This handout is for neonatal hypoglycemia. Your care team identified this based on: at-risk neonate (idm / sga / lga / late preterm / perinatal stress) with screening glucose < 2.6 mmol/l (< 47 mg/dl) (adamkin aap 2011 pmid 21357346).
Other reasons your team may use this plan: neonate with jitteriness / tremor / poor feeding / lethargy / hypotonia / seizure + low glucose (thornton pes 2015 pmid 25957977); at-risk demographic — infant of diabetic mother, sga, lga, late preterm (35-36 wk ga) (adamkin aap 2011); family history of congenital hyperinsulinism — high pretest persistent hyperinsulinism (pes 2015).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| feed_first_breast_or_formula | Breastfeed or formula 5-10 mL/kg orally; recheck glucose at 30 min | enteral PO | as soon as hypoglycemia identified if asymptomatic + glucose ≥ 2.0 mmol/L | Adamkin AAP 2011 + Thornton PES 2015 first-line for asymptomatic transitional hypoglycemia; CHYLD NEJM 2015 (PMID 26465984) supports treat-to-2.6-mmol/L approach is safe and effective |
| dextrose 10% (oral gel) | Dextrose 40% oral gel 200 mg/kg (=0.5 mL/kg) buccal massage; may repeat × 1 in 30 min | buccal_oral_gel | single dose, repeat × 1 if needed | Sugar Babies trial (Harris Lancet 2013 PMID 24075361) — reduced NICU admission for asymptomatic late-preterm / term hypoglycemia; first-line adjunct to feeding |
| dextrose 10% (D10W IV bolus) | D10W 2 mL/kg IV bolus (=200 mg/kg dextrose) over 1-2 min; recheck glucose at 15-30 min | IV | single bolus; may repeat × 1 | PES 2015 + Adamkin AAP 2011 — symptomatic or refractory hypoglycemia requires immediate IV correction; CHYLD demonstrated treat-to-2.6-mmol/L is neurodevelopmentally safe (NEJM 2015 PMID 26465984) |
| dextrose 10% (D10W continuous IV infusion) | D10W IV infusion at GIR 6-8 mg/kg/min after bolus; escalate by 2 mg/kg/min q15-30 min PRN to keep POG ≥ 3.3 mmol/L | IV continuous | continuous | PES 2015 GIR escalation; GIR > 8 mg/kg/min is hyperinsulinism red flag |
| diazoxide | diazoxide 8-15 mg/kg/day PO divided TID; titrate to glucose response over 48-72 h | PO | TID | PES 2015 first-line for diazoxide-responsive hyperinsulinism; activates KATP channels to inhibit insulin secretion; fluid retention common (often co-give furosemide / chlorothiazide). Lactation: limited data; monitor breastfed infant for glucose and edema |
| glucagon | glucagon 0.2 mg/kg SC/IM/IV; OR continuous infusion 5-20 mcg/kg/h if persistent | SC/IM/IV (single dose) or IV continuous | single salvage dose, then bridge while IV access secured; continuous if hyperinsulinism | Counter-regulatory bridge; requires glycogen stores so less reliable in SGA / prolonged hypoglycemia; PES 2015 + Neofax 2024 |
| octreotide | octreotide 5-25 mcg/kg/day SC divided q6h; may use continuous IV infusion at same total daily dose | SC q6h or IV continuous | q6h or continuous | PES 2015 second-line for diazoxide-unresponsive hyperinsulinism; risk of NEC (especially in preterm) and tachyphylaxis after days; bridge to pancreatectomy in focal forms |
| hydrocortisone | hydrocortisone 5-10 mg/kg/day IV divided q6h (= 1.25-2.5 mg/kg/dose) | IV q6h | q6h | PES 2015 for suspected AI; replaces deficient cortisol + counter-regulatory support. Lactation: compatible — low-dose physiologic hydrocortisone is one of the most-compatible glucocorticoids for breastfeeding (LactMed; AAP Section on Breastfeeding 2022) |
Plan: Neonatal hypoglycemia — feed-first → IV dextrose → hyperinsulinism / AI agents (PES 2015 PMID 25957977; Adamkin AAP 2011 PMID 21357346; CHYLD NEJM 2015 PMID 26465984; Sugar Babies Lancet 2013 PMID 24075361)
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.
Guideline: Thornton PS et al — PES 2015 Recommendations for Persistent Hypoglycemia in Neonates / Infants / Children (J Pediatr 2015 PMID 25957977); Adamkin AAP 2011 Postnatal Glucose Homeostasis (Pediatrics 2011 PMID 21357346); CHYLD (McKinlay NEJM 2015 PMID 26465984) supports treat-to-2.6-mmol/L is safe; Sugar Babies (Harris Lancet 2013 PMID 24075361) for buccal dextrose gel adjunct.