What is the management for a neonate with hyperglycemia (elevated blood glucose)?

Management of Hyperglycemia in Neonates

For a neonate with hyperglycemia (more than 3 readings), you should first adjust the glucose infusion rate, and if hyperglycemia persists above 10 mmol/L (180 mg/dL), initiate insulin therapy at a low starting dose.

Initial Assessment and Measurement

• Blood glucose measurements should preferably be performed using blood gas analyzers for the most accurate results in neonates 1
• Handheld glucose meters have limitations in neonates due to factors such as high hemoglobin levels and high bilirubin levels 1, 2
• Hyperglycemia in neonates is commonly defined as blood glucose level exceeding 10 mmol/L (180 mg/dL) 1

Management Algorithm

Step 1: Adjust Glucose Infusion Rate

• First attempt to control hyperglycemia by reasonable adaptation of the glucose infusion rate 1
• For term neonates, target glucose infusion rate should be 2.5-5 mg/kg/min (3.6-7.2 g/kg/day) on day 1 and 5-10 mg/kg/min (7.2-14.4 g/kg/day) on day 2 onwards 1
• For preterm neonates, target glucose infusion rate should be 4-8 mg/kg/min (5.8-11.5 g/kg/day) on day 1 and 8-10 mg/kg/min (11.5-14.4 g/kg/day) on day 2 onwards 1
• In case of acute illness such as infection or sepsis, temporarily reduce to day 1 glucose infusion rates 1

Step 2: Consider Insulin Therapy

• If hyperglycemia persists with repetitive blood glucose levels >10 mmol/L (180 mg/dL) despite adjustment of glucose infusion rate, initiate insulin therapy 1, 3
• Use insulin at a low starting dose to avoid hypoglycemia 1
• Monitor blood glucose levels frequently after starting insulin to prevent hypoglycemia 4

Important Considerations

• Hyperglycemia >8 mmol/L (145 mg/dL) should be avoided in neonatal ICU patients as it is associated with increased morbidity and mortality 1, 5
• Risk factors for neonatal hyperglycemia include lower gestational age, lower birthweight, severe illness, and higher parenteral glucose intake 3
• Repetitive and/or prolonged hypoglycemia ≤2.5 mmol/L (45 mg/dL) should be avoided as it can lead to adverse outcomes 1, 2
• Insulin therapy in preterm newborns can effectively treat hyperglycemia but increases the risk of hypoglycemia 1, 6

Monitoring During Treatment

• When using insulin, monitor blood glucose levels frequently, especially during the first hours of treatment 4
• Potassium levels should be monitored when administering insulin intravenously due to risk of hypokalemia 4
• Continuous glucose monitoring may help detect clinically silent hypoglycemia in high-risk neonates 5

Pitfalls to Avoid

• Avoid aggressive insulin therapy that may lead to hypoglycemia; start with low doses 1
• Do not reduce glucose infusion rates too drastically as this could lead to calorie deficits with potential adverse effects on growth and neurodevelopment 3
• Be aware that certain conditions like therapeutic hypothermia may be associated with persistent hyperglycemia requiring insulin therapy 7
• Remember that neonatal hyperglycemia can be transient or permanent (as in neonatal diabetes mellitus), requiring different management approaches 8