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Understanding Hypoglycemia and Hypocalcemia: Clinical Insights and Management
- 2. Definition •Hypoglycemia occurs whenplasma glucose levels decrease leading to signs and symptoms of impaired brain function. Categories of hypoglycemia -Mild: 35 – 45 mg /dl -Moderate: 25 – 35 mg/dl -Profound: < 25 mg/dl Any plasma glucose level < 35mg/dl at the first 1 - 3 hours of life, or < 40mg/dl (2.2 mmol/L) during the 3 - 24 hours of life and < 50mg/dl (2.8 mmol/L) after 24 hours of age, should be viewed as abnormal and treate
- 3. General Information Overall incidenceof symptomatic hypoglycemia is 1 – 3 per 1000 live births. Most common metabolic problem in neonates. Most infants with hypoglycemia are either asymptomatic or only exhibit non-specific signs and symptoms. Persistent and recurrent hypoglycemia can severely impair brain growth and function While both term and preterm infants can have neurological effects at glucose levels of 45, preterm infants are more likely to have adverse, irreversible neurological injury compared to term infants.
- 4. •Birth weight <2 kg or > 4 kg •Large for gestational age (LGA) •Small for gestational age (SGA) •Intrauterine growth restriction (IURG) •Neonates of insulin-dependent mother (1:1000 pregnant women) •Mothers with gestational diabetes (~2% of pregnant women) •Preterm or Late Preterm neonates •Suspected of sepsis or chorioamnionitis At Risk
- 5. •Significant hypoxia •Perinatal distress •5minute Apgar 5 or less •Hypothermia •Isolated hepatomegaly •Microcephaly •Multiple congenital anomalies •Suspected inborn error of metabolism •Maternal history of terbutaline, beta blockers, or oral hypoglycemic medications
- 6. Clinical features : Usuallynoted on 1st or 2nd day of life, and vary from asymptomatic to symptomatic causing CNS, CVS, and pulmonary disturbances. 1. CNS; Hypotonia, lethargy, poor feeding, jitteriness or tremor, weak or high-pitched cry, eye rolling, and convulsion are common. 2.CVS; Congestive heart failure, tachycardia, episode of cyanosis, pallor, sweating & diaphoresis. 3.Respiratory system; Intermittent apneic spells or tachypnea and hypothermia. These features are nonspecific and simulate other diseases; CHD, sepsis, IVH & hypocalcemia.
- 8. Prevention:- 1- Newborns atrisk, but who have no contraindications for feeding formula within 1st hour of life. are asymptomatic and should be breast fed or given A screen glucose test should be performed within 30 minutes of the first feed. 2. If oral is not possible give 10% glucose IV. 3.All should be monitored with serial blood glucose level during the 1st day of life. NOTE; Transient hypoglycemia is common during the 1st 2-3 hr after birth and may be part of normal adaptation to extrauterine life.
- 9. Prognosis: - For symptomatichypoglycemia with convulsion is poor and associated with abnormal neurointellectual development. - For other forms of hypoglycemia the prognosis is better.
- 11. Why do weneed calcium • Calcium messenger system – regulates cell function • Activates cellular enzyme cascades • Smooth muscle and myocardial contraction • Nerve impulse conduction • Secretory activity of exocrine glands
- 12. BODY CALCIUM EXISTSIN TWO MAJOR COMPARTMENTS: 1- Skeleton (99%). 2 - ECF (1%) : (a) bound to albumin (40%) (b) bound to anions like phosphorus, citrate, sulfate and lactate (10%) (c) free ionized form (50%)
- 13. Hypocalcemia All infants showa slight decline of serum Ca levels after birth reaches trough levels at 24-48 hours. - In premature infant <1500 gm birth weight, serum calcium is < 7 mg/dl (ionized calcium < 4 mg/dl). -In term infants or premature infants >1500 gm birth weight, total serum Ca concentration < 8 mg/dL (2 mmol/L) or an ionized fraction of < 4.4 mg/dL (1.1 mmol/L).
- 14. Early neonatal hypocalcemia: Theonset is in the first 3 days of life, mostly between 24-48 hours and is often asymptomatic Occur in; 1- LBW infants (premature and IUGR). 2- Birth asphyxia. 3- IDM.
- 15. Early neonatal hypocalcemiacauses: - Prematurity; and SGA(LBW,VLBW) due to lower amount of calcium passage via the placenta, low level or immature function of hypoparathyroid H . Congenital hypoparathyroidis m as in DiGeorge syndrome with aplasia of thymus and parathyroid glands present with early and late hypocalcemi a Infant of diabetic mother IDM : due to low PTH function and high calcitonin, low mg level comes from mother in diabetic mother . Birth asphyxia ; due to high phosphate release from damaged cells and high calcitonin level.
- 16. Prevention: - IV ororal Ca at a rate of 25-75 mg/kg/day. - Early asymptomatic hypocalcemia of preterm and IDM often resolves spontaneously. - Side effects: irritation & ↑ stool frequency.
- 17. Late neonatal hypocalcemia: Theonset is from the 2nd half of first week to several weeks in infants artificially fed. Cause :- 1.high phosphate containing mil k like whole cow milk or formula with high phosphate . 2.prematurity on breast mil k not supplemented with vit. D and oral calcium . 3.hypoparathyroidism ; congenital or transient . 4. maternal low vit.D store in breast fed baby . 5.renal dysfunction in the baby.
- 18. Clinical features: 1.Usually theinfant is well, full term, normal delivery, feed normally with normal cry before sudden onset of convulsion. 2.Fits last few seconds, generalized or focal clonic seizures can occur, between them the infant is alert, but jittery, ↑ tendon reflexes, ↑ tone with extension. 3. Fits may continue several weeks if untreated. 4. Laryngospasm with cyanosis and apnea may occur.
- 19. 6- Chvostek sign(facial muscle spasm when the side of the face over 7th nerve is tapped), and Trousseau sign (carpopedal spasm induced by partial inflation of a blood pressure cuff) are rare in immediate newborn period. 5- On occasion, heart failure has been associated with hypocalcemia.
- 20. ECG finding: Corrected QTinterval (QTc = QT/√RR) ≥ 0.45. May be as high as 0.49 sec in newborns (to 6 mo.) The QTc interval does not correlate reliably with blood ionized recommend use of Ca levels. We do not the ECG toscreen for hypocalcemia.
- 22. Treatment: Hypocalcemia should betreated when; - It is associated with signs or symptoms or - When the serum calcium level is < 7.0 mg/dL or - When the ionized calcium level is < 4 mg/dL. 1-Without seizure (Prevention); The first line of therapy generally consists of increasing the amount of calcium in the intravenous infusion to achieve 25 - 75 mg/kg/day of elemental calcium and evaluating serum levels every 6 to 8 hours.
- 23. 2.After normal calciumlevels are achieved, the intravenous dose can be weaned over 2 to 3 days. 3.With seizure; The infusion of a bolus of intravenous calcium (10% calcium gluconate, 2mL/kg) over 10 minutes should be reserved for the infant with seizures. In the asymptomatic infant, hypocalcemia most frequently resolves spontaneously without the need for further therapy.