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    Newborn with persistent hypoglycemia


    A full-term male infant was born to a 33-year-old gravida 3, para 3 mother. The prenatal course was uncomplicated, without gestational diabetes; the mother received prenatal care at an out-of-state institution. At the delivery, however, the baby was notably macrosomic, with shoulder dystocia and perinatal distress requiring positive pressure ventilation. 

    The infant’s APGAR scores were 2 and 8 at 1 and 5 minutes, respectively. Birth anthropometrics showed a weight of 4385 grams (>97th percentile); a birth length of 58.5 cm (>97th percentile); and a head circumference of 37.5 cm (~75th percentile). Physical examination was otherwise unremarkable.

    The baby’s initial point-of-care glucose value, obtained from a heel stick sample, at 2 hours of life was 22 mg/dL, with a confirmatory serum glucose of 37 mg/dL. He had no concerning symptoms such as seizures, lethargy, or poor feeding. Despite regular formula feeds, the serum glucose remained in the 40-mg/dL to 49-mg/dL range. An intravenous (IV) dextrose infusion was started with a glucose infusion rate (GIR) of 9 mg/kg/min. At this time, it was presumed that the hypoglycemia was transient, a result of the macrosomia combined with perinatal stress. The baby was evaluated for 48 hours for sepsis; his blood culture ultimately was negative.

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    Over the next 3 days, the dextrose concentration in the patient’s IV fluids was increased. By the third day of life, he was maintained on a GIR of 17 mg/kg/min to keep his serum blood sugar above 60 mg/dL. The differential diagnosis at this time expanded to include: hypopituitarism, adrenal insufficiency, growth hormone deficiency, inborn errors of metabolism, and congenital hyperinsulinism.1 A critical serum sample drawn during a hypoglycemic event of 32 mg/dL on point-of-care testing demonstrated the following: serum glucose, 41 mg/dL; cortisol, 17.6 μg/dL (normal during hypoglycemia, >17 ug/dL); growth hormone, 30.6 ng/mL (normal during hypoglycemia, >8.8 ng/mL); undetectable plasma ketones (fasting normal, 0.2-2.8 mg/dL); undetectable free fatty acids (fasting normal, 0.43-1.37 mmol/L); and insulin, 61 μU/mL (normal during hypoglycemia, <2 μU/mL).

    NEXT: Differential diagnosis

    Edward J Bellfield, MD, MPH
    Dr Bellfield is a pediatric endocrinology fellow at the University of Illinois College of Medicine, Chicago, Illinois.
    Claudia Boucher Berry, MD
    Dr Boucher Berry is assistant professor of Clinical Pediatrics, University of Illinois College of Medicine, Chicago.


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