|Year : 2014 | Volume
| Issue : 2 | Page : 108-111
Hypoglycemia in newborn in Manipur
Yumkhaibam Premchandra Singh1, Thiyam Romola Devi1, David Gangte1, Thokchom Ibetombi Devi1, Naorem Nabakishore Singh2, Maisnam Amuba Singh1
1 Department of Biochemistry, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Obstetrics and Gynaecology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||18-Sep-2014|
Prof. Maisnam Amuba Singh
Department of Biochemistry, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Background: Glucose is the major source of energy for organ function. Hypoglycemia in neonates with its high brain-to bodyweight ratio is associated with an increased risk of morbidity and mortality. The objective of this study was to determine the frequency and clinical characteristics of hypoglycemia in neonates. Methodology: Cross sectional study conducted at the Department of Biochemistry and Obstetrics and Gynaecology, RIMS, from September 2009 to August 2010. 125 newborns delivered at dept of Obst and gynae RIMS were randomly selected for the cases. Gestational age, birth weight and clinical features were recorded on questionnaire. Blood glucose level was checked and any value less than 40mg/dl was considered as hypoglycemia. Data was analyzed by SPSS version 11. Results: Out of 125 neonates, 19 (15.20%) were found to be hypoglycemic. Hypoglycemia was more common in males 11 (32.7%) of 65 male babies, as compared to females 08 (13.33%) of 60 female babies and was more frequent in first 0-24 hrs of life 12 (63.15%) than at 48-72 hrs 3 (15.78%). Hypoglycemia was present in 06 (23.08%) small-for-gestational age,13 (13.13%) appropriate-for-gestational age. Hypoglycemia was seen in 4 (19.05%) preterm and 15 (14.42%) term babies. Jitteriness was the most common symptom of hypoglycemia in 8 (88.88%) cases of 9 symptomatic hypoglycemic cases. Conclusion: Neonatal hypoglycemia is more common in male babies and occurs in the early neonatal age. Blood glucose estimation is mandatory in neonates with signs and symptoms of hypoglycemia.
Keywords: Hypoglycemia, Neonate, Neonatal hypoglycemia
|How to cite this article:|
Singh YP, Devi TR, Gangte D, Devi TI, Singh NN, Singh MA. Hypoglycemia in newborn in Manipur. J Med Soc 2014;28:108-11
| Introduction|| |
Glucose is the major source of energy for organ function. Although all organs can use glucose, the human brain uses it almost exclusively as a substrate for energy metabolism. Because cerebral glycogen stores are limited, maintenance of adequate glucose delivery to the brain is an essential physiologic function. The high brain-to bodyweight ratio in the newborn results in a proportionately higher demand for glucose compared with the capacity for glucose production than that encountered in the adult, with cerebral glucose use accounting for as much as 90% of total glucose consumption.
Neonatal hypoglycemia is one of the most frequently encountered metabolic abnormalities in newborn infants. Its importance has been greatly emphasized especially in relation to acute neurological dysfunction as well as long term neurodevelopment impairment. ,,, Estimates of the incidence of hypoglycemia in the newborn depend both on the definition of the condition and the methods by which blood glucose concentrations are measured. The overall incidence has been estimated at 1.3-5 per 1,000 live births, but it is higher in at-risk populations.  Around 8% of large-for-gestational-age infants [primarily infants of diabetic mothers (IDMs)] and 15% of preterm infants and infants who have intrauterine growth retardation (IUGR) have been reported as having hypoglycemia; the incidence in the entire population of "high-risk" infants may be as high as 30%. 
The symptomatic response of neonate to low blood glucose is variable with non-specific clinical features including pallor, feeding difficulties, tachypnea, hypotonia, abnormal cry, jitteriness, apnea, coma and convulsions. Hypoglycemia can also be presented without any apparent symptoms- the so called "asymptomatic hypoglycemia" found in neonates at risk of hypoglycemia. ,,,
Aims and objects
As very limited data is available in Indian Manipuri population, this study was done to know the frequency of hypoglycemia in neonates in Manipur and also to determine the common clinical characteristics of hypoglycemia in term and preterm neonates. By early identification of hypoglycemia, the short term as well as long term morbidity can be decreased.
| Materials and Methods|| |
A cross sectional study was conducted at the Department of Biochemistry and Obstetrics & Gynaecology, Regional Institute of Medical Sciences (RIMS), Imphal from September 2009 to August 2010. A case of 125 newborns delivered at Department of Obstetrics and Gynaecology RIMS were randomly selected. Babies born to diabetic mother, mother with gestational diabetes, preclampsia, eclampsia, hypertension, congenital malformed babies, neonatal infections, jaundice babies etc. were excluded. Blood glucose level of the mother was also measured to exclude mother with diabetes mellitus, mother with gestational diabetes.
Detailed history and clinical examinations were carried out and relevant data was collected on pre-designed questionnaire. Blood was collected from umbilical cord at birth and from cubital vein at 24, 48, 72 hours in fluoride vial by aseptic technique for blood glucose measurement. Any blood glucose value less than 40 mg/dl (2.2 mmol/l) was considered as hypoglycemia. 
Babies were categorized as small for gestational age (SGA, birth weight less than tenth centile), average for gestational age (AGA, birth weight between tenth to nineteenth centile) and large for gestational age (LGA, birth weight greater than ninetieth centile) based on fetal growth charts. Gestational age (GA, recorded as completed weeks) was assessed. Birth weight was measured without clothes and recorded in decimal of kilograms. Neonates were classified as pre-term (<37 weeks gestation), term (37-42 weeks) and post term (>42 weeks). Jitteriness was defined as non-jerky, stimulus sensitive fine movements that ceases on grasping the hands and not accompanied by abnormal ocular phenomenon.
Blood glucose was estimated by glucose oxidase-peroxidase (GOD-POD) method as described by David BS, 2001  using kits purchased from Crest Biosystem , Goa, India. Principle: Glucose oxidase (GOD) catalysed the oxidation of glucose in accordance with the following equation:
Glucose + O2 + H2O (GOD) Gluconic acid + H 2 O 2.
H2O2 + Phenol+ 4− aminoantipyrene (PEROXIDASE) Coloured complex + H2O.
The hydrogen peroxide formed in this reaction reacted with 4-aminoantipyrine and 4-hydroxybenzoic acid in the presence of peroxidase (POD) to form N− (− 4-antipyryl) -p-benzo quinoneimine. The addition of mutarotase accelerated the reactions. The amount of dye formed was proportional to the glucose concentration. The absorbance was read at 500 nm in colorimeter. It is an end point method, employing sample volume 0.01 ml,reagent volume 1.00 ml and standard concentration of 100 mg /dl , with linearity up to 500 mg/dl.
Internal quality control was used from pooled blood sample, and this is used to monitor inter assay variations.
Data were entered in computer and analyzed by using SPSS version 11. Descriptive Statistics viz, Mean ± SD was calculated for birth weight and age of babies (in days) along with frequencies in percentages for gender, gestational age (preterm, term and post-term) and clinical characteristics. Chi-square test and independent sample t-test was used to compare gender, gestational age-groups, birth weight categories and age of babies for significance of hypoglycemia. A P-value <0.01 was considered statistically significant.
| Results|| |
Mean age of our study population was 5 + 4.65 days and birth weight 2.8 ± 0.86 kg. Out of 125 neonates, 15.20% were found to be hypoglycemic [Table 1], [Figure 1]. Hypoglycemia was more common in male as compared to female babies (16.92% vs. 13.33%, P < 0.05) [Table 2]. Small for gestational age babies have higher incidence of hypoglycemia (23.08%) [Table 3]. Hypoglycemia was more common in preterm babies [Table 4].
|Table 3: Incidence of hypoglycemia in small for gestational age (SGA) and appropriate for gestational age (AGA) newborn babies|
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Similarly hypoglycemia was more frequent in 0-24 hrs than 48-72 hours after delivery (63.25% vs. 15.78%, P < 0.05) [Table 5]. Symptomatic hypoglycemia was seen in 47.36% of those having hypoglycemia, out of which jitterness constitute 88,8% [Table 6].
|Table 5: Incidence of hypoglycemia in relation to the age of the newborns|
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|Table 6: Signs and symptoms observed in symptomatic hypoglycemic newborns|
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| Discussion|| |
Hypoglycemia in neonates remains a common problem. The association of low blood glucose concentrations and abnormal development has prompted extensive research into the anticipation, clinical presentation and treatment of neonatal hypoglycemia.
Our study confirmed the high frequency of hypoglycemia in neonates especially with signs and symptoms. This high frequency could be because of more prevalent risk factors for hypoglycemia in our population including preterm births, intrauterine growth retardation, sepsis and peri-natal asphyxia.
The frequency of hypoglycemia in neonates was 15.2% in our study. These findings are consistent with those of Lodhi et al. who reported hypoglycemia in 29.1% neonates. They included babies who presented within 06 hours of birth and with known risk factor for hypoglycemia. In a study conducted in Kenya, Osler  reported that 23% of neonates were hypoglycemic, where as Dashti et al. reported 15.1% prevalence of hypoglycemia. In Tehran newborns while Shams et al. reported the frequency of hypoglycemia as 3.5%. Similarly Sasidharan CK et al. reported an incidence of hypoglycemia in 4.1% neonates. The other study  conducted in Turkey reported an incidence of neonatal hypoglycemia in 9.18% neonate. These differences may be due to variable definition of hypoglycemia, inclusion criteria, sample size and detection method of hypoglycemia.
Males were affected more than females in our study (16.99% vs 13.33%), similar results have also been reported in a study conducted by Hamid H and Chishti.  Bell JJ  also reported male predominance in 169 infants (100 males, 69 females).
The risk of hypoglycemia is increased in premature, SGA newborns and neonates born to diabetic mothers. In our study, hypoglycemia was more common in preterm as compared to term babies (19.05% vs. 14.42%). Burdan DR et al. also reported more preterm babies as hypoglycemic than term babies (52.8% vs 45.53%).
Hypoglycemia was present in 23.08% SGA babies in our studies. These findings are consistent with those of J Ho et al. who reported incidence of 34.2% in SGA.
The literature refers to numerous clinical features with low plasma glucose concentration. In our study, we found jitteriness as the most common clinical presentation (88.88%), similar to the findings of PK Misra and B Sharma  who reported 78.6% of jitterness. Asphyxia (66.66%), Convulsion (55.55%), refusal to feed and hypotonia (33.33% each), apnea and tachypnea (11.11% each) are seen in our study. Dashti et al. also reported refusal of feeding as the most frequent symptom (45%). Almost all studies from local and international literature reported these observations with more or less similar percentages as reported in our study.
We found increased incidence of hypoglycemia in early neonatal age 0-24 hours (63.15%). Lucas A et al. and Maayan-Metzger A et al. also reported increased hypoglycemia episodes in early neonatal age. This could be explained on the basis of the fact that newborn glucose levels fall to a low point in the first 1-2 hours of life and then increased and stabilize gradually. Moreover, the risk factors also expose the neonate more to hypoglycemia in the early neonatal period. The number of days on which hypoglycemia occurs is strongly related to reduced mental and motor development scores even after adjustment for a wide range of factors known to influence development.
| Conclusion and Recommendations|| |
Preterm, small or large for gestational age neonates are more prone to develop hypoglycemia. Despite serious and common consequences and years of investigation into its characteristics, the definition of hypoglycemia remains elusive. To prevent the sequelae of hypoglycemia, determination of blood glucose of newborns before the development of clinical sign and symptoms and further study in this field is recommended.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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