N/IICU Clinical Pathway for Evaluation/Treatment
of Persistent Hypoglycemia in the Newborn
Related Pathway
-
Glucose < 50 mg/dL from random glucose test or diagnostic fast
- Obtain Critical Fasting Labs
- Then perform Glucagon Stimulation Test
- Check Newborn Screen
- Consult Endocrinology
- Review
Consult Metabolism for
Suspected Metabolic Disease
Suspected Metabolic Disease
- HI Diagnostic criteria when glucose < 50 mg/dL
- Detectable insulin > 2 mIU/mL
- Low beta-hydroxybutyrate < 1.8 mmol/L
- Low free fatty acids < 1.7 mmol/L
- Etiologies of HI
- Medications: Diazoxide, Glucagon infusion
- Additional Evaluation Considerations
- Genetic Consultation, genetic testing
- Cardiology Consultation
- Treatment:
- 5 Day Trial of Diazoxide
- Start chlorothiazide
- Treatment Goal:
- Maintain euglycemia, glucose > 70 mg/dL for infants > 72 hrs of life
- Fasting Test
- On Diazoxide off IVF
- Goal: Fasting time 6-12 hrs with plasma glucose maintained > 70
Fails Fast
Tolerates Fast
- Diazoxide unresponsiveness suggests a KATP channel HI and potential surgical candidate
- Send expedited genetic testing of ABCC8 and KCNJ11
- Discontinue diazoxide
- Maintain plasma glucose above 70 mg/dL with dextrose containing IVF
- Consider central line placement to give higher dextrose concentration in IVF
- Consider continuous glucagon infusion (1 mg/day) if fluid overload is a concern
- Arrange transfer to CHOP for further care
and potential 18F-DOPA PET
- Continue diazoxide with glucose monitoring
- Obtain ECHO, CBC with diff, and BMP 1 week after starting diazoxide or prior to discharge
- Send comprehensive HI genetic testing
- Discharge Planning with Endocrinology
Evidence
- Postnatal Glucose Homeostasis in Late-Preterm and Term Infants
- Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children
- Re-Evaluating “Transitional Neonatal Hypoglycemia”: Mechanism and Implications for Management
- Hyperinsulinism in the Neonate
- Glucose Profiles in Healthy Term Infants in the First 5 Days: The Glucose in Well Babies (GLOW) Study
CHOP Program