INFANT OF DIABETIC MOTHER MEDICAL CARE
Category: Child Health
Abstract : Medical Care: • Communication between members of the perinatal team is of
crucial importance to identify infants who are at highest risk of complications
from maternal diabetes. A cost-effective screening policy for hypoglycemia
during the hours after birth is necessary to detect hypoglycemia. •
Hypoglycemic management o It is generally agreed that serum or whole b
Medical Care:
• Communication between members of the perinatal team is of
crucial importance to identify infants who are at highest risk of complications
from maternal diabetes. A cost-effective screening policy for hypoglycemia
during the hours after birth is necessary to detect hypoglycemia.
•
Hypoglycemic management
o It is generally agreed that serum or whole blood
glucose levels less than 20-40 mg/dL within the first 24 hours after birth are
significantly low. Cornblath et al's recent suggestions for approach at
treatment suggest that measurement of the blood glucose level should be
determined, as follows:
1. As soon as possible after birth
2. Within 2-3
hours after birth and before feeding
3. At any time abnormal clinical signs
are observed
o Guidelines based on glucose level
Level less than 36
mg/dL (2 mmol/L): Close surveillance of glucose levels with intervention is
needed if plasma glucose remains below this level, if it does not increase after
a feeding, or if the infant develops symptoms of hypoglycemia.
Level less
than 20-25 mg/dL (1.1-1.4 mmol/L): Intravenous glucose should be administered,
with the target glucose level of more than 45 mg/dL (2.5 mmol/L). This goal of
45 mg/dL is accentuated as a margin of safety. Should the infant be
significantly symptomatic with profound, recurrent, or persistent
hyperinsulinemic hypoglycemia, then a goal of more than 60 mg/dL (3.3 mmol/L)
may be more appropriate.
• It is difficult to determine which infants
require the highest dextrose administration to maintain euglycemia. The
following suggestions represent a guideline for glucose administration to a
hypoglycemic, clinically symptomatic, infant.
o Immediate intravenous therapy
with 2-mL/kg infusion of dextrose 10% (D10 provides 100 mg/mL of dextrose,
starting dose is 200 mg/kg of dextrose) is required in any symptomatic
hypoglycemic infant. Administration over 5-10 minutes usually is recommended
because of the high osmolarity. This is especially true for immature infants
younger than 32 weeks' gestational age who are at some risk for intracranial
hemorrhage. This procedure originally was described as a 2-minute infusion, and
it accomplishes a filling of the glucose space analogous to the volume of
distribution of glucose.
o Maintenance of a continuous infusion of dextrose
at an infusion rate of 6-8 mg/kg/min of dextrose is necessary once bolus therapy
is complete. Failure to do so may result in rebound hypoglycemia as a result of
heightened pancreatic insulin release triggered by the glucose infusion.
o
Frequent serum or whole blood glucose analyses are important to properly titrate
the dextrose infusion. Should follow-up glucose levels remain less than 40
mg/dL, the dextrose infusion may be increased by 2 mg/kg/min until euglycemia is
achieved.
o If the infant requires a dextrose concentration more than D12.5
through a peripheral vein at 80-100 mL/kg/d, placement of a central venous
catheter may be considered to avoid venous sclerosis. Continued enteral feedings
hasten improvement in glucose control because of the presence of protein and fat
in the formula.
o Once the infant's glucose levels have been stable for 12
hours, intravenous glucose may be tapered by 1-2 mg/kg/min, depending on
maintenance of preprandial glucose levels higher than 40 mg/dL.
•
Electrolyte management
o Hypocalcemia and hypomagnesemia may complicate the
clinical course.
o Because low serum calcium levels cannot be corrected in
the presence of hypomagnesemia, correction of low magnesium levels is an initial
step in the treatment of hypocalcemia.
o In IDMs, calcium and magnesium
levels are commonly measured within the first hours after birth. Ideally,
ionized levels of these electrolytes should be obtained and employed to properly
manage these electrolyte disturbances.
o True symptomatic hypocalcemia is
extremely rare in these infants. In most cases, symptoms interpreted to be
caused by low calcium or magnesium levels are due to low glucose levels
associated with perinatal asphyxia or associated with a variety of central
nervous system problems.
o When these low levels are treated, an infusion of
10% calcium gluconate at 2 mL/kg often is administered over 5 minutes (18 mg/kg
of elemental calcium). This treatment has particular hazards because the
hyperosmolal mixture may cause serious tissue necrosis and sclerosis; also,
serious cardiac arrhythmias may occur during the infusion. It is routine in many
centers to monitor the infant's ECG during infusion.
• Respiratory
management
o Pulmonary management is tailored to the individual infant's
signs and symptoms.
o Increased ambient oxygen concentrations may be required
to maintain oxygen saturations higher than 90%, transcutaneous oxygen tensions
at 40-70 mm Hg, or atrial oxygen tensions at 50-90 mm Hg.
o When an inspired
oxygen concentration (FiO2) higher than 40% is required, the most important task
is to determine a precise diagnosis of the cause for the hypoxemia. Principals
of management, which are generally agreed on, are based on monitoring of blood
levels of oxygen and carbon dioxide, as well as their maintenance within
physiologic ranges using the least invasive techniques that are
successful.
• Cardiac management
o If signs of congestive heart
failure or cardiomyopathy with cardiomegaly, hypotension, or significant cardiac
murmur are observed, echocardiographic evaluation is essential to distinguish
among cardiac anomalies, septal hypertrophy, and/or cardiomyopathy.
o Once a
precise diagnosis is available, management of the cardiac disorder is no
different for the IDM than for any other newborn with a similar cardiac
condition. It is imperative to be extremely careful in the use of cardiotonic
agents in the presence of any hypertrophic cardiomyopathy or significant septal
hypertrophy. These infants are at risk of actual decreased left ventricular
output resulting from this form of therapy.
• Congenital anomalies: A
precise and complete diagnosis is an essential prerequisite to proper
care.
Consultations: Because of the frequency with which cardiac problems
occur in these infants, early consultation with a pediatric cardiologist often
is necessary. Because malformations in several organ systems are more common in
IDMs, consultation with appropriate subspecialists often is required.
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