Neonatal hypoglycaemia — structured SAQ (15 marks)

(a) Interpretation and classification (3 marks)

• The operational treatment threshold in the first 48 hours is a blood glucose under 2.6 mmol/L; 1.7 mmol/L is below target for age.^[7]
• This baby is symptomatic (jittery), which makes the hypoglycaemia critical regardless of the absolute value — critical hypoglycaemia is under 1.5 mmol/L, or recurrent (over 3 sequential under target), prolonged (over 48 hours) or symptomatic.^[7]
• Confirmation was correct (blood gas analyser with a short collection-to-analysis interval is a diagnostic validation method); never let confirmation delay treatment.^[7]

(b) Immediate management (5 marks)

The baby is symptomatic, so gel eligibility fails on the asymptomatic criterion — intravenous access is the treatment, with gel and a feed given only while the line is established. ^[7]

• Give 40% glucose gel 0.5 mL/kg (200 mg/kg) massaged into the buccal mucosa, followed immediately by a feed, and recheck the glucose at 30 minutes — while establishing other treatments.^[7][3]
• Eligibility (more than 35 weeks, under 48 hours, oral feeds, asymptomatic, otherwise well): fails here on symptomatic — gel is interim treatment while the line goes in. Dosing ceiling: 2 or fewer in 24 hours, 2 or fewer consecutive and 5 or fewer total in 48 hours.^[7]
• Establish intravenous access (peripheral or umbilical) and commence intravenous dextrose; do not treat critical hypoglycaemia with gel alone. Notify the neonatal team and admit to the neonatal unit; contact Retrieval Services Queensland if required.^[7]
• Collect diagnostic samples before treatment — blood gas with electrolytes, glucose, haemoglobin, haematocrit and lactate; insulin, cortisol, acyl-carnitine profile first; growth hormone next; amino acids, ammonium, pyruvate, beta-hydroxybutyrate; urine metabolic screen after.^[7]

(c) Escalation (4 marks)

Once the glucose is still under target despite a feed, and the baby is critical, intravenous therapy is mandatory. ^[7]

• 10% glucose intravenous infusion at 60 mL/kg/day, or 80 mL/kg/day if symptomatic — calculating the glucose in mg/kg/minute.^[7]
• 10% glucose 1 mL/kg (100 mg/kg) intravenous bolus, repeated if indicated, used sparingly given rebound-hypoglycaemia risk; recheck no later than 30 minutes after the bolus.^[7]
• Glucagon 200 microgram/kg intramuscular or subcutaneous stat if access is difficult or delayed more than 15 minutes; if the baby stays symptomatic or under target after the bolus, urgently give glucagon by the preferred route.^[7]
• Escalation principle: increase fluid volume before concentration (20 mL/kg/day increments to 100 maximum in 24 hours); above 12% goes through a central catheter, umbilical vein catheter or PICC.^[7]

(d) Neurodevelopmental evidence and investigation (3 marks)

• The CHYLD cohort found that neonatal hypoglycaemia, treated to maintain at least 2.6 mmol/L, was not associated with neurosensory impairment at 2 years (risk ratio 0.95) — so treated promptly, the prognosis is reassuring.^[5]
• HypoEXIT showed a lower (2.0 mmol/L) threshold was non-inferior in well, asymptomatic term babies — but this does not extend to the symptomatic or preterm baby, where 2.6 mmol/L remains the standard.^[6]
• Investigate for persistent disease when the glucose infusion rate exceeds 8 mg/kg/minute, or the hypoglycaemia is recurrent, prolonged or refractory — draw the full panel during an episode before treatment, and consider a 6-hour fast test before discharge.^[7]