Endgames Case Report

A hypoglycaemic baby on the postnatal ward

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4626 (Published 27 October 2010) Cite this as: BMJ 2010;341:c4626

This article has a correction. Please see:

  1. Sagarika Ray, specialty training registrar (st5), paediatrics
  1. 1Northampton General Hospital, Northampton NN1 5BD
  1. Correspondence to: S Ray sagarikaray{at}hotmail.com

A baby girl, weighing 3520 g (91st centile) was born at 38+1 weeks’ gestation by instrumental delivery. Apgar scores were normal. The pregnancy had been uneventful with no history of maternal diabetes mellitus. She was taking breast and bottle feeds well. The midwife on the postnatal ward noted that she was jittery and sweating excessively at 34 hours of age and referred her to the paediatric team on call.

Examination on the neonatal unit showed that she was jittery and sweaty with mid-facial hypoplasia, “cherubic” facies, abnormal ear lobe creases, neonatal teeth, and right hemi-hypertrophy. Her occipito-frontal circumference measured 32.5 cm (9th centile). Other observations were oxygen saturations 95% in air, respiratory rate 45-60 breaths/min (normal range 35-55), heart rate 133-140 beats/min (normal range 100-150),1 and blood pressure 83/39 mm Hg (50th centile for systolic and diastolic cuff blood pressure measurement at this age is 70 mm Hg and 55 mm Hg, respectively).2 A capillary blood gas showed mild respiratory acidosis. The bedside blood glucose concentration was 0.8 mmol/l. She was given an intravenous dextrose bolus and a dextrose infusion was started. Despite this, she remained hypoglycaemic.

Questions

  • 1 What are the causes of hypoglycaemia in neonates?

  • 2 How would you manage a neonate with hypoglycaemia?

  • 3 What other relevant investigations should be performed?

  • 4 On the basis of the clinical findings, what is the baby’s likely diagnosis?

  • 5 What are the long term implications of neonatal hypoglycaemia?

Answers

1 What are the causes of hypoglycaemia in neonates?

Short answer

Causes of neonatal hypoglycaemia can be broadly grouped into those related to a lack of substrate (ketotic) and those related to excess insulin (non-ketotic). Ketotic causes include prematurity, being small for gestational age, sepsis, polycythaemia, hypoxic ischaemic encephalopathy, maternal labetalol intake, and enzymatic defects that affect glucose metabolism. Non-ketotic causes include maternal diabetes, fatty acid oxidation defects, and transient or persistent …

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