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.^[1]
• 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, prolonged or symptomatic.^[1][2]
• Confirmation was correct (blood gas analyser is a validated method); never let confirmation delay treatment.^[1]

(b) Immediate management (5 marks)

The baby is critical because symptomatic, so gel alone is insufficient — but gel-with-feed and IV access run in parallel. ^[1][3]

• 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.^[1][3]
• Eligibility: at least 35 weeks, under 48 hours old, able to feed orally — met here. Dosing ceiling: no more than 2 doses in 24 hours, 5 total, 2 consecutive.^[1]
• Because the baby is symptomatic, simultaneously establish intravenous access and prepare intravenous dextrose; do not treat critical hypoglycaemia with gel alone.^[1][2]
• Notify the neonatal team and admit to the neonatal unit; collect diagnostic samples before treatment if the hypoglycaemia is recurrent or persistent.^[1][2]

(c) Escalation (4 marks)

Once the glucose is still under target despite a feed, and the baby is critical, intravenous therapy is mandatory. ^[1]

• 10% glucose intravenous infusion at 60 mL/kg/day, or 80 mL/kg/day if symptomatic or not improving.^[1]
• 10% glucose 1 mL/kg intravenous bolus, repeatable once if the glucose remains low; recheck no later than 30 minutes after the bolus.^[1]
• Glucagon 200 microgram/kg intramuscular or subcutaneous if intravenous access is delayed beyond 15 minutes, and intravenously, intramuscularly or subcutaneously if the bolus fails.^[1]
• Escalation principle: increase the glucose infusion rate before the concentration; concentrations above 12% go through a central or umbilical venous line.^[1][2]

(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 in the first 24 hours, or the hypoglycaemia is recurrent, prolonged or refractory — draw insulin, cortisol, ketones, lactate and an acyl-carnitine profile during an episode before treatment.^[2]