PEDISCAN PEDISCAN ISSUE IAP BANGALORE - BPS NEWSLETTER 5 MONTHLY JOURNAL OF THE INDIAN ACADEMY OF PEDIATRICS, BANGALORE MAY 2020

Message from the editor

Dear Bengaluru IAPians,

Hope all of you are safe with lockdown being relaxed and free movement of people everywhere. Let us hope we all behave responsibly during this relaxation so that we don’t get into the second wave of corona!!

We had our leading telemedicine corona warriors in Dr. Nalina, Dr. Ramitha, Dr. Vibha, Dr. Nihad, and Dr. Shubha who had volunteered for telemedicine doctor volunteer service to serve the needy, joining hands with the govt of Karnataka.

Amidst the pandemic of corona we are having an epidemic of webinars. Plenty of Neonatal Hypoglycemia topics covered daily from central IAP, BPS, NNF, Hospital chains and even Pharma Dr. Janaki companies. It is a big challenge to choose which one to attend. It’s made a bit easy Definition: with recordings being made available by Central IAP and BPS. The operational threshold for hypoglycemia is defined as that concentration of plasma or whole blood glucose at which clinicians Amidst all this there was the quiet unveiling should consider intervention, Operational threshold has been defined of the bust of Late Dr. DG Benakappa - as plasma glucose level less than 45 mg/dL.Plasma glucose is higher Founder Director of IGICH on the than whole blood glucose by 15% occasion of his birthday on 18th May, at the premises of IGICH. It was a bit WHO defines hypoglycemia as BGL of less than 45 mg/dL. disappointing for many of us as we could not attend the function due to lockdown but still all of us are immensely pleased. Fetal Glucose Metabolism: Maternal glucose is the only source of fetal glucose. Baseline fetal We bring out this edition of Pediscan with blood glucose is 60-70% of maternal serum glucose. an article on Neonatal Hypoglycemia by Dr. Janaki and another one from Dr. Shubha Badami to keep our reader’s thirst Glucose metabolism after birth: quenched. There is Cessation of maternal glucose supply and blood glucose is as low as 30mg/dl within 1-2hrs after birth are common in normal Keep yourselves safe! newborns and is termed as transitional hypoglycemia.It occurs in upto Thank you 10% of normal newborns and represents normal physiological adaptation to postnatal life. Subsequently, the newborn must rapidly respond by glycogenolysis of hepatic stores, inducing Dr Chidananda N K gluconeogenesis, and utilizing exogenous nutrients from feeding to Editor- Pediscan 2020 maintain adequate glucose levels.

1 Neonatal Hypoglycemia | Dr. Janaki Pediscan, May 2020

AAP SCREENING GUIDELINES OF AT RISK Who do not require screening? NEWBORNS Screening for hypoglycemia is not recommended in 1. Birth weight infants (<2000 grams) term healthy breast-fed appropriate-for-gestational age 2. Gestational age(≤35 weeks) (AGA) infants. 3. Small for gestational age infants (SGA): birth weight <10th percentile Method of blood glucose level estimation: 4. Infant of diabetic mothers (IDM) Laboratory diagnosis: This is the gold standard 5. Large for gestational age (LGA) infants: method. In the laboratory, glucose can be measured by either the glucose oxidase (calorimetric) method or by birth weight > 90th percentile. the glucose electrode method (as used in blood gas & 6. Infants with Rh-hemolytic disease. electrolyte analyzer machine). Blood samples should be 7. Infants born to mothers receiving therapy with terbu- analyzed quickly to avoid erroneously low glucose taline/propranolol/lebatolol/oral hypoglycemic levels.Therefore, samples transported in tubes containing agents. glycolytic inhibitors such as fluoride. 8. Infants with morphological IUGR , with features of fetal under-nutrition such as three or more loose skin folds in thigh and gluteal region, overall decreased subcutaneous fat, and head circumference to chest circumference difference greater than 3 cm. 9. Any sick neonate such as those with perinatal asphyx- ia, polycythemia, sepsis, shock etc, when they are in active phase of illness. 10. Family history of a genetic form of hypoglycemia. 11. Congenital syndromes(e.g Beckwith-Widemann), Point of care (POC) reagent strips (Glucose oxidase abnormal physical features(midline facial malforma- method): Though widely used, glucose estimation by this tions, microphallus). method is unreliable.They are useful for screening 12. Neonates on total parenteral nutrition. purpose but low values should be confirmed by proper laboratory analysis. TIME SCHEDULED FOR SCREENING Recently continuous glucose monitoring sensors have been used in glucose monitoring in newborns.Further Category of infants Time Schedule studies are required about the same. At risk neonates 2, 6, 12, 24, 48, and 72 hrs

Sick infants Every 6-8 hrs Symptoms of hypoglycemia (Infants with sepsis, (individualize as needed) The low blood glucose level may be totally asympto- asphyxia, shock during matic but a smaller proportion of infants with hypoglyce- active phase of illness) mia include -Neurogenic signs and symptoms which originate from activation of the sympathetic nervous Neonates on parenteral Initial 72 h: every 6 to 8 hrs system in response to hypoglycemia, and neuroglyco- nutrition After 72 hr: once a day penic signs and symptoms derived from central nervous system deprivation of glucose. 1. Term infants with poor feeding, presence of inad- Clinical signs of hypoglycemia are variable and may equate lactation or presence of cold stress may be include stupor, jitteriness, tremors, apathy, episodes of considered for screening on an individual basis cyanosis, convulsions, intermittent apneic spells or 2. Infants exhibiting signs compatible with hypogly- tachypnea, weak and high pitched cry, limpness and cemia at any time also need to be investigated lethargy, difficulty in feeding, and eye rolling. Episodes 3. Educate and counsell caregivers regarding the of sweating, sudden pallor,hypothermia and cardiac screening, ensure parental participation in monitoring. arrest have also been reported.

2 Neonatal Hypoglycemia | Dr. Janaki Pediscan, May 2020

DIAGNOSIS The bolus should be followed by continuous glucose • Asymptomatic hypoglycemia is said to be present infusion at an initial rate of 6-8 mg/kg/min. BGL should when BGL is less than 45 mg/dL (to be confirmed by checked after 30 to 60 min,and then every 6 hour until laboratory estimation) and the infant does not manifest blood sugar is >50 mg/dL. with any clinical features If BGL stays below 50 mg/dL despite bolus and • Symptomatic hypoglycemia should be diagnosed glucose infusion, glucose infusion rate (GIR) should be if hypoglycemia (BGL is less than 45 mg/dL)coexists increased in steps of 2 mg/kg/min every 15 to 30 min with clinical symptoms. Neonates generally present with until a maximum of 12 mg/kg/min. nonspecific signs that result from a variety of illnesses. After 24 hours of IV glucose therapy, once two or Therefore, careful evaluation should be done to look for more consecutive BGLs are >50 mg/dL, the infusion can all possible causes especially those that can be attribut- be tapered off at the rate of 2 mg/kg/min every 6 hours ed to hypoglycemia. with BGL monitoring. Tapering has to be accompanied by concomitant increase in oral feeds. Once a rate of 4 mg/kg/min of glucose infusion is achieved and oral Management of asymptomatic hypoglycemia intake is adequate and the BGLs are consistently >50 Blood Sugar Management mg/dL, the infusion can be stopped. It is important to ensure continuous glucose infusion Blood sugar 20-45 mg/dL Trial of oral feeds (expressed breast milk or formula) and preferably using an infusion pump and without any inter- repeat blood test after 1 hour. ruption. Do not stop glucose infusion abruptly as severe 1. If repeat BGL is >45 rebound hypoglycemia may occur. Avoid using more mg/dL, two hourly feeds is than 12.5% dextrose infusion through a peripheral vein ensured with 6 hourly due to the risk of thrombophlebitis. monitoring of BGL for 48 hrs. the target blood glucose value is 50 to 120 mg/dL. Recurrent / resistant hypoglycemia 2. If repeat blood sugar is <45 This condition should be considered when infant fails mg/dL, IV Dextrose is started to maintain normal BGL despite a GIR of 12 mg/kg/min and further management is as for symptomatic hypoglyce- or when stabilization is not achieved by 7 days of thera- mia py. Hyperinsulinism is the most common cause of persis- tent hypoglycemia. Blood sugar <20 mg/dL IV Dextrose is started at 6 Critical sample should include - glucose, insulin, mg/kg/min of glucose. Subsequent management is as cortisol, betahydroxybutyrate and free fatty acids. for symptomatic hypoglyce- mia

Oral feeds-issue Direct breast feeding is the best option. If the infant is unable to suck, expressed breast milk may be given. Recently, buccal 40% dextrose gel (200mg/kg) is used for both prevention and treatment of asymptomatic Criteria for diagnosing Hyperinsulinism based on hypoglycemia. “critical” samples 1. Hyperinsulinemia (p.insulin > 2 U/mL) Management of symptomatic hypoglycemia 2. Hypofattyacidemia (p. FFA <1.5 mmol/L) All symptomatic infants should be treated with IV 3. Hypoketonemia (p. β-hydroxybutyrate: <2.0 fluids mmol/L) For symptomatic hypoglycemia including seizures, a 4. Innapropriate glycemic response to 0.1mg/kg bolus of 2 mL/kg of 10% dextrose (200 mg/kg) should IV glucagon at the time of hypoglycemia normally, be given. This mini-bolus helps to rapidly correct BGL. blood glucose level rise > 30mg/dl in 20minutes.

3 Neonatal Hypoglycemia | Dr. Janaki Pediscan, May 2020

Drugs used in management of resistant The infants can be assessed at one month corrected hypoglycemia age for vision / eye evaluation. At 3, 6, 9, 12 and 18 Hydrocortisone 5 mg/kg/day IV or PO in two divid- months corrected age they can be followed up for ed doses-reduces peripheral glucose utilization, growth, neurodevelopment, vision and hearing loss. MRI increased gluconeogenesis, increased glucagon effect at 4-6 weeks provides a good estimate of hypoglycemic Diazoxide can be given orally 5-15 mg/kg/day in injury. three divided doses-potassium channel agonist. Systemic review involving 18 studies concluded that Octreotide -synthetic somatostatin analogue-inhibits there is no good correlation between the two and further insulin secretion in dose of 5-35 µg/kg/day subcutane- well designed good quality studies are needed. ously two to three times a day. • A recent study involving 35 neonates who had Glucagon 0.2mg/kg subcutaneous or intramuscu- symptomatic hypoglycemia showed that 94% of them lar-glycogenolysis, increased gluconeogenesis.Con- had some white abnormalities and on follow up at 18 traindicated in SGA. months of age, 65% of them had demonstrated some impairment in development.

Follow up and outcome Dr. Janaki Special attention should be paid to neuro-develop- Consultant Neonatologist mental outcome, overall IQ, reading ability, arithmetic Rangadore Hospital proficiency and motor performance. Bengaluru, Karnataka

Notes from The Sunnyvale have read and loved in the original small print, sober brown /maroon hard cover! These however score, by Public Library, California, being easy on the eye and senior friendly. The library Summer of 2016 was full of that age category of citizen, me included.

Dr. Shubha Badami

Have been here an hour now. Closing time in another two. The vast library space has large polished dark wood tables, comfortable chairs and lots of natural light.

The table I sit at, has a notice, taped to it 'MATERIALS USE SURVEY IN PROGRESS TODAY. Please do not re- shelve library materials after use. Thank you.' We obey rules here.

So I promptly and artistically arrange ' Blue horses ' I browse happily. Pick up some and carry it to my by the poet Mary Oliver against the notice soon as I was table. One book 'Orchard house' by Tara Austen done reading its amazing imagery. . Weaver promises to be interesting, Jane Austen, Emily I have chosen two field guides on California birds, Bronte, Mary Stewart, Heyer are old favorites I borrow. wildflowers and weeds. And some books on Parenting Keep Rachel Carson and Wendell Berry for next time (no less than five shelves of self-help books on this topic around. alone with multiple copies of the best sellers!) Books in People watching is a pleasant pastime. Around me, the fiction and classics section, in large print with shiny are all kinds of folks sitting at tables or sunk deep in plush jackets, look unfortunately, like frauds, especially those I armchairs reading their books. The sight uplifts. Leisure is

4 Notes from the Sunnyvale Public Library | Dr. Shubha Badami Pediscan, May 2020 deeply defined here… Some with plugged in earphones facilities to photocopy, access to books from sister with music or listening to audiocassettes, others explor- libraries at a request, the numbers one could borrow( a ing stacks in the towering shelves. hundred at a time!) And the smell of books!

Books are kept in perfect order [library- using public Another placard further down this long table asks ' are as responsible] At the click of a mouse, on computers How would you improve Sunnyvale library’. I wished I kept at vantage points catalogues are available. There is could say " 'Hot coffee served at the table with cinnamon a large friendly librarian, willing to nurture your hunger buns! " I must be more hungry than I thought I told myself and dispel all ignorance and trepidation. Idyllic habitat and stepped out with my snack in hand. for a bookworm. When one walks out of the swing doors, the sight of trees in spring bloom, cherry -like pink blossom, and sap green leaves greet you. A cast iron statue of a lounging man with a book adorns the courtyard, that is paved with handsome red brick. Pink roses hang heavy on the bush and cascade down the brick walls that contain the bed. A chorus of evening song birds, some musical, some raucous. Picturesque black wrought iron tables and chairs for those who would read outdoors and snack at the same time. The sun now has long shadows on the lawn as I claim a table.

Balmy sun warming my back, I look around me, as I I am hungry, for food. Clearing throat unobtrusively, munch on my sandwich. The bank of perfect pink roses I peep into my bag. My sandwich awaits my pleasure. nod at me as the stiff evening breeze wafts their Cheese, arugula and slices of sour dough bread. My fragrance in bursts and starts. A gnarled grey trunked inhibited self can’t really eat it here though, even as I see olive tree is profusely hung with pale green flowers. Cars a young thing striding along past me, with a take away come and go at the parking area. A long white public coffee and brown paper bag with something freshly transport bus comes in, levers the platform down to street baked, so fragrant, as she went back to her nook with level and disgorges folk. A bicycle carried on its front her book in the other hand. bonnet, like an antelope with antlers, is unchained and the helmeted passenger is on his way. The library has just The young! downed shutters on time and it seems all the employees, The culture of reading is ingrained from toddlerhood streaming out, are expert cyclists. As I watched, they in these parts it seems. Children are read to sleep efficiently, hung bags, lunch boxes, water bottles onto compulsively. A small one loudly asks her different hooks of their cycles and pedaled away! Some mother'Mommy, may I please post my book into the were in their sixties! I was so happy to see their spirit! hatch now?' and mother says' No, we take it home to read it. ' My daughter arrived to fetch me, beaming indulgently. Compatibly arm in arm, we go to her car, This library is impressive. The cool air-conditioned load the borrowed books into the rear, and my library ambience, the hushed silence broken only by cultured day out has been a lovely one. voices , politeness at the shelves ("excuse me, May I?", when I had dropped a large volume of Dr Miriam Dr Shubha Badami Stoppards’ epic), the polished wooden tables and soft Senior Consultant Pediatrician carpeting, coupled with the sheer volume of books on Rangadore Hospital every topic under the sun, the reference section, the Bangalore, Karnataka

5 Photo Gallery Pediscan, May 2020

PHOTO GALLERY A glimpse into our online webinars

6 Photo Gallery Pediscan, May 2020

Our warriors!

The unveiling of the bust of Late Dr. DG Benakappa

PEDISCAN | Issue 5 | May 2020 7