Which of the following dextrose infusion rate would be appropriate for an infant with documented hypoglycemia?

Hypoglycemia is difficult to define in neonates but is generally considered a serum glucose concentration < 40 mg/dL (< 2.2 mmol/L) in symptomatic term neonates, < 45 mg/dL (< 2.5 mmol/L) in asymptomatic term neonates between 24 hours and 48 hours of life, or < 30 mg/dL (< 1.7 mmol/L) in preterm neonates in the first 48 hours. Risk factors include prematurity, being small for gestational age, maternal diabetes, and perinatal asphyxia. The most common causes are deficient glycogen stores, delayed feeding, and hyperinsulinemia. Signs include tachycardia, cyanosis, seizures, and apnea. Diagnosis is suspected empirically and is confirmed by glucose testing. Prognosis depends on the underlying condition. Treatment is enteral feeding or IV dextrose.

Neonatal hypoglycemia may be transient or persistent.

• Bedside glucose check

• IV dextrose (for prevention and treatment)

• Enteral feeding

• Sometimes IM glucagon

Most high-risk neonates are treated preventively. For example, infants of diabetic women who have been using insulin are often started at birth on a 10% D/W infusion IV or given oral glucose, as are those who are sick, are extremely premature, or have respiratory distress. Other at-risk neonates who are not sick should be started on early, frequent formula feedings to provide carbohydrates.

Any neonate whose glucose falls to ≤ 50 mg/dL (≤ 2.75 mmol/L) should begin prompt treatment with enteral feeding or with an IV infusion of up to 12.5% D/W, 2 mL/kg over 10 minutes; higher concentrations of dextrose can be infused if necessary through a central catheter. The infusion should then continue at a rate that provides 4 to 8 mg/kg/minute of glucose (ie, 10% D/W at about 2.5 to 5 mL/kg/hour). Serum glucose levels must be monitored to guide adjustments in the infusion rate. Once the neonate’s condition has improved, enteral feedings can gradually replace the IV infusion while the glucose concentration continues to be monitored. IV dextrose infusion should always be tapered, because sudden discontinuation can cause hypoglycemia.

If starting an IV infusion promptly in a hypoglycemic neonate is difficult, glucagon 100 to 300 mcg/kg IM (maximum, 1 mg) usually raises the serum glucose rapidly, an effect that lasts 2 to 3 hours, except in neonates with depleted glycogen stores. Hypoglycemia refractory to high rates of glucose infusion may be treated with hydrocortisone 12.5 mg/m2 every 6 hours. If hypoglycemia is refractory to treatment, other causes (eg, sepsis) and possibly an endocrine evaluation for persistent hyperinsulinism and disorders of defective gluconeogenesis or glycogenolysis should be considered.

• Small and/or premature infants often have low glycogen stores and become hypoglycemic unless they are fed early and often.

• Infants of diabetic mothers have hyperinsulinemia caused by high maternal glucose levels; they may develop transient hypoglycemia after birth, when maternal glucose is withdrawn.

• Signs include diaphoresis, tachycardia, lethargy, poor feeding, hypothermia, seizures, and coma.

• Give preventive treatment (using oral or IV glucose) to infants of diabetic mothers, extremely premature infants, and infants with respiratory distress.

• If glucose falls to ≤ 50 mg/dL (≤ 2.75 mmol/L), promptly give enteral feeding or an IV infusion of 10% to 12.5% D/W, 2 mL/kg over 10 minutes; follow this bolus with supplemental IV or enteral glucose and closely monitor glucose levels.

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