Neonatal Metaboloic Problems

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


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


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


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


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


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


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


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


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)


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)


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


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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Neonatal Metaboloic Problems

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