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Neonatal Hyperglycemia Ppt

A Case Of Neonatal Diabetes Presentation, Diagnosis And Management

A Case Of Neonatal Diabetes Presentation, Diagnosis And Management

Abstract We present a case of neonatal diabetes with special focus on the diagnostic therapeutic and education problems faced by the pediatric endocrinology team (physicians, nurses and diabetes educators) during the hospital course. Keywords: NDM: Neonatal Diabetes Mellitus Introduction Neonatal diabetes mellitus (NDM) is an extremely rare presentation of diabetes. Affected infants are often found to be hyperglycemic (but rarely ketotic). Once considered a single disease, neonatal DM is now known to be caused by mutation affecting insulin synthesis and release, and by several mutations causing severe insulin resistance. Knowing the cause is important to selection of appropriate therapy. The therapy is also different from the typical pediatric because of size and diet. Training the family to care for the diabetic neonate is challenging for all. This case report will review the presentation, work up needed to reach the diagnosis, and the management plan and goals. Case Report A preterm male infant was born at 37 weeks’ gestation, weighing 1565 grams. His mother is a 25 year old G2P0010. The mother denied any history of diabetes. The baby’s parents were first cousins of Pakistani origin. Her pregnancy was complicated by intrauterine growth retardation (IUGR) and low amniotic fluid index score (AFI). Labor was induced because of severe IUGR. The APGAR scores were 8 at 1 minute and 9 at 5 minutes. Patient was admitted to the neonatal intensive care unit because of the severely wasted appearance. On physical examination at birth, temperature was 96.5°–97.1° F, heart rate 118, respiratory rate 31, and blood pressure 83⁄48. The patient was very pale with light skin; the head was normocephalic without deformities. Cardiovascular and respiratory examinations were norma Continue reading >>

Neonatal Hypoglycemia

Neonatal Hypoglycemia

Presentation on theme: "NEONATAL HYPOGLYCEMIA"— Presentation transcript: 1 NEONATAL HYPOGLYCEMIA 3 References 5 Hypoglycemia is one of the most frequent metabolic problems in neonatal medicine 6 Neonatal glucose concentrations decrease after birth to as low as 30 mg/dL during the first 1 to 2 hours after birth 7 هموستاز گلوکز و سازگاری متابولیک طی انتقال از زندگی جنینی به نوزادی 9 Numerical definition of hypoglycemia/ determination of a cut- off value Is it true? 10 Approach based on clinical manifestation 11 Approach based on neurologic and developmental outcomes Data for this functional definition that correlates the glucose concentration with adverse neurodevelopmental outcome is still very limited 12 Approach based on neurologic and developmental outcomes 13 Approach based on neurologic and developmental outcomes This statement remains unchanged by more recently published evidence from a 15-year follow-up cohort of preterm infants (<32 weeks of gestation) with frequent low blood glucose measurements in the first 10 days and their carefully matched controls 14 Of concern is the widespread adoption of a single numerical value based on two published papers (whose results are now generally considered not to justify their conclusions) that a level of less than 2.6mmol/L (<47 mg/dL) should be used to define neonatal hypoglycemia 16 First The numerical ‘cut off’ value of the definition was widely adopted as <2.6 mmol/l (47 mg/dl) from the late 1980s, influenced by an important publication in 1988 by Lucas et al. They reported serious impairment in motor and cognitive development at 18 months in babies with recurrent ‘asymptomatic hypoglycemia’. 17 They stated that: ‘the association between modest hypoglyce Continue reading >>

Neonatal Hypoglycemia

Neonatal Hypoglycemia

Summary A consistent definition for neonatal hypoglycemia in the first 48 h of life continues to elude us. Enhanced understanding of metabolic disturbances and genetic disorders that underlie alterations in postnatal glucose homeostasis has added useful information to understanding transitional hypoglycemia. This growth in knowledge still has not led to what we need to know: “How low is too low and for how long?” This article reviews the current state of understanding of neonatal hypoglycemia and how different approaches reach different “expert” opinions. Continue reading >>

Neonatal Hypoglycemia:

Neonatal Hypoglycemia:

Why This Topic is Important? Inability to breast feed and weight <2500 g were independently associated with hypoglycaemia. Mortality was 45.2% compared to 19.6% in normoglycaemic neonates (p < 0.001). Osier FH, Berkley JA, Ross A, Sanderson F, Mohammed S, Newton CR. Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome. Arch Dis Child. 2003 Jul;88(7):621-5. 41% newborn infants had mild (less than 2.6 mmol/l) and 11% had moderate hypoglycaemia: Hospital based study. Pal DK, Manandhar DS, Rajbhandari S, Land JM, Patel N, de L Costello AM. Arch Dis Child Fetal Neonatal Ed. 2000 Jan;82(1):F46-51. Koivisto M, Blaco-Sequeiros M, Krause U. Neonatal symptomatic hypoglycaemia: a follow-up study of 151 children. Dev Med. Child Neurol 1972; 14:603-14 Their conclusions? TIME is most important factor affecting onset of sx and SYMPTOMATIC hypoglycemia with convulsions has poor prognosis for permanent CNS damage, while asymptomatic hypoglycemia without convulsions appears to have no influence on CNS pathology Long term neurological outcomes Lucus A, Morley R, Cole TJ. Adverse neurodevelopmental outcome of moderate neonatal hypoglycemia. British Medical Journal 1988; 297:1304-1308 661 preterm infants (BW <1850 g) surviving >48hrs Weekly glucose level taken; reagent strips q6h for first 48-72 hours (if <1.5 or 2 low values below 2.5 ïƒ blood test) Treated by feeds/iv or bolus if less than 1 mmol/l or sx At 18 months ïƒ 92% assessed with Bayley motor and development scale Results examined by statistical adjustment for differences between infants with and without hypoglycemia Lucus A, Morley R, Cole TJ. Their findings? <2.6 on 3 to 30 separate days ïƒ associated with reductions in Bayley motor ad mental development scores even Continue reading >>

Current Perspectives On Neonatal Hypoglycemia, Its Management, And Cerebral Injury Risk

Current Perspectives On Neonatal Hypoglycemia, Its Management, And Cerebral Injury Risk

Authors Chandran S, Rajadurai V, Alim A, Hussain K Accepted for publication 1 December 2014 Checked for plagiarism Yes Peer reviewer comments 2 1Department of Neonatology, KK Women’s and Children’s Hospital, Singapore; 2Duke-NUS Graduate School of Medicine, Singapore; 3Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 4Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; 5Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, 6The Institute of Child Health, University College London, London, UK Abstract: Glucose is an essential substrate for mammalian cells; in particular, the brain needs glucose continuously as a primary source of energy. Hypoglycemia is the most common biochemical finding in the neonatal period. However, despite the common occurrence, there is still controversy on the definition of hypoglycemia in the newborn period. This has led to the development of guidelines designed to identify infants “at-risk” and the implementation of an “operational threshold” for physicians to consider intervention. In healthy term infants, the optimal hormonal and metabolic adaptations during the immediate neonatal period ensure an adequate energy substrate for the vital organs, whereas the abnormal glucose homeostasis observed in preterm and growth-retarded infants is multifactorial in origin. For these high-risk infants, it is important to identify, screen, and prevent significant hypoglycemia. Detailed investigations are warranted in infants with severe and persistent hypoglycemia. Neonatal hypoglycemia is a major cause of brain injury. The speculated mechanisms of cellular injury include excitatory neurotoxins active at N-methyl-D-aspartate recept Continue reading >>

Factors That Contribute To Have A High-risk Neonate:

Factors That Contribute To Have A High-risk Neonate:

Introduction: Definition of High-risk Neonate: Any baby exposed to any condition that make the survival rate of the neonate at danger. A) High-risk pregnancies: e.g.: Toxemias B) Medical illness of the mother: e.g.: Diabetes Mellitus C) Complications of labor: e.g.: Premature Rupture Of Membrane (PROM), Obstructed labor, or Caesarian Section (C.S). D)  Neonatal factors: e.g.: Neonatal asphyxia Identification of some High-risk Neonates: The previous conditions often will result in Premature birth, Low birth weight infants, or infants suffering from: Hypothermia, Hyperthermia, Hypoglycemia, Infant of Diabetic Mother (IDM), Neonatal Sepsis, Hyperbilirubinemia, and Respiratory Distress Syndrome (RDS). Some Definitions: -  Low Birth Weight Infant: Is any live born baby weighing 2500 gram or less at birth. (VLBW: <1500 gm, ELBW:<1000 gm). - Preterm: When the infant is born before term. i.e.: before 38 weeks of gestation.  -  Premature: When the infant is born before 37weeks of gestation. -  Full term: When the infant is born between 38 – 42 weeks of gestation.  -  Post term: When the infant is born after 42 weeks of gestation. Definition: It is a condition characterized by lowering of body temperature than 36°C. Types of Hypothermia: Could be classified according to: Causes and according to Severity. I)     According to Causes: 1-   Primary Hypothermia: (immediately associated with delivery) In which the normal term infant delivered into a warm environment may drop its rectal temperature by 1 – 2°C shortly after birth and may not achieve a normal stable body temperature until the age of 4 – 8 hours. In low birth weight infants, the decrease of body temperature may be much greater and more rapid unless spec Continue reading >>

Update On Childhood Diabetes Mellitus

Update On Childhood Diabetes Mellitus

DEFINITION The term diabetes mellitus describes a metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects of insulin secretion, insulin action or both. DIABETES EPIDEMIOLOGY Diabetes is the most common endocrine problem & is a major health hazard worldwide. Incidence of diabetes is alarmingly increasing all over the globe. Incidence of childhood diabetes range between 3-50/100,000 worldwide; in Oman it is estimated as 4/100000 per year. OLD CLASSIFICATION (1985) Type 1, Insulin-dependent (IDDM) Type 2, Non Insulin-dependent (NIDDM) obese non-obese MODY IGT Gestational Diabetes WHO CLASSIFICATION 2000 Is based on etiology not on type of treatment or age of the patient. Type 1 Diabetes (idiopathic or autoimmune b-cell destruction) Type 2 Diabetes (defects in insulin secretion or action) Other specific types WHO CLASSIFICATION/2 Both type 1 & type 2 can be further subdivided into: Not insulin requiring Insulin requiring for control Insulin requiring for survival Gestational diabetes is a separate entity Impaired Glucose Tolerance (IGT) indicates blood glucose levels between normal & diabetic cut off points during glucose tolerance test. DIAGNOSTIC CRITERIA Fasting blood glucose level Diabetic Plasma >7.0 mmol Capillary >6.0 mmol IGT Plasma 6.0-6.9 mmol Capillary 5.6-6.0 mmol 2 hours after glucose load (Plasma or capillary BS) IGT 7.8-11.0 Diabetic level > 11.1 (200 mg) GENETIC FACTORS Evidence of genetics is shown in Ethnic differences Familial clustering High concordance rate in twins Specific genetic markers Higher incidence with genetic syndromes or chromosomal defects ENVIRONMENTAL SUSPECTS Viruses Coxaschie B Mumps Rubella Reoviruses Nutrition & dietary factor Continue reading >>

Background Drug Information

Background Drug Information

One Year Post-Exclusivity Adverse Event Review: Insulin Aspart Recombinant Pediatric Advisory Committee Meeting November 16, 2006 Hari Cheryl Sachs, MD, FAAP Medical Officer Pediatric and Maternal Health Staff Office of New Drugs Center for Drug Evaluation and Research Food and Drug Administration Background Drug Information Drug: NovoLog® (insulin aspart recombinant) Therapeutic Category: human insulin analog Sponsor: Novo Nordisk Inc Original Market Approval: June 7, 2000 Mechanism of action: regulation of glucose metabolism Binds to insulin receptors on muscle and fat Facilitates cellular uptake of glucose Inhibits output of glucose from liver Background Drug Information Indication: treatment of patients with diabetes mellitus, for the control of hyperglycemia Normally with regimen of intermediate or long-acting insulin May be infused via external insulin pumps May be used intravenously under medical supervision Dosage: Individualized, immediately prior to a meal Note: more rapid onset and shorter duration of regular insulin, usually used win regimens with intermed or long acting Dosage individualized, immediately before meal (within 5 to 10 min) Total daily requirement: typically 0.5 to 1.0 units/kg/day Meal related: 50 to 70 % total insulin may be provided by NovoLog Drug Use Trends (Outpatient Settings): Insulin Aspart Recombinant Dispensed prescriptions for NovoLog have been increasing (June 2004 to May 2006)1 Total NovoLog® and NovoLog® Mix 70/30 prescriptions increased by estimated 29% (~ 2.4 to 3.4 million)1 Relative increase in pediatric patient count: 22% (~47,000 to 57,000)2 Pediatric patients accounted for ~13% of prescriptions2 Majority of pediatric NovoLog® prescriptions to patients ages 12-16 years1 1Verispan LLC, Vector One National, Jun 20 Continue reading >>

Neonatal Hypoglycemia

Neonatal Hypoglycemia

Neonatal hypoglycemia is a transient or temporary condition of decreased blood sugar or hypoglycemia in a neonate.[1][2] Mechanism and pathophysiology[edit] Temporary hypoglycemia in the first three hours after birth is a normal finding. Most of the time it resolves without medical intervention. The lowest blood sugars occur one to two hours after birth. After this time, lactose begins to be available through the breast milk. In addition, gluconeogenesis occurs when the kidneys and liver convert fats into glucose..[3] Risk[edit] Those infants that have an increased risk of developing hypoglycemia shortly after birth are: preterm asphyxia cold stress congestive heart failure sepsis Rh disease discordant twin erythroblastosis fetalis polycythemia microphallus or midline defect respiratory disease maternal glucose IV maternal epidural postmaturity hyperinssulinnemia endocrine disorders inborn errors of metabolism diabetic mother maternal toxemia intrapartum fever[4] Treatment[edit] Some infants are treated with 40% dextrose (a form of sugar) gel applied directly to the infant's mouth.[5] See also[edit] Congenital hyperinsulinism Hyperinsulinemic hypoglycemia [edit] Bibliography[edit] Walker, Marsha (2011). Breastfeeding management for the clinician : using the evidence. Sudbury, Mass: Jones and Bartlett Publishers. ISBN 9780763766511. External links[edit] Hypoglycemia in the Newborn, Lucile Packard Children’s Hospital Continue reading >>

Neonatal Hyperglycemia Due To Transient Neonatal Diabetes Mellitus In Puerto Rico

Neonatal Hyperglycemia Due To Transient Neonatal Diabetes Mellitus In Puerto Rico

Copyright © 2015 N. Fargas-Berríos et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Neonatal hyperglycemia is a metabolic disorder found in the neonatal intensive care units. Neonatal diabetes mellitus (NDM) is a very uncommon cause of hyperglycemia in the newborn, occurring in 1 in every 400,000 births. There are two subtypes of neonatal diabetes mellitus: permanent neonatal diabetes mellitus (PNDM) and transient neonatal diabetes mellitus (TNDM). We describe a term, small for gestational age, female neonate with transient neonatal diabetes mellitus who presented with poor feeding tolerance and vomiting associated with hyperglycemia (385 mg/dL), glycosuria, and metabolic acidosis within the first 12 hours of life. The neonate was treated with intravenous insulin, obtaining a slight control of hyperglycemia. An adequate glycemia was achieved at 5 weeks of life. The molecular studies showed complete loss of maternal methylation at the TND differentially methylated region on chromosome 6q24. The etiology of this neonate’s hyperglycemia was a hypomethylation of the maternal TND locus. A rare cause of neonatal diabetes mellitus must be considered if a neonate presents refractory hyperglycemia. To our knowledge, this is the first case reported in Puerto Rico of transient neonatal mellitus due to the uncommon mechanism of maternal hypomethylation of the TND locus. Its prevalence in Puerto Rico is unknown. 1. Introduction Neonatal hyperglycemia is a metabolic disorder found in the neonatal intensive care units [1]. There are several and different etiologies for neonatal hyperglycemia with different clin Continue reading >>

Case Based Pediatrics For Medical Students And Residents

Case Based Pediatrics For Medical Students And Residents

Department of Pediatrics, University of Hawaii John A. Burns School of Medicine Chapter III.8. Neonatal Hypoglycemia Return to Table of Contents This is a newborn infant male delivered to a 25 year old G5P3, A+ mother at 37 weeks gestation by C section (for non-reassuring fetal heart tones). The pregnancy is notable for an antenatal ultrasound diagnosis of cleft lip and palate. Maternal serologies are unremarkable and her prenatal glucose tolerance test is normal. At delivery, blow-by oxygen is given for about 2 minutes for poor color and respiratory effort. Apgar scores are 6 (-2 color, -1 tone, -1 respiratory effort) and 9 (-1 color) at one and five minutes, respectively. Exam: Vital signs are normal. Oxygen saturation is 99% in room air. Weight is 3950 gms, height is 54 cm and head circumference is 37.5 cm (all >95th percentile for gestational age). The infant is active and jittery with an obvious left sided cleft lip and palate. Heart is regular without murmurs. Lungs are clear. Abdomen is soft, without masses or hepatosplenomegaly. The remainder of the initial exam is normal. The infant is transferred to the term nursery for transitioning. A bedside glucose is obtained and the blood sugar is read as close to 0 mg/dl. A serum sample is then sent STAT to the lab. An IV is started and 8 ml (2 mg/kg) of 10% dextrose in water (D10W) is given IV. The infant is transferred to the intermediate nursery where a repeat blood sugar 30 minutes after the bolus is still <20 mg/dl. A second IV bolus of D10W is given. The earlier serum glucose sent to the lab, comes back at <2 mg/dl. IV D10 is infusing at 80 ml/kg/day, which is a glucose infusion rate of 5.6 mg/kg/min. A blood sugar obtained 30 minutes after a second bolus is 31 mg/dl. The fluid is changed to 12.5% dextrose (D12.5W Continue reading >>

Implementing A Protocol Using Glucose Gel To Treat Neonatal Hypoglycemia

Implementing A Protocol Using Glucose Gel To Treat Neonatal Hypoglycemia

Historically, determining evidence-based protocols for the treatment of neonatal hypoglycemia has been difficult because of a lack of clinical evidence defining pathologic glucose levels in neonates during the first hours of life (Committee on Fetus and Newborn & Adamkin, 2011). As recently as 2008, an expert panel at the Eunice Kennedy Shriver National Institute of Child Health and Human Development found that no threshold values had been established relating levels of glucose to pathologic neonatal hypoglycemia in infants, which remains true to this day (Cornblath et al., 2000, Hay et al., 2009). This lack of scientific knowledge has led clinicians across the country to use a wide range of disparate interventions. In 2011, in an effort to address this lack of an agreed-on treatment protocol for neonatal hypoglycemia, the American Academy of Pediatrics (AAP) published new management guidelines. These guidelines were necessary because, as the AAP explained, “The generally adopted plasma glucose concentration that defines neonatal hypoglycemia for all infants (< 47 mg/dl) is without rigorous scientific justification” (Committee on Fetus and Newborn & Adamkin, 2011, p. 576). Fetal glucose levels are dependent on maternal glucose supply and placental transfer, with a low-end normal value of 50 mg/dl. A physiologic decrease in glucose levels normally occurs immediately after birth and continues for the first 2 to 3 hours of life. Studies referenced by Hay et al. (2009)) found levels as low as 23 mg/dl in healthy breastfed infants. The Committee on Fetus and Newborn and Adamkin (2011)) found that levels of 30 mg/dl are common in healthy neonates during the initial 1 to 2 hours of life. After this temporary decrease, glucose levels in healthy neonates soon increase to 40 Continue reading >>

Low Socioeconomic Level Of The Mother

Low Socioeconomic Level Of The Mother

Identification of At-risk Newborn Low socioeconomic level of the mother Limited or no prenatal care Exposure to environmental dangers Preexisting maternal conditions Maternal factors such as age or parity Medical conditions related to pregnancy Pregnancy complications Impact of Maternal Diabetes Mellitus (DM) on the Newborn LGA SGA Hypoglycemia Hypocalcemia Hyperbilirubinemia Birth trauma Polycythemia RDS Congenital malformations Preterm Infant: GI Alterations Poorly developed gag reflex Incompetent esophageal cardiac sphincter Poor sucking and swallowing reflexes Difficulty meeting caloric needs for growth Inability to handle the increased osmolarity of formula protein Difficulty with absorbing saturated fats Difficulty with lactose digestion Deficiency of calcium and phosphorous Increased basal metabolic rate and increased oxygen requirements Feeding intolerance Potential for the development of necrotizing enterocolitis (NEC Infants Born to HIV/AIDS Infected Mothers: Consequences Prematurity SGA Failure to thrive Enlarged spleen and liver Swollen glands Recurrent respiratory infection Rhinorrhea Recurrent GI problems Persistent or recurrent candidiasis Continue reading >>

Neonatal Hyperglycemia

Neonatal Hyperglycemia

Hyperglycemia is a serum glucose concentration > 150 mg/dL (> 8.3 mmol/L). The most common cause of neonatal hyperglycemia is Iatrogenic causes usually involve too-rapid IV infusions of dextrose during the first few days of life in very low-birth-weight infants (< 1.5 kg). The other important cause is physiologic stress caused by surgery, hypoxia, respiratory distress syndrome, or sepsis; fungal sepsis poses a special risk. In premature infants, partially defective processing of proinsulin to insulin and relative insulin resistance may cause hyperglycemia. In addition, transient neonatal diabetes mellitus is a rare self-limited cause that usually occurs in small-for-gestational-age infants; corticosteroid therapy may also result in transient hyperglycemia. Hyperglycemia is less common than hypoglycemia, but it is important because it increases morbidity and mortality of the underlying causes. Treatment of iatrogenic hyperglycemia is reduction of the IV dextrose concentration (eg, from 10% to 5%) or of the infusion rate; hyperglycemia persisting at low dextrose infusion rates (eg, 4 mg/kg/min) may indicate relative insulin deficiency or insulin resistance. Treatment of other causes is fast-acting insulin. One approach is to add fast-acting insulin to an IV infusion of 10% dextrose at a uniform rate of 0.01 to 0.1 unit/kg/h, then titrate the rate until the glucose level is normalized. Another approach is to add insulin to a separate IV of 10% D/W given simultaneously with the maintenance IV infusion so that the insulin can be adjusted without changing the total infusion rate. Responses to insulin are unpredictable, and it is extremely important to monitor serum glucose levels and to titrate the insulin infusion rate carefully. In transient neonatal diabetes mellitus, gluc Continue reading >>

Glucose Regulation In Preterm Newborn Infants

Glucose Regulation In Preterm Newborn Infants

Abstract After birth, continuous transplacental transfer of glucose is interrupted. Neonates have to provide brain and vital organs with sufficient glucose. In term newborn infants, this is accomplished through well-coordinated hormonal and metabolic adaptive changes. During the first week of life, preterm infants are at high risk of abnormal glucose homeostasis. They are at risk of hypoglycemia due to limited glycogen and fat stores that should have occurred in the third trimester. Continuous glucose infusion is always required soon after birth to maintain the glucose level. However, under such conditions, many preterm infants develop hyperglycemia. Defective islet β-cell processing of proinsulin is likely related to hyperglycemia. There is also evidence that preterm infants are partially resistant to insulin. By contrast with adults, hepatic glucose production is not suppressed during parenteral glucose infusion. Exogenous insulin infusion partially reduces endogenous glucose production in preterm newborn infants. This treatment is efficient and safe when used with caution. More research is needed to understand the specificity of glucose homeostasis in preterm infants and to evaluate the long-term consequences of metabolic and nutritional support during early life. © 2007 S. Karger AG, Basel Introduction Transition from fetal to neonatal life requires a number of adaptations which are more difficult to accomplish by preterm than term newborn infants. Knowledge of key regulatory mechanisms of glucose homeostasis during fetal life and the early neonatal period is essential to understand the specificities of glucose homeostasis in preterm infants. During early postnatal life, infants born prematurely are at high risk of altered glucose homeostasis. Early continuous glu Continue reading >>

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