eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Infant of Diabetic Mother: Treatment & Medication

Author: Charles F Potter, MD, Consulting Neonatologist, Newborn Care Physicians of Southeastern Wisconsin
Coauthor(s): Stephen D Kicklighter, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Neonatology, University of North Carolina at Raleigh and Wake Medical Center
Contributor Information and Disclosures

Updated: Jun 9, 2009

Treatment

Medical Care

Communication between members of the perinatal team is of crucial importance to identify infants who are at highest risk of complications from maternal diabetes. Improved maternal glucose control during the pregnancy and labor improves postnatal glucose adaptation and a decreased need for intravenous (IV) glucose treatment in the infant. A screening policy for hypoglycemia during the hours after birth is necessary to detect hypoglycemia.

• Hypoglycemic management
  • Serum or whole blood glucose levels less than 20-40 mg/dL within the first 24 hours after birth are generally agreed to be abnormal and require intervention. Cornblath et al have made a recommendation critical values of glucose that require intervention.⁵  Determination of plasma or whole blood glucose should be made at the following points:
    • As soon as possible after birth
    • Repeat determinations at 30 min, 1 hr, 2 hr, 4 hr, 8 hr and 12 hr after birth
    • At any time abnormal clinical signs are observed
  • Guidelines based on glucose level
    • Plasma values less than 36 mg/dL (2 mmol/L): Intervention is needed if plasma glucose remains below this level, if it does not increase after a feeding, or if the infant develops symptoms of hypoglycemia.
    • Plasma value less than 20-25 mg/dL (1.1-1.4 mmol/L): IV glucose should be administered, with the target glucose level of more than 45 mg/dL (2.5 mmol/L). This goal of 45 mg/dL is accentuated as a margin of safety. This should include a bolus of dextrose followed by a constant infusion of dextrose. Profound hypoglycemia may require therapy with hydrocortisone.
  • Determining which infants require the highest dextrose administration to maintain euglycemia is difficult. The following suggestions represent a guideline for glucose administration to an infant with hypoglycemia:
    • Immediate IV therapy with 2-mL/kg infusion of dextrose 10% is required in any symptomatic infant with hypoglycemia; dextrose 10% (D10) provides 100 mg/mL of dextrose, and the starting dose is 200 mg/kg of dextrose. Administration over 5-10 minutes is usually recommended because of the high osmolarity. This is especially true for immature infants younger than 32 weeks' gestational age who are at some risk for intracranial hemorrhage. This procedure originally was described as a 2-minute infusion and accomplishes a filling of the glucose space analogous to the volume of distribution of glucose.
    • Maintenance of a continuous infusion of dextrose at an infusion rate of 6-8 mg/kg/min of dextrose is necessary once bolus therapy is complete. Failure to do so may result in rebound hypoglycemia as a result of heightened pancreatic insulin release triggered by the glucose infusion.
    • Frequent serum or whole blood glucose analyses are important to properly titrate the dextrose infusion. Should follow-up glucose levels remain less than 40 mg/dL, the dextrose infusion may be increased by 2 mg/kg/min until euglycemia is achieved.
    • If the infant requires a dextrose concentration more than D12.5 through a peripheral vein at 80-100 mL/kg/d, placement of a central venous catheter may be considered to avoid venous sclerosis. Continued enteral feedings hasten improvement in glucose control because of the presence of protein and fat in the formula. Hydrocortisone therapy may be required for ongoing hypoglycemia.
    • Once the infant's glucose levels have been stable for 12 hours, IV glucose may be tapered by 1-2 mg/kg/min, depending on maintenance of preprandial glucose levels higher than 40 mg/dL.
• Electrolyte management
  • Hypocalcemia and hypomagnesemia may complicate the clinical course.
  • Because low serum calcium levels cannot be corrected in the presence of hypomagnesemia, correction of low magnesium levels is an initial step in the treatment of hypocalcemia.
  • In infants of diabetic mothers (IDMs), calcium and magnesium levels are commonly measured within the first hours after birth. Ideally, ionized levels of these electrolytes should be obtained and used to properly manage these electrolyte disturbances.
  • True symptomatic hypocalcemia is extremely rare in these infants. In most cases, symptoms interpreted to be caused by low calcium or magnesium levels are due to low glucose levels associated with perinatal asphyxia or associated with various CNS problems.
  • Low levels may be treated by adding calcium gluconate to the IV solution to deliver 600-800 mg/kg/d of calcium gluconate. Bolus therapy should be avoided unless cardiac arrhythmia is present. Bolus therapy may result in bradycardia.
• Respiratory management
  • Pulmonary management is tailored to the individual infant's signs and symptoms.
  • Increased ambient oxygen concentrations may be required to maintain oxygen saturations higher than 90%, transcutaneous oxygen tensions at 40-70 mm Hg, or arterial oxygen tensions at 50-90 mm Hg.
  • When an inspired oxygen concentration (FiO₂) higher than 40% is required, the most important task is to determine a precise diagnosis of the cause for the hypoxemia and administration of therapy appropriate for the underlying pathophysiology.
• Cardiac management
  • If signs of congestive heart failure or cardiomyopathy with cardiomegaly, hypotension, or significant cardiac murmur are observed, echocardiographic evaluation is essential to distinguish among cardiac anomalies, septal hypertrophy, and/or cardiomyopathy.
  • Once a precise diagnosis is available, management of the cardiac disorder is no different for the infant of a diabetic mother than for any other newborn with a similar cardiac condition. Extreme care in the use of cardiotonic agents is important in the presence of any hypertrophic cardiomyopathy or significant septal hypertrophy. These infants are at risk of actual decreased left ventricular output resulting from this form of therapy. Beta-blockers such as propranolol may be used to relieve the outflow obstruction that is seen with septal hypertrophy.
• Congenital anomalies: A precise and complete diagnosis is an essential prerequisite to proper care.

Consultations

• Because of the frequency with which cardiac problems occur in these infants, early consultation with a pediatric cardiologist often is necessary.
• Other consultations depend on which other congenital malformations or complications are present.

Medication

Treatment is mainly focused on management of hypoglycemia and electrolyte abnormalities.

Minerals

True symptomatic hypocalcemia is rare in these infants. Intravenous (IV) calcium or magnesium is indicated for acute treatment to correct symptomatic low serum levels. Hypomagnesia must be corrected prior to correction of hypocalcemia.

Calcium gluconate (Kalcinate)

Used by some clinicians to correct hypocalcemia (serum ionized calcium level <4 mg/dL or serum total calcium level <8 mg/dL). The 10% IV solution provides 100 mg/mL of calcium gluconate that equals 9 mg/mL (0.46 mEq/mL) of elemental calcium.

Calcium chloride

Rarely used in pediatric patients due to vascular irritation and extravasation risk. Used by some clinicians to correct hypocalcemia (serum ionized calcium level <4 mg/dL or serum total calcium level <8 mg/dL). The 10% IV solution provides 100 mg/mL of calcium chloride that equals 27.2 mg/mL (1.4 mEq/mL) of elemental calcium.

Magnesium sulfate

Used to correct low levels of serum ionized or total magnesium prior to correcting hypocalcemia. Cofactor in enzyme systems involved in neurochemical transmission and muscular excitability. Magnesium sulfate 1 g equals 98 mg elemental magnesium (8.12 mEq or 4.06 mmol elemental magnesium).

Dextrose

Emergent need to elevate blood glucose requires IV dextrose.

Dextrose

Parenterally injected dextrose is used in patients unable to sustain adequate PO intake. Direct PO absorption results in a rapid increase in blood glucose concentrations. Dextrose is effective in small doses; no evidence suggests that it causes toxicity. Concentrated dextrose infusions provide higher amounts of glucose and increased caloric intake in a small volume of fluid.

• Search for CME/CE on This Topic »

• Pediatrics, Hypoglycemia (Emergency Medicine)
• Hypocalcemia (Pediatrics: General Medicine)
• Diabetes Mellitus and Pregnancy (Endocrinology)