NEONATAL METABOLIC PROBLEMS

WILFREDO R. SANTOS, MD.,FPPS

Neonatal Cold Injury

Signs and symptoms:

Apathy, refusal to eat, oliguria, coldness to touch, edema, and redness of the extremities

Temperature between 29.5 35 C Bradycardia, apnea, hypoglycemia, acidosis And massive pulmonary hemorrhage

Treatment of Neonatal Cold Injury

Warming Correction of metabolic disturbances

Complications: Mortality Rate: 25% Brain damage: 10%

Hypoglycemia
Incidence: 8% full term and LGA infants; 15% for SGA infants Definition: < 40 mg/dL Maintain blood glucose level > 40 mg/dL and > 50-60 mg/dL thereafter

Hypoglycemia

Etiology:
1. Increased glucose utilization: Hyperinsulinism a. Infant of Diabetic Mother b. Erythroblastosis c. Islet cell hyperplasia d. Beckwith-Wiedmann Syndrome e. Insulin producing tumors f. B2 sympathomimetics g. Maternal chlorpropamide tx h. Malpositioned UA catheter i. Abrupt cessation of high glucose infusions j. After ET with blood containing high glucose concentration

Hypoglycemia
2. Decreased production/storage of glucose PREMATURITY: Preterm SGA 67% Preterm LGA 38% IUGR: Preterm SGA 67% Post term SGA 18% Inadequate caloric intake

Hypoglycemia
3. Other Causes: a. Perinatal stress- sepsis, shock, asphyxia hypothermia b. Exchange transfusion c. Defects in CHO metabolism d. Endocrine deficiency e. Defects in AA metabolism f. Polycythemia g. Maternal Tx with propranolol prevention of sympathomimetic stimulation of glycogenolysis

Hypoglycemia

1.

DIAGNOSIS: Non-specific symptoms: a. lethargy, apathy and limpness b. apnea c. cyanosis d. weak or high-pitched cry e. seizures, coma f. poor feeding/ vomiting g. tremors, jitteriness, irritability h. asymptomatic

Hypoglycemia
DIAGNOSIS: 2. Capillary blood glucose and reagent strips and glucometer

3. Laboratory Diagnosis: serial random blood glucose level; insulin; cortisol; ACTH; T4; glucagon; AAs; organic acids; ketones; urine reducing substances DIFFERENTIAL DIAGNOSIS: adrenal insufficiency, maternal drug use, heart disease, renal failure, liver disease, CNS disease, metabolic disease, sepsis, asphyxia

HYPOGLYCEMIA
MANAGEMENT: 1. Well infants those with risk factors blood glucose determination early feeding 2. Infants who cannot tolerate oral feeding, are symptomatic or in whom oral feedings do not maintain normal glucose levels a. administer D10W at 2 ml/kg over 1 min. b. GIR at 6-8 mg/kg/min c. Increase dextrosity to 12.5 to 15 d. Hydrocortisone/ Glucagon

Hyperglycemia
DEFINITION: defined as a whole blood glucose level higher than 125 mg/dl or plasma glucose values higher that 145 mg/dl ETIOLOGIES: a. Exogenous parenteral glucose b. Drugs: steroids, caffeine, theophylline, phenytoin and diazoxide c. VLBW (<1000 grams) infants d. stressed preterm infants on mech. Vent. e. Surgical procedures f. Transient neonatal DM g. DM due to pancreatic lesions h. Ingestion of hyperosmolar formula

Hyperglycemia
TREATMENT: 1. VLBW and ELBW (< 800 grams) preterm babies: decrease dextrosity of IVF to D5 and GIR at 4-6 mg/kg/min

2. Exogenous insulin therapy has been used when glucose values exceed 250 mg/dl a. continuous insulin infusion (regular insulin 100 units/ml) 0.01 to 0.10 unit/kg/hour b. subQ insulin 0.10 to 0.20 unit /kg q 6 (rarely used exceot in neonatal diabetes) . Monitor glucose and potassium levels

Hypocalcemia
DEFINITION: defined as a total serum calcium concentration of 7 mg/dl and an ionized calcium concentration of < 4 mg/dl Early-onset hypocalcemia (first 3 days of life) a. preterm newborns b. IDM c. Birth asphuxia

Hypocalcemia
Late onset Hypocalcemia (end of 1st wk) a. Hypoparathyroidism = idiopathic, transient; congenital ( Di George Syndrome) b. Pseudohypoparathyroidism c. Maternal hyperparathyroidism d. Magnesium deficiency

Hypocalcemia

Vitamin D deficiency a. maternal Vit D deficiency b. malabsorption c. maternal anticonvulsant therapy d. renal insufficiency e. impaired enterohepatic circulation f. hepatobiliary disease

Hypocalcemia

Miscellaneous: a. rapid skeletal mineral deposition b. hyperphosphatemia c. hypoalbuminemia d. alkalosis and bicarbonate treatment e. exchange transfusions f. lipid/albumin infusions g. shock or sepsis h. furosemide i. Hypothyroidism j. phototherapy

Hypocalcemia

CLINICAL MANIFESTATIONS: Hypocalcemia increases cellular permeability to sodium ions and increases cell membrane excitability Apnea, seizures, jitteriness, hyperreflexia, stridor, carpopedal spasms, Chvosteks sign

Hypocalcemia

LABORATORY EVALUATION: Monitoring calcium levels

ECG Q-T interval longer than 0.4 seconds (due to prolonged systole) Diagnosis for specific causes of hypocalcemia

Hypocalcemia

TREATMENT: 100 -200 mg/kg of 10% calcium gluconate Precautions: bradycardia; dysrythmia; hepatic necrosis via UA catheter; necrosis of skin and subcutaneous tissues Treat concomittant hypomagnesemia Treat specific causes of hypocalcemia

Hypercalcemia
Increased bone resorption a. Hyperparathyroidism b. Hyperthyroidism c. Hypervitaminosis A d. Phosphate depletion e. Hypophophatasia B. Increased intestinal absorption of calcium a. Hypervitaminosis D b. Variation in Vitamin D content of HMF
A.

Hypercalcemia
DEFINITION: Neonatal hypercalcemia with serum total calcium level > 11 mg/dl or serum ionized calcium level> 5 mg/dl Etiology: The physiologic mechanisms that prevent hypercalcemia and inhibition of PTH and 1,25 (OH)2 D3 synthesis which reduces calcium mobilization from bone, absorption from intestine and reclamation from kidney

Hypercalcemia

PHYSICAL EXAMINATION: a. SGA b. Craniotabes, fractures c. lfin facies d. cardiac murmur (AS, PS) e. SubQ fat necrosis f. Blue discoloration of diaper

Hypercalcemia

a.

b.

c.

d.

LABORATORY EVALUATION: Serum and urine mineral levels (calcium, ionized calcium, phosphorous) Serum hormone levels ( PTH, (OH)D, 1,25 (OH)2 D Serum alkaline phosphatase X-ray of hand/wrist (demineralization, subperiosteal resorption)

Hypercalcemia

1.

TREATMENT:
Emergency medical TX (symptomatic or with calcium levels > 14 mg/dl a. volume expansion with isotonic saline solution b. furosemide c. inorganic phosphates d. glucocorticoids Other therapies: a. low calcium, low vitamin D diet b. calcitonin c. parathyroidectomy

2.

Hypermagnesemia

1.
2. 3. 4.

ETIOLOGY: Maternal MgSO4 treatment Magnesium containing antacids Excessive Mg in parenteral nutrition MgSO4 enemas (contraindicated in the NB)

Hypermagnesemia

1.

2.

3.

DIAGNOSIS: Elevated serum Mg level (N= 1.6 2.8 mg/dl) S/Sx: apnea, respiratory depression, lethargy. hypotonia, hyporeflexia, poor suck, decreased intestinal motility, delayed passage of meconium Aminoglycosides increased risk of respiratory compromised

Hypermagnesemia

TREATMENT: Removal of the source of exogenous Mg IV calcium infusion Begin feedings if with sucking/ intestinal motility Saline enemas/glycerine suppositories

1. 2. 3.

4.

THANK YOU

THANK YOU THANK YOU THANK YOU THANK YOU