Which of the following best defines neonatal hypoglycemia and its initial management steps in the NICU?

• A. Hypoglycemia is plasma glucose <60 mg/dL; treat with phototherapy.
• B. Hypoglycemia is plasma glucose <20 mg/dL; immediate exchange transfusion.
• C. Hypoglycemia is plasma glucose <40 mg/dL in term infants with symptoms; initial management includes feeds if mild and IV glucose (2 mL/kg of 10% dextrose) if symptomatic or persistent.
• D. Hypoglycemia is plasma glucose <40 mg/dL in term infants with symptoms; management is to withhold feeds.

Answer: (D)

The key idea is how neonatal hypoglycemia is defined in a term infant with symptoms and how to start treatment to rapidly correct the low glucose. In this context, hypoglycemia is defined as a plasma glucose below 40 mg/dL in a term infant who has symptoms. The first step is to restore glucose quickly and safely: if the infant is mild or can tolerate feeding, start with feeds to provide a gentle increase in blood glucose. If the infant is symptomatic or the glucose remains low after feeding, give an IV dextrose bolus to raise the level promptly—2 mL/kg of 10% dextrose is a common initial dose. After the bolus, start maintenance IV fluids with dextrose to keep glucose above a safe range, and recheck glucose promptly to ensure it rises and stays up. Withholding feeds would not correct the problem and could worsen brain energy deprivation, so feeding is not the preferred initial step when hypoglycemia is symptomatic.