatrogenic causes: exchange transfusion andor low lying umbilical artery catheter. j. Decreased glycogen stores: Associated with pre and postmature infants. B Persistent andor recurrent hypoglycemia: 1. Hyperinsulinism conditions which cause persistentrecurrent hypoglycemia: a. Nesidioblastosis: rare; hyperinsulinemic hypoglycemia due to beta cell hypertrophy. It is on a continuum with islet cell adenoma and usually requires subtotal or total pancreatectomy to treat, however octreotide and diazoxide are useful Rx. b. Beckwith-Wiedemann syndrome: Visceromegaly, macroglossia, hypoglycemia. 2. Endocrine deficiency conditions which cause persistentrecurrent hypoglycemia: a. Pituitary insufficiency: septo-optic dysplasia, craniofacial defects and anencephaly Deficiency of pituitary hormones such as growth hormone and ACTH, results in hypoglycemia. b. Cortisol deficiencyadrenal failure. c. Congenital glucagon deficiency. d. Epinephrine deficiency: Extremely rare. 3. Inborn errors of metabolism conditions which cause persistentrecurrent hypoglycemia: a. Carbohydrate metabolism: Galactosemia, glycogen storage disease, fructose intolerance. b. Amino acid meta:MSUD, propionicacidemia, methylmalonic aciduria, tyrosinemia, glutaric acidemia. c. Fatty acid metabolism: Carnitine metabolism defect, Acyl-CoA dehydrogenase defect. Rx: The goal of Rx is to establish normoglycemia, usually defined as a stable glucose value above 40 or 50 mgdl. Asymptomatic babies: Asymptomatic infants in the 20-40 mgdl range may have a trial of oral feeding, but if the glucose fails to normalize, an IV glucose infusion should be started. Although dextrose 5 oral solution is occasionally used for Rx, formula has the advantage of containing fats and proteins which are metabolized slowly and provide a more sustained level of substrates for glucose production. Blood glucose should be rechecked in 30-60 minutes after feeding. Symptomatic babies: with severe hypoglycemia 20 mgdl, a small IV bolus of dextrose has been shown to raise blood sugar levels safely and more quickly to adequate levels than intravenous infusion alone. The usual bolus is 2 mlkg of a dextrose 10 solution given intravenously followed by a glucose infusion rate of 6 to 8 mgkgmin. The first part of the infusion, i.e., the bolus is given as a dose of mlkg, but the second part of the infusion is given in mgkgmin. A simplified formula for glucose infusion rate in mgkgmin is: Glucose infusion rate GIR dextrose concentration X mlkgd 144 So if dextrose 10 is used at 80 mlkgday that gives us: GIR 10 x 80 144 800 144 5.6 mgkgmin. A faster way to figure this out is to use one of the following formulas to achieve a glucose infusion rate of 7 mgkg minute. D5W: IV rate in mlhr 8.4 X Body Wt in kg D10W: IV rate in mlhr 4.2 X Body Wt in kg For a 3 kg newborn infant, using D5W would result in an IV rate of 25 mlhr, which results in 600 mlday, or 200 cckg day, which is too much. This is why D10W must be used instead. The D10W infusion rate using the above formula would still give 100 cckgday. FU and outcome: If the plasma glucose cannot be raised by glucose infusion alone, other options include a trial of corticosteroids hydrocortisone 5-15 mgkgday IV in 2-3 divided doses or prednisone 2 mgkgday by mouth. If this fails, other drugs that may be used to raise the plasma glucose include human growth hormone, diazoxide, glucagon or long acting synthetic somatostatin octreotide. The first step in evaluating persistentrecurrent hypoglycemia is to obtain serum glucose, insulin, and ketone levels. If the ratio of insulin to glucose IG ratio is 0.3, then the cause is hyperinsulinism. Ketones should be low or absent in hyperinsulinism. 