Neonatal Hypoglycemia Nursing Review

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Neonatal hypoglycemia is a condition in which the newborn child has a low blood glucose level. Because glucose is the brain’s primary source of energy, the condition must be recognized quickly and treatment promptly initiated to avoid long-term complications. It is the most common metabolic disturbance in newborns.

Definition of key terms

Glycogen: The stored form of glucose in the body

Gluconeogenesis: The process of creating glucose from components found in fats and proteins

Glycogenolysis: The process by which glycogen is broken down into glucose 

Neonatal hypoglycemia pathophysiology

In normal physiology, the fetus receives a continuous supply of glucose from the mother and does not have to rely on synthesis of glucose for survival. Once the fetus is delivered and the umbilical cord is cut, gluconeogenesis, glycogenolysis, and feeding are required in order to maintain adequate blood glucose levels in the newborn. It’s important to note that even healthy infants can experience temporary hypoglycemia as they adapt to life outside the womb. In healthy infants, this transient hypoglycemia is brief and usually causes no symptoms. 

Risk factors for prolonged neonatal hypoglycemia

Though many infants experience a drop in blood glucose as they transition to extrauterine life, some infants are at higher risk for more significant or prolonged hypoglycemia. This includes:

• Infants born to diabetic mothers
• Late term infants
• Large for gestational age infants (LGA)
• Pre-term infants
• Small for gestational age infants (SGA)
• Infants who experienced intrauterine growth restriction (IUGR)
• Infants experiencing perinatal stress
• Infants whose mothers receive certain medications in the intrapartum period, such as terbutaline or labetalol

Infants born to diabetic mothers and infants who are late-term or large for gestational age are at higher risk for hypoglycemia due to fetal hyperinsulinism and increased peripheral glucose metabolism. Prolonged maternal glucose levels lead to fetal hyperglycemia which causes the fetal pancreas to produce more insulin. This elevated level of insulin persists after the child is born, resulting in hypoglycemia. In addition, infants born to diabetic mothers are not able to sufficiently mobilize glycogen stores after they are born which further exacerbates the low blood glucose levels.

Small for gestational age infants, those who are pre-term, and infants who experienced intrauterine growth restriction are at higher risk for hypoglycemia because they are born with reduced glycogen stores, increased metabolic demands relative to their large brain size, and decreased adipose tissue. In addition, very low birth weight infants have lower levels of enzymes that are involved in gluconeogenesis. 

Infants who experience perinatal stress are at higher risk for hypoglycemia due to increased metabolic demands that can persist for weeks. Some causes of perinatal stress include preeclampsia/eclampsia, fetal distress, infection in the mother, and neonatal hypothermia, among others.

Complications of neonatal hypoglycemia

When hypoglycemia is prolonged, the infant can suffer devastating consequences. This includes long-term neurodevelopmental disabilities, cerebral palsy, brain damage, and even death. 

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L: How does the patient LOOK? What are the signs and symptoms of neonatal hypoglycemia?

While some infants will have transient hypoglycemia that causes no symptoms, it’s important to be on the lookout for symptoms which indicate the infant needs supplemental glucose. Key symptoms include: 

• Irritability, tremors
• Lethargy or coma
• Tachypnea, grunting, periods of apnea, cyanosis
• A high-pitched or weak cry
• Hypotonia, seizures
• Hypothermia
• Difficulty feeding
• Sweating

A: How do you ASSESS the patient?

The most important assessment is to know which infants are at highest risk for hypoglycemia since blood glucose testing is not done routinely on all infants. Much of this information can be obtained through chart review and also by asking the mother questions about her health history. 

Observe all children for signs and symptoms of hypoglycemia, especially those who are at higher risk. Pay particular attention to signs of lethargy, seizure activity, hypothermia or jitteriness as these are common signs of hypoglycemia. 

In addition, you should assess the infant’s feeding patterns, suck strength, latch and duration of feeding. If the child is receiving formula, monitor volume to ensure the child is receiving adequate exogenous glucose from the formula. Delayed or inadequate feeding can precipitate or exacerbate hypoglycemia.

T: What TESTS are utilized for an infant with hypoglycemia?

The key test utilized is the blood glucose level. This is done via a heel-prick blood test using a bedside glucometer. If the blood glucose is lower than the glucometer can read, then a lab draw will be utilized. The infant will require repeated blood glucose testing until the hypoglycemia has resolved.

Other tests that may be utilized in serious or prolonged cases include: 

• Labs – Insulin, cortisol, growth hormone, and glucagon levels may be drawn to determine any underlying endocrine-related causes for hypoglycemia. Lactate and ketone levels may also be done to evaluate metabolic status. Ketones will be present if the infant is using alternative sources of energy when blood glucose levels are low.
• Arterial Blood Gas (ABG) – An ABG can assess for metabolic acidosis in cases of prolonged hypoglycemia.
• Infection workup – If infection is suspected as the underlying cause, tests can include CBC and blood cultures.
• Imaging – If neurological damage is suspected, an MRI or CT scan of the brain may be conducted.

T: What TREATMENTS are utilized in neonatal hypoglycemia?

Protocols can vary from one facility to another, but, in general, infants with blood glucose levels less than 40 mg/dL require prompt treatment to restore adequate glucose levels. 

Treatments typically include:

• Glucose gel, which is administered buccally. This is often the first intervention unless levels are critically low.
• For critically low levels, IV dextrose is administered as a bolus, followed by a continuous dextrose infusion with the goal of maintaining blood glucose levels between 40 and 50 mg/dL. 
• Infants requiring IV dextrose will be admitted to the neonatal intensive care unit (NICU) for close monitoring.
• Possible use of corticosteroids, which increase blood glucose levels by decreasing peripheral utilization of glucose.
• Possible use of glucagon, which is a hormone that stimulates glucose production.

Other key treatments include:

• Early feeding within the first hour of life.
• Increased feeding frequency.
• Formula may be needed for infants who have difficulty breastfeeding due to latching difficulties or poor sucking ability.
• Referral to a lactation consultant as needed.

E: What EDUCATION is provided to the parents?

Any abnormality in a newborn is a significant cause of stress and concern for the parents. You can help lessen this burden by communicating all assessments and interventions in an easy-to-understand way. Key things to teach include: 

• Normal blood glucose levels and what the infant’s levels are.
• The things you are watching for that would alert you to symptomatic hypoglycemia. This can also ensure the parents know to alert you if they notice any of these signs.
• Why it’s important to check blood glucose frequently. Since this does require a heel stick each time, new parents may fear their child is being put through a stressful or painful experience. Assure the parents that this is done for the child’s safety.
• How often the infant should be feeding and how much intake is adequate.
• Tips for successful breastfeeding.
• How to reconstitute formula, if using.
• How to measure the child’s intake, either through amount of time breastfeeding or the volume of formula (or bottle-fed breastmilk) the child receives.

I hope this overview of neonatal hypoglycemia has helped you feel more confident when facing this condition in the clinical setting or on a nursing school exam! For more lessons on Maternal-Newborn topics, click here.

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References:

Abramowski, A., Ward, R., & Hamdan, A. (2024a). Neonatal Hypoglycemia. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537105/

Abramowski, A., Ward, R., & Hamdan, A. H. (2024b). Neonatal Hypoglycemia. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK537105/

Beardsall, K., & Thankamony, A. (2024). Untangling the physiology and pathophysiology of neonatal hypoglycaemia. Archives of Disease in Childhood. Fetal and Neonatal Edition, 109(6), 572–573. https://doi.org/10.1136/archdischild-2024-327009

Cleveland Clinic. (2022, July 13). Glycogen: What It Is & Function. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/23509-glycogen

Editors of Encyclopaedia Britannica. (2024, November 8). Glycogenolysis | Glucose Metabolism, Liver Function & Regulation. Britannica Encyclopaedia. https://www.britannica.com/science/glycogenolysis

Harding, J. E., Alsweiler, J. M., Edwards, T. E., McKinlay, C. J., & Gough, L. (2024). Neonatal hypoglycaemia. BMJ Medicine, 3(1). https://doi.org/10.1136/bmjmed-2023-000544

Infant Feeding Coordinator. (2019, May 13). Protecting your Baby from Low Blood Glucose. Hull University Teaching Hospitals NHS Trust. https://www.hey.nhs.uk/patient-leaflet/protecting-your-baby-from-low-blood-glucose/

National Cancer Institute. (2011, February 2). Definition of gluconeogenesis. National Cancer Institute. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gluconeogenesis

Rosenfeld, E., & Thornton, P. S. (2000). Hypoglycemia in Neonates, Infants, and Children. In K. R. Feingold, B. Anawalt, M. R. Blackman, A. Boyce, G. Chrousos, E. Corpas, W. W. de Herder, K. Dhatariya, K. Dungan, J. Hofland, S. Kalra, G. Kaltsas, N. Kapoor, C. Koch, P. Kopp, M. Korbonits, C. S. Kovacs, W. Kuohung, B. Laferrère, … D. P. Wilson (Eds.), Endotext. MDText.com, Inc. http://www.ncbi.nlm.nih.gov/books/NBK594592/

Stanford Medicine. (n.d.). Hypoglycemia in a Newborn Baby. Stanford Medicine. https://www.stanfordchildrens.org/en/topic/default?id=hypoglycemia-in-a-newborn-baby-90-P01961

The Canadian Preterm Labor Investigators Group. (1992). Treatment of Preterm Labor with the Beta-Adrenergic Agonist Ritodrine. New England Journal of Medicine, 327(5), 308–312. https://www.nejm.org/doi/full/10.1056/NEJM199207303270503

Thompson-Branch, A., & Havranek, T. (2017). Neonatal Hypoglycemia. Pediatrics In Review, 38(4), 147–157. https://doi.org/10.1542/pir.2016-0063

Last Updated on January 27, 2025 by Maureen Osuna, MSN, RN