What is the management for a newborn with seizures due to hypoglycemia?

Management of Neonatal Hypoglycemic Seizures

Activate emergency medical services immediately and administer intravenous glucose as the definitive treatment for a newborn with seizures due to hypoglycemia, as oral glucose is contraindicated during active seizures or altered consciousness. 1

Immediate Seizure Management

During active seizure activity:

• Place the newborn on their side in the recovery position to reduce aspiration risk 1
• Clear the area around the infant to prevent injury 1
• Never place anything in the mouth or attempt to give oral glucose, liquids, or medications during the seizure 1
• Do not restrain the seizing infant 1
• Maintain airway patency and provide high-flow oxygen 1

Emergency activation is mandatory for any newborn with hypoglycemia who has a seizure, cannot swallow, or is in an infant under 6 months of age 1

Glucose Administration Protocol

For newborns with active seizures or altered consciousness:

• Intravenous glucose is the primary treatment since oral administration is contraindicated 1
• Maintain blood glucose >50 mg/dL (2.8 mmol/L) until diagnosis is established 2
• Continuous dextrose infusion should be initiated for symptomatic hypoglycemia 3

Glucagon administration for severe hypoglycemia: 4

• Newborns weighing <20 kg: 0.5 mg (0.5 mL) or 20-30 mcg/kg subcutaneously or intramuscularly
• Newborns weighing ≥20 kg: 1 mg (1 mL) subcutaneously or intramuscularly
• Healthcare providers may administer intravenously under medical supervision
• If no response after 15 minutes, repeat the dose while awaiting emergency assistance
• Once the infant responds and can swallow, provide oral carbohydrates to restore liver glycogen 4

Critical Glucose Thresholds

Intervention is required when: 5

• Single blood glucose measurement <1 mmol/L (18 mg/dL)
• Blood glucose <2 mmol/L (36 mg/dL) that remains low at next measurement
• Single measurement <2.5 mmol/L (45 mg/dL) with abnormal clinical signs (including seizures)

Target glucose levels: 5, 6

• Hypoglycemia is defined as <2.5 mmol/L (45 mg/dL) in newborns
• Repetitive or prolonged hypoglycemia ≤2.5 mmol/L should be avoided due to potential adverse neurodevelopmental outcomes
• Recent evidence suggests neurological injury can occur with glucose <36 mg/dL (<2 mmol/L) 7

Post-Seizure Management

After seizure cessation:

• Monitor hourly capillary glucose, heart rate, respiratory rate, blood pressure, and neurologic status 1
• Repeat laboratory tests (electrolytes, blood glucose, blood gases) every 2-4 hours 1
• Once the infant is awake and able to swallow safely, provide oral carbohydrates to prevent recurrence 1, 4

If the newborn does not return to baseline within 5-10 minutes after seizure stops, this requires emergency medical intervention 1

Investigation for Persistent Hypoglycemia

Neonates requiring dextrose infusion rates >12 mg/kg/min warrant investigation for underlying causes: 3

• Hyperinsulinism
• Hypopituitarism
• Hereditary hepatic enzyme deficiencies
• Fatty acid β-oxidation disorders
• Glycogen storage diseases

Obtain diagnostic tests during spontaneous hypoglycemia: 2

• Blood insulin level
• Cortisol
• Growth hormone
• Urine ketone bodies

Measurement Considerations

Use blood gas analyzers with glucose modules for most accurate measurements in newborns, as handheld glucose meters have significant accuracy concerns due to interference from high hemoglobin and bilirubin levels 5, 8

Long-Term Neurological Risk

Severe hypoglycemia with seizures carries significant neurodevelopmental risk: 9

• Status epilepticus (seizures lasting >5 minutes) occurred in 32% of hypoglycemic neonates in one series
• Epilepsy developed in patients following hypoglycemic status epilepticus, particularly with grey matter lesions
• Recurrent status epilepticus is often triggered by fever after initial hypoglycemic seizure
• Aggressive screening and treatment is recommended to prevent poor neurodevelopmental outcomes 3