12-phase flow (12)

1. 1FRAME
   Frame by postnatal age (transitional <48 h vs persistent >48 h per PES 2015), GA cohort (late preterm 35-36 wk vs term), birth weight percentile (SGA <10th, LGA >90th).
   inputs: gestational_age_weeks, birthweight_grams_and_percentile, postnatal_age_hours
   advance: Cohort + postnatal age + percentile classified
2. 2ENTRY
   Identify trigger: at-risk cohort screening (IDM, SGA, LGA, late preterm) at predefined intervals OR symptomatic hypoglycemia (jitteriness, lethargy, poor feeding, seizure) OR persistent low glucose beyond 48 h.
   inputs: plasma_or_point_of_care_glucose, jitteriness_or_tremor_or_seizure
   advance: Hypoglycemia confirmed (POC + plasma confirmation if low)
3. 3CONTEXT
   Maternal diabetes status + medication exposure (oral hypoglycemics, beta-blockers); perinatal stress (asphyxia, sepsis, hypothermia); feeding history (BF / formula / NPO); family history of hyperinsulinism or hypopituitarism.
   inputs: maternal_diabetes_status, perinatal_stress_asphyxia_sepsis_hypothermia, family_history_congenital_hyperinsulinism, temperature_neonate
   advance: Risk context documented
4. 4RED_FLAGS
   Symptomatic hypoglycemia (jitteriness + lethargy + seizure) → IV D10W bolus immediately regardless of degree of hypoglycemia. Refractory hypoglycemia despite GIR ≥ 10 mg/kg/min → hyperinsulinism vs adrenal insufficiency workup. Severe / prolonged hypoglycemia → neurologic monitoring + neurodevelopmental follow-up.
   inputs: jitteriness_or_tremor_or_seizure, plasma_or_point_of_care_glucose
   advance: Red flags addressed; IV access secured; first dose of glucose given
5. 5INITIAL_WORKUP
   POC glucose with plasma confirmation if low. Feed-first attempt if asymptomatic + glucose ≥2.0 mmol/L (≥36 mg/dL). Buccal dextrose gel 200 mg/kg as adjunct to feeding per Sugar Babies (Harris Lancet 2013 PMID 24075361). IV D10W 2 mL/kg bolus if symptomatic OR refractory to feed/gel. Recheck glucose 30 min after intervention.
   inputs: plasma_or_point_of_care_glucose, cbc_with_diff_neonate
   actions: panel.cbc
   advance: First intervention given + glucose rechecked
6. 6BRANCHING_WORKUP
   Critical sample at hypoglycemia event (insulin, C-peptide, BHB, FFA, lactate, ammonia, cortisol, GH) per PES 2015 for refractory or persistent cases. Genetic panel (ABCC8, KCNJ11, GLUD1, GCK, HNF4A) if hyperinsulinism. Sepsis workup if perinatal stress. Echo if cardiac anomaly suspected.
   inputs: critical_sample_at_hypoglycemia_event, serum_sodium_neonate, blood_culture
   actions: panel.hormone
   advance: Source-directed branches resolved or empirically covered
7. 7DIFFERENTIAL
   Transitional hypoglycemia (<48 h, resolves with feeding). Hyperinsulinism (high insulin + low BHB / FFA at hypoglycemia; congenital / IDM / Beckwith-Wiedemann / perinatal stress). Adrenal insufficiency (congenital adrenal hyperplasia, primary AI). Hypopituitarism (low cortisol + low GH). Inborn errors of metabolism (organic acidemias, fatty acid oxidation defects, glycogen storage disease). Sepsis. Hypothermia. Polycythemia. Drug exposure (maternal beta-blocker, oral hypoglycemic).
   advance: Mimics excluded or co-managed
8. 8RISK_STRATIFICATION
   Transitional (<48 h, mild, asymptomatic, responds to feeding) — outpatient / well-baby with serial monitoring. Symptomatic OR refractory OR persistent (>48 h) — NICU + critical sample + endocrinology consult. Hyperinsulinism vs AI vs metabolic — labs + critical sample drive treatment selection.
   inputs: plasma_or_point_of_care_glucose
   advance: Severity tier + etiology hypothesis documented
9. 9TREATMENT
   Feed-first if asymptomatic + glucose ≥2.0 mmol/L. Buccal dextrose gel 200 mg/kg as adjunct (Harris 2013 PMID 24075361). D10W 2 mL/kg IV bolus if symptomatic / refractory. D10W GIR 6-8 mg/kg/min IV; escalate by 2 mg/kg/min q15-30 min PRN to keep POG ≥ 3.3 mmol/L (per PES 2015). Diazoxide 8-15 mg/kg/day PO TID for confirmed hyperinsulinism. Glucagon 0.2 mg/kg SC/IM/IV for emergency salvage (max 1 mg). Octreotide 5-25 mcg/kg/day SC q6h for refractory hyperinsulinism. Hydrocortisone 5-10 mg/kg/day IV q6h for suspected adrenal insufficiency.
   inputs: birthweight_grams_and_percentile, plasma_or_point_of_care_glucose
   advance: First-line intervention in; recheck glucose at 30 min; escalation tier ready
10. 10DISPOSITION
    Well-baby unit (inpatient) for transitional hypoglycemia + adequate feeding + sustained glucose ≥2.6 mmol/L. NICU (icu) for refractory / symptomatic / persistent hypoglycemia + escalating IV dextrose + diazoxide / octreotide / hydrocortisone. Discharge with home-glucose-monitoring plan + endocrinology follow-up for confirmed hyperinsulinism.
    inputs: plasma_or_point_of_care_glucose
    advance: Disposition + level of care assigned
11. 11MONITORING
    Glucose pre-feed × first 24-48 h (every 3 h initially). After resolution, q4-6h × 24 h. Critical sample at any hypoglycemic event during workup. Continuous monitoring if hyperinsulinism on diazoxide / octreotide. Discharge criteria: ≥4 consecutive pre-feed glucose ≥2.6 mmol/L without intervention.
    inputs: plasma_or_point_of_care_glucose
    advance: Sustained euglycemia × 24 h without intervention
12. 12FOLLOWUP
    Pediatric endocrinology referral for confirmed hyperinsulinism, AI, hypopituitarism, or metabolic disorder. Neurodevelopmental follow-up at 6-12-24 mo (Bayley III) if severe / symptomatic / prolonged hypoglycemia. Hearing screen + family education on hypoglycemia warning signs + home glucose monitoring if discharged on diazoxide / octreotide.
    advance: Outpatient endocrine + neurodev follow-up scheduled