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ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 8 - Issue 1 | Jan - Mar 2016

INTRODUCTION

Neonatal hypoglycemia is a frequent metabolic problem in neonatal period. It is especially related to acute neurological

1-3 dysfunction and long term neurodevelopment impairment.Estimates of its incidence depends on the definition of hypoglycemia and the methods of measurement. The overall incidence of hypoglycemia in newborn has is 1.3-5/1000 live births. The definition of neonatal hypoglycemia has remained elusive amongst the text books, pediatricians and experts in this

4-9field. After birth, blood glucose is lower than what was present in utero. This partly stimulates endocrine and metabolic pathways

10-13aiming at adaptation. If this doesn't work due to immaturity, illness or inadequate substrate, it may disturb cerebral function.Severe hypoglycemia is so serious that if not properly treated can cause death or in less severe cases, it may lead to permanent brain damage and neurological sequelae. Thus, the

11treatment of real hypoglycemia is imperative. The incidence of neonatal hypoglycemia is higher in developing countries probably due to high incidence of low birth weight or intrauterine growth retarded (IUGR) babies and inadequate

14,15feeding or poor nursing practices. The probability of hypoglycemia may increase many folds in the presence of certain risk factors i.e. prematurity, small and large for date,

16-18infants of diabetic mothers, etc. Different conditions are in association with neonatal hypoglycemia including poor substrate such as inborn errors, prematurity and intra-uterine growth retardation; hyperinsulinemia as in islet cell hyperplasia, infants of diabetic mother, Beckwith-Wiedemann Syndrome, erythroblastosis fetalis, exchange transfusion, maternal β-mimetic tocolytic agents, abrupt cessation of intravenous glucose and high umbilical arterial catheter; other endocrine abnormalities such as adrenal insufficiency, pan-hypopituitarism, and hypothyroidism; increased glucose utilization as in sepsis, cold stress, , and perinatal asphyxia; increased work of breathing and miscellaneous conditions such as central nervous system

19-21abnormalities, polycythemia and congenital heart disease. This study aims to determine the frequency of neonatal hypoglycemia and its risk factors in neonatal nursery of maternity hospital in Duhok and to determine the leading causes of admission in hypoglycemic neonates.

METHODOLOGY

This cross sectional study included all neonates admitted to neonatal nursery in maternity hospital in Duhok, north of Iraq

st stfor 6 months period from March 1 to September 1 2015. All neonates less than 28 days old who were born in maternity hospital and admitted to neonatal nursery for different reasons

ABSTRACT

OBJECTIVE: To determine the frequency of neonatal hypoglycemia and its underlying risk factors in neonatal nursery of maternity hospital and to determine the leading causes of admission among hypoglycemic neonates.STUDY DESIGN: A cross sectional study.

st stPLACE AND DURATION: The Duration of study was six months from March 1 2015 to September 1 2015 and conducted at The Neonatal Nursery in Maternity Hospital in Duhok, North of Iraq.METHODOLOGY: All neonates admitted to neonatal nursery in maternity hospital during the study were included. Blood glucose was measured by heel stick. Diagnosis of hypoglycemia was made as blood glucose <35 mg/dl, <40 mg/dl and <45 mg/dl at age 1-3 hours, 3-24 hours in > 24 hours respectively. Their data including age, gestational age, weight and weight for gestational age, feeding, Apgar score and the underlying cause of admission. These data were analysed using SPSS 19 to find the clinical significance.RESULTS: Among 342 neonates, 17.78% (n=61) had hypoglycemia. The age of hypoglycemic is 1-2 days in 83.6% (n=51) p=0.075. Of hypoglycemics 19.67% (n=12) were premature p=0.041. Low birth weight was seen in 29.5% (n=18) of hypoglycemic neonate. Large birth weight was seen in 11.47% (n=7) p=0.031 .Of hypoglycemics 13.11% (n=8) had low oxygen saturation SpO2 p=0.106. Only 22.95% (n= 14) of cases started oral feeding p=0.13. In 52.45 %( n= 32) of cases there was a low APGAR p=0.029. The leading underlying diseases in hypoglycemic neonates were transient tachypnea of newborn37.7% (n=23), hypoxic ischemic encephalopathy 32.9 %( n=20) respiratory distress syndrome 13% (n=8) p=0.019.CONCLUSION: Hypoglycemia is common on neonatal nursery. Most common age is 1-2 days. Prematurity, low and high birth weight and low Apgar score are significant factors. The leading causes of admission were transient tachypnea of newborn, hypoxic ischemic encephalopathy and respiratory distress syndrome.KEY WORDS: Neonates, Hypoglycemia, Nursery, APGAR, Aetrology

Correspondence to:Akrem M. AtrushiAssistant Professor of Pediatrics, College of Medicine, University of DuhokNakhoshkhana Road 91014 A M Duhok, IraqEmail: ammt1975@gmail.com

FREQUENCY AND RISK FACTORS OF HYPOGLYCEMIAIN NEONATAL NURSERY IN DUHOK

1AKREM M. ATRUSHI

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were included Exclusion criteria: neonates born in the hospital and didn't need admission to neonatal nursery because of being well and given to mothers were excluded.Blood glucose was measured for all of them by capillary blood that was obtained by heel stick with a reflectance meter (Roche Diagnostics, Mannheim, Germany) then was confirmed by lab test. Diagnosis of hypoglycemia was made as blood glucose <35 mg/dl at age 1-3 hours, less than 40 mg/dl at age 3-24 hours and less than 45 mg/dl in more than 24 hours. Blood was withdrawn from peripheral vein by an aseptic technique and then sent for blood glucose, electrolytes, serum calcium, and complete blood count. Blood cultures and cerebrospinal fluid analysis, chest Xray and echocardiography were done accordingly.

Of hypoglycemic neonates 19.67% (n=12) were premature which is a significant factor. Low birth weight was seen in 29.5% (n=18) of hypoglycemic neonate. Large birth weight was seen in

Of the neonates with hypoglycemia 13.11 %( n=8) had low oxygen saturation SpO2 but this is not a significant factor affecting hypoglycemia. Only 22.95 %( n= 14) of hypoglycemic cases started oral feeding (but this has no significant relation to

All neonates had data including age, gestational age (as assessed from maternal last menstrual period , ultrasound in the first trimester and Dubowitz examination), weight and weight for gestational age( according to the Canadian Perinatal Surveillance System) , feeding, Apgar score and the underlying cause of admission. These data were analysed using SPSS 19 to find the clinical significance where P<0.05 is significant.

RESULTS

The study included 342 neonates. Of them 17.78% (n= 61) had hypoglycemia. The age of neonates with hypoglycemia was in the first 2 days in 83.6% (n=51) of cases but the age was not found to be significant factor as shown in Table – I.

11.47% (n= 7) and both are also significant factors as shown Table – II.

hypoglycemia. In 52.45%(n=32)of cases there was a low APGAR score and this is significantly related to hypoglycemia as shown in Table – III.

P=0.075

(n=342)

51 (14.91%)8 (2.34%)

0 (0%)2 (0.58%)

61 (17.84%)

12 (3.51%)49 (14.31%)

18 (5.26%)36 (10.53%)

7 (2.05%)

8 (2.34%)53 (15.50%)

32 (9.36%)29 (8.48%)

25 (7.31%)256 (74.85%)

115 (33.63%)166 (48.54%)

14 (4.09%)47 (13.74%)

68 (19.88%)213 (62.28%)

89 (26.02%)192 (56.14%)

99 (28.95%)168 (49.12%)

14 (4.09%)

220 (64.33%)48 (14.03%)

5 (1.46%)8 (2.34%

281 (82.16%)

271 (79.24%)56 (16.37%)

5 (1.46%)10 (2.92%)

342

(n=342)

(n=342)

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DISCUSSION

The incidence of hypoglycemia among neonates admitted to the neonatal nursery in this study is 17.78%.This is higher than the results of similar studies where the incidences were 15.2% 22 16 4, 10.38% and 15.15% This indicates that hypoglycemia in . neonates has high frequency. This high frequency could be because of more prevalent risk factors for hypoglycemia in our population. But the incidence is still much lower than other

1 23studies where the incidence was as high as 29.3% and 51% . These differences may be due to variable inclusion criteria, detection method of hypoglycemia, definition of hypoglycemia and sample sizes.Majority of neonates 83.6% developed hypoglycemia in the first two days of life which the most critical period of the life in high risk neonates when counter- regulatory mechanisms are less able to overcome the hypoglycemic tendency . This is comparable to other studies where it was 81.57% in first two

16 23days in one study , 81% in day1 in another and 63.15% in day 1 22in another .

Prematurity was present in 19.67% of cases and is considered a significant risk factor. This is mostly because of immaturity of homeostatic mechanisms and inadequate substrate. This result

1is close to another study where it was 19.05% , higher than in 22 another study 11.9% but much lower than in other studies

24 19where they were 52.8% and 61.5% . These variations are again mostly due to variable definition of hypoglycemia, inclusion criteria, sample size and detection method of hypoglycemia.Low birth weight was present in 29.5% of cases .This is higher

22 16than other studies where they were 23.08% and 14.75% but 1lower than another study34% . Such babies have small size

substrate to help overcome hypoglycemia. Large birth weight causes hypoglycemia through hyperinsulinemia. In this study this was present in 11.47% of cases which is higher than another

1 16 26study 8.3% but lower than other studies 22.22% and 29.3% .

Although not significant, hypoxia was present in 13.11% of cases because oxygen fuels chemical reactions of glycolysis and glycogenolysis. Birth asphyxia reflected as low APGAR score was present in 52.45% of cases which is a significant risk factor since it disturbs homeostatic mechanisms responsible for correction of hypoglycemia. This is much higher than other studies where

16 19the results were 26.86% and 9.6 . Poor management of labor and delayed decision making to do Caesarean section are

25responsible for such a variation .Majority of cases (77.05%) couldn't feed orally and this reflects the severity of hypoglycemia making the patients unable to

1feed. This was present in other studies where it was 72.7% and 445% of cases couldn't feed orally.

Transient tachypnea of newborn (37.7%), hypoxic ischemic encephalopathy (32.9%) and respiratory distress syndrome (13%) were at the top of the list of diseases for which the hypoglycemic neonates were admitted. This is different from other studies where the leading causes were prematurity

19(61.5%), diabetic mother (13.6%) and septicemia (9.6%) While in other studies were hypoxic ischemic encephalopathy (26.86%%) and respiratory distress syndrome(15%) and

16sepsis(15%) and in another the leading causes were 26prematurity, low birth weight and maternal diabetes .

Lack of laboratory facilities made me unable to study the underlying hormonal and metabolic causes of hypoglycemia like hyperinsulinemia and different inborn errors of metabolism which cause hypoglycemia.

CONCLUSION

Hypoglycemia is common among neonates admitted to neonatal nursery. Most of them present in the first two days of life. Prematurity, low and high birth weight and low Apgar score were found significant risk factors. The leading causes of admission were transient tachypnea of newborn, hypoxic

The underlying diseases the neonates with hypoglycemia had were most commonly transient tachypnea of newborn followed by hypoxic ischemic encephalopathy while among neonates without hypoglycemia transient tachypnea of newborn was the

most common followed by respiratory distress syndrome then hypoxic ischemic encephalopathy. There is a significant relation between these causes and hypoglycemia as shown in Table – IV

(n=342)

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ischemic encephalopathy and respiratory distress syndrome.

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