新生兒低血糖
BACKGROUND and PATHOPHYSIOLOGY: Glucose is the major energy source for背景與病理生理學：
胎兒和新生兒主要能量來源為葡萄糖 fetus and neonate.。The newborn brain depends upon glucose almost exclusivel新生兒的大腦幾乎完全依靠葡萄糖，Up 90% of total glucose used is consumed by the br90％的總用葡萄糖消耗的大腦。 Alternate fuels ( eg , ketone
替代燃料（ 例如...，酮，乳酸）的生產量非常低。lactate) are produced in very low quantThe usual rate of glucose utilization is 4通常的速度對葡萄糖的利用是 4-8毫克/公斤/分鐘 。出生時葡萄糖調節機制是緩慢的。因此，嬰兒容易低血糖葡萄糖需求增加時 ，或當外源或內源性葡萄糖供應是有限的 。嚴重或長期低血糖可能導致長期的神經損傷。
mg/kg/min Glucose regulatory mechanisms are sluggish at birtThus, the infant is定義：
低血糖在出生後的頭幾天是指血糖<40毫克/分升。而mg/dL. In preterm infants, repeated blood glucose levels below 50 mg/dL may be associated早產兒，反覆血糖值低於50毫克/分升可能是與神經發育延遲有相關。
with neurodevelopmental desusceptible to hypoglycemia when glucose demands are increased or when exogor endogenous glucose supply is limited . Severe or prolonged hypoglycemia mresult in long term neurologic damaDEFINITION: Hypoglycemia in the first few days after birth is defined as blood glucose <40
ETIOLOGY: conditions associated with an increased risk for neonatal hypoglycemia include:病因：
相關條件與新生兒低血糖的風險增加，包括：
1.1、Decreased substrate availabilit減少基質可用性：
•Intra-uterine growth retardation •子宮內發育遲緩
•Glycogen storage disease •肝醣儲積症
•Inborn errors ( eg , fructose intolerance) • Prematurity •遺傳的失誤（例如 ，左旋糖不耐）
•早產兒
•Prolonged fasting without IV glucose •長期禁食沒有靜脈輸注葡萄糖
2.2、Hyperinsulinemia:高胰島素血症：
•Infant of diabetic mother •糖尿病母親的嬰兒
•Islet cell hyperplasia •胰島細胞增生
•Erythroblastosis fetalis •胎兒紅血球增多症
•Exchange transfusion •換血
•Beckwith-Wiedemann Syndrome •貝克威思- Wiedemann症候群
•Maternal ß-mimetic tocolytic agents •產婦β-凝似宮縮劑
•”High” umbilical arterial catheter •“高”臍動脈導管
•Abrupt cessation of IV glucose •靜脈輸注血糖突然停止
3.3、Other endocrine abnormalities其它內分泌異常：
•Pan-hypopituitarism •泛垂體功能低下
•Hypothyroidism •甲狀腺功能減退症
•Adrenal insufficiency •腎上腺功能不全
4.4、Increased glucose utilization增加葡萄糖的利用：
•Cold stress •冷壓力
•Increased work of breathing •提高呼吸功
•Sepsis •敗血症
•Perinatal asphyxia •周產期窒息
5.5、Miscellaneous conditions:多方面的情況：
•Polycythemia •紅血球細胞增多症
•Congenital heart disease •先天性心臟病
•CNS abnormalities •中樞神經系統異常
SIGNS AND SYMPTOMS of hypoglycemia are nonspecific and include: jitteriness,低血糖的症狀及徵候是沒有特異性，其中包括： 悸動， irritability, lethargy, seizures, apnea, grunting and sweating (uncommon易怒，嗜睡，抽搐，呼吸暫停，呻吟聲和出汗（罕見）。 Hypoglycemic低血糖infants may not always be symptomatic. Therefore, routine glucose monitoring for at-risk的嬰兒可能不是有症狀的。因此，高風險的嬰兒規則的監測血糖是必須履行的infants is mandatory.。 Lack of symptoms does not guarantee absence of long term sequelae.症狀的不足並不能保證沒有長時期缺乏的後遺症。
DIAGNOSTIC WORKUP: Specimens for measurement of glucose should be obtained from診斷檢查：
測量血糖標本應從足跟穿刺，靜脈穿刺，留置導管或從一個不具有葡萄糖注入其中獲得heelstick, venipuncture, or from an indwelling catheter that does not have glucose infusing in it.。
154SCREENING OF AT RISK INFANTS危險性嬰幼兒的篩檢:：
低血糖危險性的Infants at risk for hypoglycemia should be screened嬰兒，血糖儀篩檢by measuring blood sugar by Glucometer at ages 1, 2, 4, 6, 9 and 12h .測量血糖的年齡在1，2，4，6，9和12小時。 假如血糖是穩定的Less frequent沒有頻繁測量是適當的。無論如何，在極早產兒應持續的監測和more frequent measurements may be needed until blood glucose is stable >40 mg/dL or >50更頻繁地測量，可能需要直到血糖穩定> 40毫克/分升或> 50measurements are appropriate if blood glucose is stable. However continued surveillance and毫克/分升。
MANAGEMENT OF HYPOGLYCEMIA:低血糖症的控制：
• Glucometer reading >40 mg/dL and infant is feeding normally: follow usual nursery • 血糖測量顯示大於40毫克/分升和嬰兒正常的餵食：按照通常的新生兒室的protocol.議定。
• Glucometer reading 20-40 mg/dL , infant is term and is able to feed: • 血糖測量顯示20-40毫克/分升，嬰兒是足月和能夠餵食：
*立刻抽取血液測血糖-Draw blood for stat blood glucose.。
-Feed 5 mL/kg of D5W. *餵食5毫升/公斤D5W。
-Repeat blood glucose or Glucometer 20 min after feeding. *餵食20分鐘後重複測得血糖或血糖測量。
• Glucometer reading: (a) <20 mg/dL or • 血糖測量顯示：
（1）<20毫克/分升或
(b) <40 mg/dL and NPO or preterm or （2）<40毫克/分升和禁食或早產或
(c) <40 mg/dL after feeding or （3）<40毫克/分升或餵食後或
(d) <40 mg/dL and symptomatic （4）<40毫克/分升且有症狀
-Draw blood for stat glucose measurement. *立刻抽取血液監測葡萄糖。
-Give IV bolus of 2-3 mL/kg of D10W. *給予靜脈推注D10W 以2-3毫升/公斤。
-Begin continuous infusion of D10W at 4-6 mg/kg/min. *開始持續輸注D10W在4-6毫克/公斤/分鐘。
-If infant of diabetic mother, begin D10W at 8-10 mg/kg/min (100-125 cc/kg/d). *如果糖尿病母親的嬰兒，開始D10W在8-10毫克/公斤/分鐘（100至125毫升 /公斤/日）。
-Repeat blood glucose in 20 min and pursue treatment until blood sugar >40 mg/dL. *重複測得血糖在20分鐘和繼續治療，直到血糖> 40毫克/分升。
•For persistent hypoglycemia despite above measures:•對於持續性低血糖，儘管上述措施：
*-Increase rate of glucose infusion stepwise in 2 mg/kg/min* increments up to 12-15葡萄糖輸注率逐步升幅在2毫克/公斤/分鐘*增量可達12-15 mg/kg/min glucose.毫克/公斤/分鐘葡萄糖。 於嬰兒需Use increased volume with caution in infants where volu謹慎使用增量，過量overload is a concern是一個重要的事。 Maximal concentration of glucose in peripheral IV is D12.5.葡萄糖的最高濃度在周圍靜脈是D12.5。
-If infant requires IV dextrose concentrations >12.5%, insert central venous catheter.*如果嬰兒需要靜脈注射葡萄糖含量> 12.5％，需插入中央靜脈導管。
••Do not use D25W or D50W IV or large IV volume boluses as this creates reboun不要使用D25W或D50W 靜脈或大靜脈輸注容量推注 ，因為這造成低血糖回復而hypoglycemia in infants who are hyperinsulinemic.嬰幼兒有高胰島素血症。 In addition, administration of D25W 此外，D25W的管理或 D50W can cause dangerous increase in plasma osmolarity. D50W可能導致危險增加血漿滲透壓。
•If hypoglycemia is not controlled with above measures: Obtain Endocrine Consult to guide•如果低血糖上述措施已無法控制：
獲取內分泌諮詢指導further diagnostic evaluation and management.進一步的診斷評估和管理。 While awaiting consult, send blood (while blood 在等待會診時，發送血液（當血sugar is low) for glucose, plasma cortisol, growth hormone and insulin concentrations.糖是低），葡萄糖，血漿皮質醇，生長激素和胰島素濃度。 Further進一步management may include glucocorticoids, diazoxide, somatostatin or pancreatectomy.管理人員可包括糖皮質激素，二氮，生長抑素或胰腺切除。
• Weaning IV dextrose infusion: When blood glucose has been stable for 12-24 h, begin • 移除靜脈注射葡萄糖輸液：在12-24小時當血糖已經穩定，每3-4個小時1-2毫升/每小時，開始decreasing IV infusion by 1-2 mL/hr q3-4 hours if blood glucose remains ≥60 mg/dL.減少靜脈注射，假如血糖仍維持≥60毫克/分升。
* To calculate rate of glucose administration, use either of the following formulas: *為了計算速度葡萄糖管理，使用下列公式：
% glucose x mL/kg/d = glucose infusion rate (mg/kg/min) ％葡萄糖x毫升/公斤/天÷144=葡萄糖輸注率（毫克/公斤/分鐘）
1
o或
% glucose x mL/h = glucose infusion rate (mg/kg/m％葡萄糖x毫升/小時÷6 ×體重（公斤）=葡萄糖輸注率（毫克/公斤/分鐘）
6 x body weight (