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Neonatal Hypoglycemia Workup

  • Author: Hilarie Cranmer, MD, MPH, FACEP; Chief Editor: George T Griffing, MD  more...
Updated: Apr 24, 2014

Approach Considerations

Fingerstick glucose levels or bedside testing may lead to overtreatment of hypoglycemia, because the primary error with the chemically treated strips is an underestimation of the serum glucose value.

Serum or plasma glucose levels

Serum glucose level is higher than whole blood glucose level. Whole blood measurements of glucose may underestimate the plasma glucose concentration by approximately 10-15%, because red blood cells (RBCs) contain relatively low concentrations of glucose. Arterial and capillary samples may overestimate the plasma glucose concentration by 10% in nonfasting patients. Hold an extra tube of serum or plasma and refrigerate until laboratory glucose is known.

Serum insulin

When blood glucose is less than 40 mg/dL, plasma insulin concentration should be less than 5 and no higher than 10 µU/mL. This testing may not be available in the emergency department.


Obtain a first voided urine dipstick for ketones. Failure to find large ketones with hypoglycemia suggests that fat is not being metabolized from adipose tissue (hyperinsulinism) or that fat cannot be used for ketone body formation (enzymatic defects in fatty acid oxidation). Send urine for organic acid analysis.

Screening for metabolic errors

Electrospray ionization-tandem mass spectrometry in asymptomatic persons allows earlier identification of clearly defined inborn errors of metabolism. These disorders include aminoacidemias, urea cycle disorders, organic acidurias, and fatty acid oxidation disorders. Earlier recognition of these inborn errors of metabolism has the potential to reduce morbidity and mortality rates in infants with these conditions.[1] This testing may not be available in the emergency department.

Imaging studies

The detection of adenomas by celiac angiography has had limited success. The chance of detecting a tumor blush must be balanced against the potential risk of causing vascular trauma in infants younger than age 2 years. This testing may not be available in the emergency department.

Contributor Information and Disclosures

Hilarie Cranmer, MD, MPH, FACEP Director of Disaster Response, MGH Center for Global Health; Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor, Harvard Medical School and School of Public Health

Hilarie Cranmer, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Massachusetts Medical Society, Physicians for Human Rights, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Michael Shannon, MD, MPH†,to the development and writing of the source article.

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Normal hypoglycemic counterregulation.
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