NEONATAL HYPOGLYCAEMIA - MEDICAL NEGLIGENCE SOLICITORS
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Neonatal hypoglycaemia is the most common metabolic issue in newborns. Symptomatic hypoglycaemia occurs in about 1.3 to 3 percent of newborn births. It is defined as a blood sugar of less than 30 mg/dL in a newborn in the first day of life and a blood sugar of less than 45 mg/dL after day one of life. It is most common in very large infants, in infants who have suffered neonatal distress, in infants who have infection or in infants of diabetic mothers. The baby may have no symptoms of the condition or can have severe cardio-respiratory problems or CNS (central nervous system) problems. The baby most often presents with irritability, an altered level of consciousness, seizures, lethargy and vomiting. Any child that appears acutely ill should be evaluated for neonatal hypoglycaemia.
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Neonatal hypoglycaemia is a condition of low blood sugar or low blood glucose in a baby within hours to days following its birth. It can be a serious complication of birth that can result in neonatal seizures and death. This is why many hospitals routinely check the neonate's blood glucose shortly after birth and especially in cases of diabetic mothers, large infants or difficult births.
Glucose is the primary chemical used in the foetal brain for nutrition. The glucose is normally obtained from the mother in the form of glucose passed through the umbilical cord. In some cases, once the umbilical cord is severed, the infant doesn't have enough glucose to feed the body and brain and the glucose level plummets. There can be low blood sugar levels if there is too much insulin floating around the infant's body, such as what happens when the mother's glucose is too high. If there isn't enough glycogen storage in the body because the baby lacks glycogen stores in the liver, there can be neonatal hypoglycaemia. If the baby is using up too much glucose, there can be a low blood glucose situation. This can happen if there was a difficult delivery requiring extra glucose to get through it.
The actual diagnosis of neonatal hypoglycaemia includes a blood sugar of less than 30 mg/dL if checked within the first day of life or if the blood sugar is less than 45 mg/dL if checked after the first day of life. This is not a rare condition and occurs about one to three times out of a thousand live births. Risk factors for the disease include infant sepsis (blood infection), low thyroid conditions or hypothyroidism, certain inborn errors of metabolism, poor oxygenation after birth, intrauterine growth retardation, a big baby, a mother with a diabetic condition, preterm births, small for gestational age children that have no glycogen stores or an infection of the amniotic sac, called chorioamnionitis.
There are many symptoms that would lead the nurse or doctor to suspect neonatal hypoglycaemia. These include being cyanotic or blue in the skin, low motor tone, grunting, breathing problems, neonatal irritability, nausea or vomiting, listlessness, pale skin, breathing pauses or apneic spells. There can also be a poor suck with poor feeding, difficulty maintaining the temperature, rapid breathing, sweating in the infant, tremors or shaking and seizures. When a baby looks sick, it is time to check a blood sugar to see what is going on.
The major test for neonatal hypoglycaemia is a blood glucose test, which can be done using a blood glucose monitor rather than a large laboratory machine. It is usually confirmed in the laboratory if it is low on the monitor screen. The blood sugar is tested every 1-2 hours until the blood sugar is normalized. If there is any question, blood is taken for inborn errors of metabolism or other metabolic disorders. Urine tests tell if there is sugar in the urine or if there are other abnormalities.
The treatment of neonatal hypoglycaemia includes immediately feeding the infant with glucose water, breast milk or formula. This can bring up the level of blood sugar in minor cases of low blood sugar. A nasogastric tube may need to be used to put in glucose if the infant is not sucking vigorously. Sometimes IV glucose may need to be given to keep the blood glucose at a level that is appropriate for life and for brain nourishment. The treatment may last just one day or up to a full week before the infant can bring up its own glucose.
Medications including diazoxide can bring up blood glucose levels in difficult patients and a medication known as ocreotide will lessen the level of insulin produced by the pancreas. In rare cases, an infant cannot lower his or her insulin level and will need a surgery to remove a portion of the pancreas. Sometimes the neonatal hypoglycaemia can be treated once, only to come back in a day or a few hours. This is why careful screening of the glucose level, even after treatment, is warranted.
Once treated, most infants do well after their bout of neonatal hypoglycaemia. If it is not treated adequately or long enough, there can be permanent developmental delay, heart failure, seizure disorder or mental delay.
Medical Negligence Solicitors
If Neonatal Hypoglycaemia was worsened or was not diagnosed due to mistakes by a doctor or hospital, it is important that you protect your interests and make certain that you are compensated for injury to yourself or your child. Our medical negligence solicitors normally deal with claims using a no win no fee arrangement which means that if you don't win then you don't pay them their professional costs. If you would like legal advice at no cost then just complete the contact form or email our offices or call the helpline and a Neonatal Hypoglycaemia solicitor will telephone to discuss your potential claim.
Neonatal Hypoglycemia Overview
Glucose is one of the main sources of energy in the prenatal period and in the neonatal period. Organ and brain function depends on glucose. Because the brain does not carry glycogen stores to any degree, there must be a constant source of glucose to keep the brain going. There is a high brain to body weight so that cerebral glucose accounts for up to 90 percent of glucose consumption.
Glucose is a major source of foetal nutrition. The foetal source of glucose is almost exclusively from the mother with the enzymes to create glucose dormant in the foetus. Glucose is reduced into CO2 and carbon from about 60-70 percent of the utilization of glucose.
While the foetus is dependent on glucose almost entirely, a switch happens upon birth so that the foetus can create glucose and store glucose on its own. There is a decrease in the insulin to glucose ratio so that glucose rises. Infants can create gluconeogenesis by the sixth hour of life, although full enzyme activity doesn’t happen until 1-2 weeks of age. In neonatal hypoglycaemia, the blood glucose goes too low.
The incidence of neonatal hypoglycaemia is from 1-5 out of every 1,000 live births but is about 8 percent for children born to diabetics and 15 percent of all preterm infants. Those with multiple risk factors can have neonatal hypoglycaemia as high as 30 percent. Upon the birth, the diagnosis of neonatal hypoglycaemia is made when the sugar is lower than 35 mg/dL. Concentrations among different paediatricians include levels as low as 20 mg/dL or as high as 70 mg/dL. These are the levels within the first 72 hours of life. The condition is made possible when the glucose delivery is poor and not enough to meet up with demands. It is estimated that a sustained level of less than 20 mg/dL can cause brain damage within a few hours.
The normal blood sugar as a newborn would be considered hypoglycaemic at 18 hours of age. This is why nursing staff frequently check the glucose level in the first few days of life.
The presentation of neonatal hypoglycaemia can be tachypnea, respiratory distress, lack of breathing, shakiness and jitteriness, tachycardia, bradycardia, poor suck, temperature dysregulation, seizures and lethargy. These signs can mimic sepsis, low calcium and intracranial haemorrhage so that further evaluation needs to be made when such symptoms come along.
Causes of neonatal hypoglycaemia include being premature and having intrauterine growth restriction. In both cases, there is a low amount of liver-stored glycogen. In some cases, multiple gestations or post-term infants can suffer from the condition. When there has been increased metabolic use as in a difficult delivery, there can be low blood sugar after birth.
Cases of hyperinsulinism can result in low blood sugar. This happens when a woman who is diabetic delivers an infant. The infant has high blood insulin levels with a sudden drop in serum glucose at birth. The baby suffers from prolonged blood sugar problems and impaired glycogenolysis and gluconeogenesis.
Infants who are born with erythroblastosis foetalis have higher than normal insulin levels. The same is true of infants who were maintained in utero on beta agonist tocolytics medication. This gradually wears off as the tocolytics is washed from the system. Infants with hyperinsulinism can have their symptoms last as long as 4 weeks after the birth.
Management of neonatal hypoglycaemia includes rapid feeding enterally. It should be done with 5 percent dextrose water because it is rapidly metabolized, bringing up the glucose quickly. Only later is formula started. In symptomatic patients, it is recommended to try IV glucose therapy, especially for the sickest babies.
The biggest complication includes the hypoglycaemic brain injury. This can happen when the patient is under-treated during his or her early life.
If a baby has sustained or repetitive hypoglycaemia, it can strongly impact brain development and brain function. Ischemia (lack of blood supply) and hypoxia (lack of oxygen) make the hypoglycaemia worse; they add to the potential for brain damage. Glucose levels drop after birth with a low at about 1-3 hours after birth. The levels of liver glycogen are quickly depleted after birth so that gluconeogenesis kicks in, accounting for ten percent of glucose turnover in the newborn infant. If this is insufficient, hypoglycaemia and brain injury can occur.
In neonatal hypoglycaemia, there are changes in hormone secretion that favour low blood sugar. There is little in the way of glycogen stores and muscle stores are inadequate to provide amino acids for gluconeogenesis. The baby often has little fat on it so fatty acids can’t be released.
The history of an infant suffering from neonatal hypoglycaemia is one that can include newborns weighing more than 4 kg or less than 2 kg. Large for gestational age babies and small for gestational age babies (including those with intrauterine growth restriction) are at higher risk. One in a thousand pregnant women is diabetic and 2 percent of women have diabetes of pregnancy. Their infants have a higher risk of developing neonatal hypoglycaemia. Preemies can develop neonatal hypoglycaemia as can infants who are suspected of having sepsis or have been born to a mother with a uterine infection.
Symptoms of neonatal hypoglycaemia include poor feeding, low Apgar scores, tachypnea (fast breathing), jitteriness, instability of temperature, lethargy and seizures. If the baby has had perinatal distress, has had a mother on terbutaline, beta-blockers or hypoglycaemic medications, or has a large liver, the staff should check for neonatal hypoglycaemia. Things like microcephaly, enlarged tongue or gigantism, then neonatal hypoglycaemia should be suspected.
Infants suspected of having neonatal hypoglycaemia should have hourly blood glucose measurements until the blood glucose normalizes. If the blood sugar is markedly low, dextrose should be given orally or by IV to bring up the blood sugar to more normal levels. Serious cases need to be treated with anti-convulsant therapy to control seizures. Acidosis with a pH less than 7.1 needs therapy with sodium bicarbonate. The goal of therapy is to bring the blood sugar to above 45 mg/dL on a consistent basis. Eventually the infant will be able to drink sugar water on his or her own and can be bottle fed dextrose until the crisis has passed. Regular infant formula can be started when the baby is stable.
Hypoglycaemia needs prompt treatment in order to prevent brain or other neurological damage. Early feeding of suspected infants should be encouraged so that the blood sugar can continue to rise. A nasogastric tube can be used if the infant’s suck reflex is poor or if the infant is otherwise unable to eat due to lethargy. Cortisol is not recommended because it doesn’t work fast enough and has minimal benefit to the infant. Its use may, in fact, mask the true cause of the hypoglycemia.
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The author of the substantive medical writing on this website is Dr. Christine Traxler MD whose biography can be read here