Newborn Persistent Hypoglycemia Clinical Pathway — N/IICU

Medications for HI

Use these medications after consultation with and under guidance of Pediatric Endocrinology.

Medication Action/Dose Side Effects
Diazoxide

Beta cell KATP channel activator leads to inhibition of insulin secretion

  • Oral Dose:
  • 5-15 mg/kg/day divided in 2 doses
  • Response: Within 2-4 days of therapy
  • Trial: 5 – 8 days at maximum dosage to determine efficacy
  • Hypertrichosis
  • Salt and water retention
  • Cardiac failure and pulmonary edema
  • Start chlorothiazide at the time of diazoxide initiation rather than waiting for fluid retention to become clinically apparent
  • Chlorothiazide Dosing
    • Chlorothiazide 10-20 mg/kg/DAY PO divided twice daily . May titrate up to a max of 40 mg/kg/DAY PO divided twice daily
    • Conversion from enteral chlorothiazide to enteral hydrochlorothiazide:
      • Chlorothiazide 10 mg PO = hydrochlorothiazide 1 mg PO
      • Can consider furosemide if high rates of IV fluids are required and infants develops signs of fluid overload
Glucagon infusion
  • Counter-regulatory hormone of insulin
  • Continuous infusion of fixed dose: 1 mg/day.
  • Use dilute continuous infusion
    • 0.04 mg/mL in dextrose 5%, run at 1 mL/hr. (=1 mg/day)
  • Infusion is stable for 24 hours
  • Hyponatremia
    • Monitor sodium levels
    • Hypertonic saline (3%) may be considered for severe symptomatic hyponatremia
  • Thrombocytopenia
  • Erythema necrolyticum migrans (Chronic, high-dose glucagon)
  • Occlusion of catheters due to crystallization of glucagon
     
  • DO NOT administer glucagon infusion with any saline or heparin containing rider fluids due to precipitation. The only IV solution compatible with glucagon is dextrose ALONE.

Medications NOT Recommended

Octreotide
  • To be used only in consultation with Pediatric Endocrinology
  • Long-acting somatostatin analogue that inhibits insulin secretion
  • Growth restriction, hypothyroidism
  • Cholelithiasis
  • Reduction in splanchnic blood flow in a dose-dependent manner
  • Risk of fulminant necrotizing enterocolitis
Glucocorticoids
  • Are never useful as a non-specific therapy for hypoglycemia in neonates and should not be used in patients with suspected HI. Only use is in confirmed adrenal insufficiency
  • Dexamethasone and hydrocortisone
  • Adrenal insufficiency/adrenal crisis
  • Growth suppression
  • Immunosuppression
  • Hypertension
  • Spontaneous perforation of GI tract
  • Adverse neurodevelopmental outcomes
Nifedipine
  • Blocks calcium channels, but is not effective in infants with hyperinsulinism
  • Sudden cardiac death
  • Dizziness, flushing
  • Headaches
  • Nausea