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help ! persistent neonatal hypo-hyperglycemia ?

Aymen Eshene

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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)



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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

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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

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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 .

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  • 5 weeks later...

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