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NEONATAL NEONATAL METABOLIC METABOLIC PROBLEMSPROBLEMS
WILFREDO R. SANTOS, MD.,FPPSWILFREDO R. SANTOS, MD.,FPPS
Neonatal Cold InjuryNeonatal Cold Injury
Signs and symptoms:Signs and symptoms: Apathy, refusal to eat, oliguria, coldness to touch,Apathy, refusal to eat, oliguria, coldness to touch,
edema, and redness of the extremitiesedema, and redness of the extremities
Temperature between 29.5 – 35 ‘CTemperature between 29.5 – 35 ‘C
Bradycardia, apnea, hypoglycemia, acidosisBradycardia, apnea, hypoglycemia, acidosis
And massive pulmonary hemorrhage And massive pulmonary hemorrhage
Treatment of Neonatal Cold InjuryTreatment of Neonatal Cold Injury
WarmingWarming Correction of metabolic disturbancesCorrection of metabolic disturbances
Complications:Complications: Mortality Rate: 25%Mortality Rate: 25% Brain damage: 10% Brain damage: 10%
HypoglycemiaHypoglycemia Incidence: 8% full term and LGA Incidence: 8% full term and LGA
infants; 15% for SGA infantsinfants; 15% for SGA infants Definition: < 40 mg/dLDefinition: < 40 mg/dL
Maintain blood glucose level > 40 Maintain blood glucose level > 40 mg/dLmg/dL
and > 50-60 mg/dL thereafterand > 50-60 mg/dL thereafter
HypoglycemiaHypoglycemia Etiology:Etiology:
1. Increased glucose utilization: Hyperinsulinism1. Increased glucose utilization: Hyperinsulinism a. Infant of Diabetic Mothera. Infant of Diabetic Mother b. Erythroblastosisb. Erythroblastosis c. Islet cell hyperplasiac. Islet cell hyperplasia d. Beckwith-Wiedmann Syndromed. Beckwith-Wiedmann Syndrome e. Insulin producing tumorse. Insulin producing tumors f. B2 sympathomimeticsf. B2 sympathomimetics g. Maternal chlorpropamide txg. Maternal chlorpropamide tx h. Malpositioned UA catheterh. Malpositioned UA catheter i. Abrupt cessation of high glucose infusionsi. Abrupt cessation of high glucose infusions j. After ET with blood containing high glucose concentration j. After ET with blood containing high glucose concentration
HypoglycemiaHypoglycemia
2. Decreased production/storage of glucose2. Decreased production/storage of glucose
PREMATURITY: Preterm SGA 67%PREMATURITY: Preterm SGA 67% Preterm LGA 38%Preterm LGA 38%
IUGR: Preterm SGA 67%IUGR: Preterm SGA 67% Post term SGA 18%Post term SGA 18%
Inadequate caloric intakeInadequate caloric intake
HypoglycemiaHypoglycemia
3. Other Causes:3. Other Causes:a. Perinatal stress- sepsis, shock, asphyxiaa. Perinatal stress- sepsis, shock, asphyxia
hypothermiahypothermiab. Exchange transfusionb. Exchange transfusionc. Defects in CHO metabolismc. Defects in CHO metabolismd. Endocrine deficiencyd. Endocrine deficiencye. Defects in AA metabolisme. Defects in AA metabolismf. Polycythemiaf. Polycythemiag. Maternal Tx with propranolol – prevention of g. Maternal Tx with propranolol – prevention of sympathomimetic stimulation of glycogenolysis sympathomimetic stimulation of glycogenolysis
HypoglycemiaHypoglycemia DIAGNOSIS:DIAGNOSIS:1.1. Non-specific symptoms:Non-specific symptoms:
a. lethargy, apathy and limpnessa. lethargy, apathy and limpnessb. apneab. apneac. cyanosisc. cyanosisd. weak or high-pitched cryd. weak or high-pitched crye. seizures, comae. seizures, comaf. poor feeding/ vomitingf. poor feeding/ vomitingg. tremors, jitteriness, irritabilityg. tremors, jitteriness, irritabilityh. asymptomatich. asymptomatic
HypoglycemiaHypoglycemia DIAGNOSIS:DIAGNOSIS:2. Capillary blood glucose and reagent strips and glucometer2. Capillary blood glucose and reagent strips and glucometer
3. Laboratory Diagnosis: serial random blood glucose level; 3. Laboratory Diagnosis: serial random blood glucose level; insulin; cortisol; ACTH; T4; glucagon; AA’s; organic acids; insulin; cortisol; ACTH; T4; glucagon; AA’s; organic acids; ketones; urine reducing substancesketones; urine reducing substances
DIFFERENTIAL DIAGNOSIS: adrenal insufficiency, maternal DIFFERENTIAL DIAGNOSIS: adrenal insufficiency, maternal drug use, heart disease, renal failure, liver disease, CNS drug use, heart disease, renal failure, liver disease, CNS disease, metabolic disease, sepsis, asphyxiadisease, metabolic disease, sepsis, asphyxia
HYPOGLYCEMIAHYPOGLYCEMIA MANAGEMENT:MANAGEMENT:1.1. Well infants – those with risk factorsWell infants – those with risk factors blood glucose determinationblood glucose determination
early feedingearly feeding2. Infants who cannot tolerate oral feeding, are symptomatic or 2. Infants who cannot tolerate oral feeding, are symptomatic or
in whom oral feedings do not maintain normal glucose in whom oral feedings do not maintain normal glucose levelslevelsa. administer D10W at 2 ml/kg over 1 min.a. administer D10W at 2 ml/kg over 1 min.b. GIR at 6-8 mg/kg/minb. GIR at 6-8 mg/kg/minc. Increase dextrosity to 12.5 to 15c. Increase dextrosity to 12.5 to 15d. Hydrocortisone/ Glucagond. Hydrocortisone/ Glucagon
HyperglycemiaHyperglycemia DEFINITION: defined as a whole blood glucose level higher DEFINITION: defined as a whole blood glucose level higher
than 125 mg/dl or plasma glucose values higher that 145 mg/dlthan 125 mg/dl or plasma glucose values higher that 145 mg/dl ETIOLOGIES:ETIOLOGIES:a. Exogenous parenteral glucosea. Exogenous parenteral glucoseb. Drugs: steroids, caffeine, theophylline, phenytoin and b. Drugs: steroids, caffeine, theophylline, phenytoin and
diazoxidediazoxidec. VLBW (<1000 grams) infantsc. VLBW (<1000 grams) infantsd. “stressed” preterm infants on mech. Vent.d. “stressed” preterm infants on mech. Vent. e. Surgical procedurese. Surgical proceduresf. Transient neonatal DMf. Transient neonatal DMg. DM due to pancreatic lesionsg. DM due to pancreatic lesionsh. Ingestion of hyperosmolar formulah. Ingestion of hyperosmolar formula
HyperglycemiaHyperglycemia TREATMENT:TREATMENT:1. VLBW and ELBW (< 800 grams) preterm babies: decrease 1. VLBW and ELBW (< 800 grams) preterm babies: decrease
dextrosity of IVF to D5 and GIR at 4-6 mg/kg/mindextrosity of IVF to D5 and GIR at 4-6 mg/kg/min
2. Exogenous insulin therapy has been used when glucose values 2. Exogenous insulin therapy has been used when glucose values exceed 250 mg/dlexceed 250 mg/dla. continuous insulin infusion (regular insulin 100 units/ml) a. continuous insulin infusion (regular insulin 100 units/ml) 0.01 to 0.10 unit/kg/hour0.01 to 0.10 unit/kg/hourb. subQ insulin 0.10 to 0.20 unit /kg q 6 (rarely used exceot in b. subQ insulin 0.10 to 0.20 unit /kg q 6 (rarely used exceot in neonatal diabetes) . Monitor glucose and potassium levels neonatal diabetes) . Monitor glucose and potassium levels
HypocalcemiaHypocalcemia
DEFINITION: defined as a total serum DEFINITION: defined as a total serum calcium concentration of 7 mg/dl and an calcium concentration of 7 mg/dl and an ionized calcium concentration of < 4 mg/dlionized calcium concentration of < 4 mg/dl
Early-onset hypocalcemia (first 3 days of life)Early-onset hypocalcemia (first 3 days of life)
a. preterm newbornsa. preterm newborns
b. IDMb. IDM
c. Birth asphuxiac. Birth asphuxia
HypocalcemiaHypocalcemia
Late – onset Hypocalcemia (end of 1Late – onset Hypocalcemia (end of 1stst wk) wk)
a.a. Hypoparathyroidism = idiopathic, Hypoparathyroidism = idiopathic, transient; congenital ( Di George transient; congenital ( Di George Syndrome)Syndrome)
b.b. PseudohypoparathyroidismPseudohypoparathyroidism
c.c. Maternal hyperparathyroidismMaternal hyperparathyroidism
d.d. Magnesium deficiencyMagnesium deficiency
HypocalcemiaHypocalcemia
Vitamin D deficiency Vitamin D deficiency
a. maternal Vit D deficiencya. maternal Vit D deficiency
b. malabsorptionb. malabsorption
c. maternal anticonvulsant therapyc. maternal anticonvulsant therapy
d. renal insufficiencyd. renal insufficiency
e. impaired enterohepatic circulatione. impaired enterohepatic circulation
f. hepatobiliary diseasef. hepatobiliary disease
HypocalcemiaHypocalcemia Miscellaneous:Miscellaneous:
a. rapid skeletal mineral depositiona. rapid skeletal mineral depositionb. hyperphosphatemiab. hyperphosphatemiac. hypoalbuminemiac. hypoalbuminemiad. alkalosis and bicarbonate treatmentd. alkalosis and bicarbonate treatmente. exchange transfusionse. exchange transfusionsf. lipid/albumin infusionsf. lipid/albumin infusionsg. shock or sepsisg. shock or sepsish. furosemideh. furosemidei. Hypothyroidismi. Hypothyroidismj. phototherapy j. phototherapy
HypocalcemiaHypocalcemia
CLINICAL MANIFESTATIONS:CLINICAL MANIFESTATIONS:- Hypocalcemia increases cellular permeability Hypocalcemia increases cellular permeability
to sodium ions and increases cell membrane to sodium ions and increases cell membrane excitabilityexcitability
- Apnea, seizures, jitteriness, hyperreflexia, Apnea, seizures, jitteriness, hyperreflexia, stridor, carpopedal spasms, Chvostek’s signstridor, carpopedal spasms, Chvostek’s sign
HypocalcemiaHypocalcemia
LABORATORY EVALUATION:LABORATORY EVALUATION:- Monitoring calcium levelsMonitoring calcium levels
- ECG Q-T interval longer than 0.4 seconds ECG Q-T interval longer than 0.4 seconds (due to prolonged systole)(due to prolonged systole)
- Diagnosis for specific causes of hypocalcemia Diagnosis for specific causes of hypocalcemia
HypocalcemiaHypocalcemia
TREATMENT:TREATMENT:
- 100 -200 mg/kg of 10% calcium gluconate100 -200 mg/kg of 10% calcium gluconate- Precautions: bradycardia; dysrythmia; hepatic Precautions: bradycardia; dysrythmia; hepatic
necrosis via UA catheter; necrosis of skin and necrosis via UA catheter; necrosis of skin and subcutaneous tissuessubcutaneous tissues
- Treat concomittant hypomagnesemiaTreat concomittant hypomagnesemia- Treat specific causes of hypocalcemiaTreat specific causes of hypocalcemia
HypercalcemiaHypercalcemia
A.A. Increased bone resorptionIncreased bone resorptiona. Hyperparathyroidisma. Hyperparathyroidismb. Hyperthyroidismb. Hyperthyroidismc. Hypervitaminosis Ac. Hypervitaminosis Ad. Phosphate depletiond. Phosphate depletione. Hypophophatasiae. Hypophophatasia
B. Increased intestinal absorption of calciumB. Increased intestinal absorption of calciuma. Hypervitaminosis Da. Hypervitaminosis Db. Variation in Vitamin D content of HMF b. Variation in Vitamin D content of HMF
HypercalcemiaHypercalcemia
DEFINITION:DEFINITION: Neonatal hypercalcemia with serum total Neonatal hypercalcemia with serum total
calcium level > 11 mg/dl or serum ionized calcium level > 11 mg/dl or serum ionized calcium level> 5 mg/dlcalcium level> 5 mg/dl
Etiology: The physiologic mechanisms that Etiology: The physiologic mechanisms that prevent hypercalcemia and inhibition of PTH prevent hypercalcemia and inhibition of PTH and 1,25 (OH)2 D3 synthesis which reduces and 1,25 (OH)2 D3 synthesis which reduces calcium mobilization from bone, absorption calcium mobilization from bone, absorption from intestine and reclamation from kidneyfrom intestine and reclamation from kidney
HypercalcemiaHypercalcemia
PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:
a. SGAa. SGA
b. Craniotabes, fracturesb. Craniotabes, fractures
c. Ëlfin” faciesc. Ëlfin” facies
d. cardiac murmur (AS, PS)d. cardiac murmur (AS, PS)
e. SubQ fat necrosise. SubQ fat necrosis
f. Blue discoloration of diaperf. Blue discoloration of diaper
HypercalcemiaHypercalcemia
LABORATORY EVALUATION:LABORATORY EVALUATION:
a.a. Serum and urine mineral levels (calcium, Serum and urine mineral levels (calcium, ionized calcium, phosphorous)ionized calcium, phosphorous)
b.b. Serum hormone levels ( PTH, (OH)D, 1,25 Serum hormone levels ( PTH, (OH)D, 1,25 (OH)2 D(OH)2 D
c.c. Serum alkaline phosphataseSerum alkaline phosphatase
d.d. X-ray of hand/wrist (demineralization, X-ray of hand/wrist (demineralization, subperiosteal resorption) subperiosteal resorption)
HypercalcemiaHypercalcemia
TREATMENT:TREATMENT:1.1. Emergency medical TX (symptomatic or with calcium Emergency medical TX (symptomatic or with calcium
levels > 14 mg/dllevels > 14 mg/dla. volume expansion with isotonic saline solutiona. volume expansion with isotonic saline solutionb. furosemideb. furosemidec. inorganic phosphatesc. inorganic phosphatesd. glucocorticoidsd. glucocorticoids
2.2. Other therapies:Other therapies: a. low calcium, low vitamin D dieta. low calcium, low vitamin D diet
b. calcitoninb. calcitoninc. parathyroidectomyc. parathyroidectomy
HypermagnesemiaHypermagnesemia
ETIOLOGY:ETIOLOGY:
1.1. Maternal MgSO4 treatmentMaternal MgSO4 treatment
2.2. Magnesium containing antacidsMagnesium containing antacids
3.3. Excessive Mg in parenteral nutritionExcessive Mg in parenteral nutrition
4.4. MgSO4 enemas (contraindicated in the NB)MgSO4 enemas (contraindicated in the NB)
HypermagnesemiaHypermagnesemia
DIAGNOSIS:DIAGNOSIS:1.1. Elevated serum Mg level (N= 1.6 – 2.8 Elevated serum Mg level (N= 1.6 – 2.8
mg/dl)mg/dl)2.2. S/Sx: apnea, respiratory depression, lethargy. S/Sx: apnea, respiratory depression, lethargy.
hypotonia, hyporeflexia, poor suck, hypotonia, hyporeflexia, poor suck, decreased intestinal motility, delayed decreased intestinal motility, delayed passage of meconiumpassage of meconium
3.3. Aminoglycosides – increased risk of Aminoglycosides – increased risk of respiratory compromised respiratory compromised
HypermagnesemiaHypermagnesemia
TREATMENT:TREATMENT:
1.1. Removal of the source of exogenous MgRemoval of the source of exogenous Mg
2.2. IV calcium infusionIV calcium infusion
3.3. Begin feedings if with sucking/ intestinal Begin feedings if with sucking/ intestinal motilitymotility
4.4. Saline enemas/glycerine suppositoriesSaline enemas/glycerine suppositories
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