Neonatal Hypoglycemia Clinical PresentationAuthor: Hilarie Cranmer, MD, MPH, FACEP; Chief Editor: George T Griffing, MD more...

Updated: Apr 24, 2014

HistoryThe clinical presentation of hypoglycemia reflects decreased availability of glucose for the CNS as well as adrenergicstimulation caused by a decreasing or low blood sugar level. During the first or second day of life, symptoms vary fromasymptomatic 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 kgLarge 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 restrictionInfants 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 weeksNewborns suspected of sepsis or born to a mother suspected of having chorioamnionitisNewborns with symptoms suggestive of hypoglycemia, including jitteriness, tachypnea, hypotonia, poorfeeding, apnea, temperature instability, seizures, and lethargy

Additionally, consider hypoglycemia screening in infants with significant hypoxia, perinatal distress, 5-minute Apgarscores of less than 5, isolated hepatomegaly (possible glycogen-storage disease), microcephaly, anterior midlinedefects, gigantism, macroglossia or hemihypertrophy (possible Beckwith-Wiedemann Syndrome), or any possibility ofan 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 thetime of documented hypoglycemia. Transient neonatal hyperinsulinism occurs in macrosomic infants of diabeticmothers (who have diminished glucagon secretion and in whom endogenous glucose production is significantlyinhibited). 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:

SGAHaving perinatal asphyxiaBorn to mothers with toxemiaHaving 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, whousually become symptomatic after an overnight or prolonged fast, especially with illness and poor oral intake. Childrenoften present as inexplicably lethargic or frankly comatose, having only marked hypoglycemia with ketonuria.

Physical ExaminationClinical manifestations are broad and can result from adrenergic stimulation or from decreased availability of glucosefor the CNS. Unlike older children, infants are not able to verbalize their symptoms and are particularly vulnerable tohypoglycemia.

Infants in the first or second day of life may be asymptomatic or have life-threatening CNS and cardiopulmonarydisturbances. Symptoms can include the following:

HypotoniaLethargy, apathyPoor feedingJitteriness, seizuresCongestive heart failureCyanosisApneaHypothermia

Clinical manifestations associated with activation of the autonomic nervous system include the following:

Anxiety, tremulousnessDiaphoresisTachycardiaPallorHunger, nausea, and vomiting

Clinical manifestations of hypoglycorrhachia or neuroglycopenia include the following:

HeadacheMental confusion, staring, behavioral changes, difficulty concentratingVisual disturbances (eg, decreased acuity, diplopia)DysarthriaSeizuresAtaxia, somnolence, comaStroke (hemiplegia, aphasia), paresthesias, dizziness, amnesia, decerebrate or decorticate posturing

Contributor Information and DisclosuresAuthorHilarie Cranmer, MD, MPH, FACEP Director of Disaster Response, MGH Center for Global Health; AttendingPhysician, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor, HarvardMedical School and School of Public Health

Hilarie Cranmer, MD, MPH, FACEP is a member of the following medical societies: American College of

Neonatal Hypoglycemia Clinical Presentation http://emedicine.medscape.com/article/802334-clinical#showall

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Medscape Reference 2011 WebMD, LLC

Emergency Physicians, American Medical Association, Massachusetts Medical Society, Physicians for HumanRights, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor BoardDebra 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 ofPharmacy; 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 EmergencyMedicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief EditorGeorge 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 Advancementof 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 ContributorsThe authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authorMichael Shannon, MD, MPH,to the development and writing of the source article.

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