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Neonatal Hypoglycemia Clinical Presentation

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http://emedicine.medscape.com/article/802334-clinical#showall

Neonatal Hypoglycemia Clinical Presentation


Author: Hilarie Cranmer, MD, MPH, FACEP; Chief Editor: George T Griffing, MD more...
Updated: Apr 24, 2014

History
The clinical presentation of hypoglycemia reflects decreased availability of glucose for the CNS as well as adrenergic
stimulation caused by a decreasing or low blood sugar level. During the first or second day of life, symptoms vary from
asymptomatic to CNS and cardiopulmonary disturbances.
High-risk groups who need screening for hypoglycemia in the first hour of life include the following[3, 4] :
Newborns who weigh more than 4 kg or less than 2 kg
Large for gestational age (LGA) infants who are above the 90th percentile, small for gestational age (SGA)
infants below the 10th percentile,[5] and infants with intrauterine growth restriction
Infants born to insulin-dependent mothers (1:1000 pregnant women) or mothers with gestational diabetes
(occurs in 2% of pregnant women)
Gestational age less than 37 weeks
Newborns suspected of sepsis or born to a mother suspected of having chorioamnionitis
Newborns with symptoms suggestive of hypoglycemia, including jitteriness, tachypnea, hypotonia, poor
feeding, apnea, temperature instability, seizures, and lethargy
Additionally, consider hypoglycemia screening in infants with significant hypoxia, perinatal distress, 5-minute Apgar
scores of less than 5, isolated hepatomegaly (possible glycogen-storage disease), microcephaly, anterior midline
defects, gigantism, macroglossia or hemihypertrophy (possible Beckwith-Wiedemann Syndrome), or any possibility of
an inborn error of metabolism or whose mother is on terbutaline, beta blockers, or oral hypoglycemic agents
The onset of hyperinsulinemia is from birth to age 18 months. Insulin concentrations are inappropriately elevated at the
time of documented hypoglycemia. Transient neonatal hyperinsulinism occurs in macrosomic infants of diabetic
mothers (who have diminished glucagon secretion and in whom endogenous glucose production is significantly
inhibited). Clinically, these infants are macrosomic and have increasing demands for feeding, intermittent lethargy,
jitteriness, and frank seizures.[6]
Infants with prolonged neonatal hyperinsulinism can be described by the following:
SGA
Having perinatal asphyxia
Born to mothers with toxemia
Having high rates of glucose use and often requiring dextrose infusion for a prolonged period of time
Ketotic hypoglycemia is an uncommon, but dramatic, illness. It is observed in children younger than age 5 years, who
usually become symptomatic after an overnight or prolonged fast, especially with illness and poor oral intake. Children
often present as inexplicably lethargic or frankly comatose, having only marked hypoglycemia with ketonuria.

Physical Examination
Clinical manifestations are broad and can result from adrenergic stimulation or from decreased availability of glucose
for the CNS. Unlike older children, infants are not able to verbalize their symptoms and are particularly vulnerable to
hypoglycemia.
Infants in the first or second day of life may be asymptomatic or have life-threatening CNS and cardiopulmonary
disturbances. Symptoms can include the following:
Hypotonia
Lethargy, apathy
Poor feeding
Jitteriness, seizures
Congestive heart failure
Cyanosis
Apnea
Hypothermia
Clinical manifestations associated with activation of the autonomic nervous system include the following:
Anxiety, tremulousness
Diaphoresis
Tachycardia
Pallor
Hunger, nausea, and vomiting
Clinical manifestations of hypoglycorrhachia or neuroglycopenia include the following:
Headache
Mental confusion, staring, behavioral changes, difficulty concentrating
Visual disturbances (eg, decreased acuity, diplopia)
Dysarthria
Seizures
Ataxia, somnolence, coma
Stroke (hemiplegia, aphasia), paresthesias, dizziness, amnesia, decerebrate or decorticate posturing

Contributor Information and Disclosures

Author
Hilarie Cranmer, MD, MPH, FACEP Director of Disaster Response, MGH Center for Global Health; Attending
Physician, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor, Harvard
Medical School and School of Public Health
Hilarie Cranmer, MD, MPH, FACEP is a member of the following medical societies: American College of

11/01/2015 22:16

Neonatal Hypoglycemia Clinical Presentation

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http://emedicine.medscape.com/article/802334-clinical#showall

Emergency Physicians, American Medical Association, Massachusetts Medical Society, Physicians for Human
Rights, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Specialty Editor Board
Debra Slapper, MD Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center;
Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio
Wayne Wolfram, MD, MPH, is a member of the following medical societies: American Academy of Emergency
Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
George T Griffing, MD Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement
of Science, American College of Medical Practice Executives, American College of Physician Executives,
American College of Physicians, American Diabetes Association, American Federation for Medical Research,
American Heart Association, Central Society for Clinical Research, International Society for Clinical Densitometry,
Southern Society for Clinical Investigation, and The Endocrine Society
Disclosure: Nothing to disclose.
Additional Contributors
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author
Michael Shannon, MD, MPH,to the development and writing of the source article.

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Medscape Reference 2011 WebMD, LLC

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