help ! persistent neonatal hypo-hyperglycemia ?

[Aymen Eshene]

hello to everyone >>

 

i will write to you a story of my friends baby ,, whose i follow closly during his admition to neonatal ICU

 

B/O nadia , male , delivered via s.section .at preterm age 34 weeks gestation ,b.wt 1.850

A.SCORE :4   8   9  .

Baby delivered through meconium stained liquor . ill . o2 given via ambibag

cord ABG sever metabolic acidosis .baby was drowzy weak cry , tachycardia , ivf resusc.given

antibiotic started and after 2 hrs NCPAP  because sat was 83 .

initail diagnosis was sepsis ( possible listeriosis) ampicillin gentamicin given .

inv initialy platlet40 crp positive 82mg  prolonged pt and aptt

platlet transfusion given , FFP given and  respiratory status was ok ( clinicaly ,sat, ABG ) was normal .

after a 6 days of intensive care : platlet raised , pt ptt normal , crp down to almost negative values .

 

what i want to ask you is ::   on admition blood sugar was 15mg/dl (explained ) and to manage concentration of fluid raised to 15percent through UVC .

 

now baby aged 12 days : still has fluctuation blood sugar > and what surprise me is blood sugar at morning normal .. drop slowly slowly so at 4:00 or 5:00pm  every day on the last three days to become 30mg, 25mg and even lower . and become higher at night reach up to 250-300mg

 

clinicaly : baby looks pale , OFC 31.5 not increasing , R.R 65 H.R 135-145  .blood pressure on borderline of high reading .

now he is awake ,conscoius , taking trophic feeding .

CNS : OFC 31.5 not increasing ,Normal tone ,full ant.font

Genitalia : A little dark .male .normal .

Other syst.normal 

investigation over the course of managment : normal urea and electrolyte ,normal calcium , normal LFT , no more abnormality on ABG since acute illnes (the first two days was acidosis :explained by abnormal perfusion which improved on dopamine )

 

so do you have any helpful points : any idea about high readings at night and low in the evening time ? please write any helpful point help me in rearrange my plane .

note : parent has history infertiltiy 5 years with no cause identified . 

ULTRASOUND HEAD not done ( no facility)

 

 

[rehman_naveed]

Can you plz tell are these sugars prefeed or post. Did you simultaneously checked bedside PCX and lab value. Since on trophic feeds, what is GIR, what fluids baby is receiving with dextrose load? Sample is taken from ??

[Stefan Johansson]

Seems like a baby at risk for hypoglycemia, a BW of 1850g at 34 weeks (SGA?) and signs of antepartal stress (low apgar at 1' and mec-stained waters).

Although atypical, substrate deficiency could still be a possibility, although that it getting more and more unlikely as the infants gets older.

How is the baby fed in ml/kg/d and what is the baby given (breastmilk/formula)? Glucose-infusion?

I would vote for the following strategy:

1. ensure that the baby is well fed (I'd go up to 200 ml/kg/d and possibly also enrich the breast milk/formula)

2. help the baby to preserve energy: maintain body temp at 37C but assisted by warmth through a heated matress or blanket, and if necessary - assist feeding with tube feeding

3. if the baby is still hypoglycemic - a more thourough investigation is needed: seems that this review on UpToDate is open access: http://www.uptodate.com/contents/neonatal-hypoglycemia

The further and initial metabolic/endocrine evaluation could include the tests below. Take the blood samples when the baby is hypoglycemic:

* acid-base balance

* Electrolytes

* keton acid in urine

* S-insuline

* C-peptid

* Lactate

* Growth hormone

* Cortisol

* Thyroid status (fT4, TSH)

* Liver enzymes

* 17-OH-progesteron

[Aymen Eshene]

thanks for replying

we attributed the hypo-hyper attack initialy to sepsis , but as the baby getting better , we expect to see a normalaization in his sugar profile .

i categorize the baby as a case of persistent hypoglycemia since his glu.req above 12mgper kg per min more than 6 days now :

1- taking 180cc/kg/day IvF 15percent dextrose concentration .

2- trophic feeding 5cc/kg/day, EBM .

yesterday i got an advice from endocrain dep and i sent some (but not all) of the inv.listed above

i will write them down here.

thanks for every one

[Aymen Eshene]

hello every one ,

just now i recieve my friends baby inv ,it shows :

1- urine ketones negative

2- plasma ketones negative

3- Acth 21pg/ml' normal ' the range 2.7 --- 63.3

4- cortisol 225.5 ' very high ' the range 24.6---171.5ng/ml

5- growth 50ng/ml. ' high ' the range 0.21---17.8ng/ml

6- insulin 2.12ui/ml. normal range 2.6---24.9

7- acid base status : normal , no met.acidosis.

8- lactate : on ABG paper 2mmol .

so , whats your intrepetation ?

what can i see a normal counter-regulatory response ,

so should we look for another area for the diagnosis ?

waiting for helpful tips .

thanks .

[Aymen Eshene]

last update about my baby :

grade 4 IVH , shunt insreted , complicated by sever meningitis .

passed away 2 days back , we couldnt help , meningitis was very aggressive .

by the way : his name was : Rostom ( persian name ) .

may allah support his family .