Nigerian Journal of
Paediatrics 2011;38(2):90-94
ORIGINAL
Dedeke I.O.F
Point-of-admission neonatal hypoglycaemia in a
Okeniyi J.A.O
Nigerian
tertiary
hospital:
incidence,
risk
Owa
J.A
factors and outcome.
Oyedeji G.A
Received: 7 March
2011
Abstract
Background Neonatal
(p = 0.034), admission
weight less
Accepted: 27 June
2011
hypoglycaemia
is
a
major
t h a n
2 5 0 0 g
( p
=
0 . 0 0 9 ) ,
metabolic problem. It
may result in
hypothermia (p = 0.001)
and
I.O.F. Dedeke (
)
mortality or severe
handicap
preterm birth (p =
0.020) were
Department of
Paediatrics,
among survivors. Many
babies
significantly more common
in
Federal Medical
Centre,
admitted for neonatal
care are at
babies with
hypoglycaemia. Poor
Abeokuta,
Nigeria
high risk for
hypoglycaemia. The
suck (p = 0.010),
cyanosis (p =
E-mail:
present study set out
to determine
0.020), convulsion (p =
0.040) and
bisiwunmiddk@yahoo.com
its point-of-admission
prevalence,
pallor (p = 0.048) were
also more
Tel: +234803 4547
231
clinical presentation
and outcome.
common among babies
with
Methods: Consecutive
neonates
hypoglycaemia. The
mortality rate
Okeniyi JAO, Owa
JA
who met the study
criteria had
in babies with
hypoglycaemia was
Department of
Paediatrics and
plasma glucose
determined at
32.7%, higher than
18.8% in babies
Child Health,
Obafemi
admission into the
special care
without hypoglycaemia
but the
Awolowo University,
Ile-Ife,
baby unit of Wesley
Guild
difference was not
statistically
Nigeria
Hospital. Hypoglycaemia
was
significant (p =
0.060).
defined as plasma
glucose of <
Conclusion: Hypoglycaemia
is
Oyedeji GA
2.5mmol/L. Babies with
and
common among high-risk
neonates
Department of
Paediatrics,
without hypoglycaemia
were
and is often associated
with
Ladoke Akintola
University of
compared for risk
factors, clinical
morbidity and
mortality. Routine
Technology, Osogbo,
Nigeria
features and
outcome.
monitoring of blood
glucose is
Results: A
total of
150 neonates
therefore recommended
for this
Ogunlesi TA
were studied out of
which 49
class of babies
Department of
Paediatrics,
(32.7%) had
hypoglycaemia. The
Olabisi Onabanjo
University,
mean age, 38.3 ± 71.6
in hours was
Sagamu, Nigeria
significantly
lower
among
Key
Words:
Prevalence,
Point-
neonates with
hypoglycaemia than
o f - a d m i s s i o n
,
N e o n a t a l
those without
hypoglycaemia [p =
Hypoglycaemia,
Morbidity and
0.006]. Low
socioeconomic class
Mortality,
Nigeria.
Introduction
Outcome of NNH depends
on the rapidity of onset;
associated
co-morbidities and adequacy of therapy.
2
Neonatal hypoglycaemia
(NNH) is one of the most
Long-term sequelae
include poor neurological
common metabolic
problems in contemporary
development, poor
intellectual function, motor
neonatal medicine. It
is defined either as whole
1
deficits (especially
spasticity and ataxia) and seizure
disorders.
3
blood glucose of less
than 2.2 mmol/L or plasma
glucose of less than or
equal to 2.5 mmol/L.
1
Risk factors for NNH
include maternal diabetes
91
mellitus,
corticosteroid administration during
monitoring blood
glucose levels.
pregnancy, toxaemia of
pregnancy, prematurity,
Data analysis was done
using the Computer Package
intrauterine growth
restriction (IUGR), septicaemia,
for Epidemiologists
(PEPI). Tests of statistical
polycythaemia and
erythroblastosis. Other factors
4
significance was done
using Chi-square analysis for
include adverse
perinatal events like prolonged
discreet and Student
t-test for continuous variables
labour, birth asphyxia,
cold stress, severe respiratory
respectively.
Statistical significance was set at p
distress (due to
increased energy utilisation).
4
values less than
0.05.
While several studies
have been done on neonatal
hypoglycaemia in the
developed world, reports from
Nigeria and perhaps
many other developing
countries on NNH are
sparse. Specifically, there has
Results
been no previous
documentation on the prevalence
of neonatal
hypoglycaemia at the Wesley Guild
A total of 150 babies
were studied. They consisted of
Hospital (WGH), Ilesa,
Nigeria, a tertiary health
88 males and 62 females
giving a male: female ratio
facility which had been
in existence for close to a
of 1.42: 1. Table 1
compares the socio-demographic
century. Wesley Guild
Hospital is a unit of the
data
between
babies
with
and
without
Obafemi Awolowo
University Teaching Hospitals
hypoglycaemia. Of the
150 babies studied, 49
Complex, Ile-Ife. The
hospital provides general and
(32.7%) had
hypoglycaemia at the time of admission.
specialist paediatric
care to the adjourning
Of the remaining 101
(67.3%), 93 (92.1%) babies had
communities of at least
four states in Nigeria. The
normal glucose levels
while eight (7.9%) had
objective of the
present study was to determine the
hyperglycaemia (plasma
glucose > 8.3 mmol/l). Of
prevalence, risk
factors, clinical presentations at
the 49 babies with
hypoglycaemia, 29 (59.2%) were
time of admission, and
outcome of NNH in a
males and 20 (40.8%)
were females giving a male:
population of
hospitalized Nigerian newborn babies.
female ratio of 1.45: 1
similar to overall male: female
ratio of 1.42: 1. A
significantly higher proportion [43
(37.1%) of 116] of
babies from lower social class had
Methodology
hypoglycaemia compared
with six (17.6%) of 34
babies from higher
social class (p = 0.034).
This was a prospective
study, conducted over a six-
Ahigher proportion of
referred babies compared with
month period.
Institutional Ethical Clearance and
inborn babies
experienced hypoglycaemia but the
parental informed
consent were obtained. All
difference was not
statistically significant [p = 0.16].
consecutive neonates
admitted into the unit during
Babies who experienced
hypoglycaemia were
the study period were
included except those who had
significantly younger
than their counterparts who did
intravenous infusion of
fluid(s) that contained
not (p = 0.033). The
admission weights ranged
dextrose prior to
admission into the unit.
between 600g and 4,100g
with a mean of 2,100 ±
Information obtained
and entered into a proforma
900g. Hypoglycaemia
occurred in 30 (43.5%) of 69
included demographic
characteristics of the mothers
babies who were of low
birthweight (birth weight less
and their babies, past
medical history and illnesses
than 2,500g) compared
with 19 (23.5%) of 81 who
during pregnancy
especially that of diabetes mellitus
weighed 2,500g or more
[p = 0.009].
and hypertension,
antenatal booking status, the
The gestational age of
babies with hypoglycaemia
mode of delivery,
duration and details of the
ranged between 26 to 44
weeks. Hypoglycaemia was
management of labour
and place of delivery (for
significantly commoner
among preterm babies than
referred babies), birth
asphyxia as well as history of
term babies (p =
0.000). The number of post term
feeding prior to
admission. Anthropometry, rectal
babies was remarkably
smaller than those with
temperature and
clinical features were documented.
normal or low values.
The frequency of
One millilitre of blood
was taken into dry fluoride
hypoglycaemia was more
among post-term than term
oxalate-containing
specimen bottle and immediately
babies but the
difference was not statistically
processed in the
laboratory for plasma glucose
significant (p =
0.071). Hypoglycaemia was recorded
estimation using the
glucose oxidase reaction
more commonly among
twins (13 (41.9%) of 31
method. Other
investigations were done as
compared with 36
(30.1%) of 119 singletons though
indicated.
Hypoglycaemia, for this study was
the difference was not
statistically significant (p =
defined as plasma
glucose of = 2.5 mmol/l. Babies
1
0.217).
with hypoglycaemia were
managed initially with a
Three (6.1%) of the 49
babies were infants of mothers
bolus of 10 percent
intravenous Dextrose-in-water at
with toxaemia of
pregnancy.
2 ml/kg. This was
followed with 10 percent
Dextrose-in-water at a
rate of 6 mg/kg/min (86
ml/kg/24hrs). Babies
who had no contraindications
to oral feeding were
commenced on feeding while
92
Table 1: Comparison of Socio-demographic
Data
Features identified in
hypoglycaemic as well as non-
of Babies with and
without Hypoglycaemia
hypoglycaemic babies.
In comparison however,
Babies with
Babies without
hypoglycaemia was
significantly more commonly
Parameters
hypoglycaemia
hypoglycaemia
Total
Statistics
(49)
(101)
150
associated with poor
suck, cyanosis, convulsions and
pallor.
Age in hrs (mean
±
38.3 (71.6)
106.0 (162.1)
150
t = 2.79,
SD)
p = 0.006
Sex:
Table 2: Comparison
of Clinical
Features among
29 (33.0)
59 (67.0)
88
χ
2
Male
= 0.01,
Babies with and without
Hypoglycaemia.
Female
20 (32.3)
42 (67.7)
62
p = 0.929
Clinical
Babies with
Babies without
χ
2
hypoglycaemia
hypoglycaemia
Total
p value
Social Class:
features
No (%)
No (%)
χ
2
Higher classes I
and
6 (17.6)
28 (82.4)
34
= 4.51,
II
p = 0.034
Floppiness
12 (24.5)
16 (15.8)
28 (18.7)
1.63
0.202
Poor suck
12 (24.5)
9 (8.9)
21 (14.0)
6.65
0.010
Lower classes
III-V
43 (37.1)
73 (62.9)
116
Cyanosis
11 (22.5)
9 (8.9)
20 (13.3)
5.23
0.022
Respiratory
Gestational age
distress
8 (16.3)
28 (27.7)
36 (24.0)
2.35
0.125
(wk):
Convulsions
8 (16.2)
6 (5.9)
14 (9.3)
4.21
0.040
< 37
30 (44.1)
38 (55.9)
68
χ
2
= 7.42,
Pallor
7 (14.3)
5 (5.0)
12 (8.0)
3.91
0.048
p = 0.006
High pitched
6 (12.2)
4 (4.0)
10 (6.7)
2.43
0.119*
χ
2
37 to 42
15 (20.3)
59 (79.7)
74
= 10.20,
cry
0 .144
*
p = 0.001
Jitteriness
5 (62.5)
3 (3.0)
8 (5.3)
2.14
0.171
*
χ
2
> 42
4 (50.0)
4 (50.0)
8
= 0.47,
Apnoea
4 (8.2)
2 (2.0)
6 (4.0)
1.87
p = 0.492
+
*
Hypothermia
22 (44.9)
20 (19.8)
42 (28.0)
10.31 0.001
Maternal age
(years):
* =Yates' correction
applied
3 (25.0)
9 (75.0)
12
χ
2
<
= 0.07,
p = 0.788
+
20
Figures in parenthesis
are percentages of total in
χ
2
20–35
41(32.8)
84 (67.2)
125
= 0.01,
each row
p = 0.938
χ
2
>35
5 (38.5)
8 (61.5)
13
= 0.22,
Admission
diagnoses
p = 0.641
*
Maternal parity:
14 (23.7)
45 (76.3)
59
χ
2
= 3.53,
Table 3 shows that
preterm delivery, birth asphyxia
Primipara
p = 0.060
and septicaemia were
the commonest admission
χ
2
Multipara
31 (37.4)
52 (62.6)
83
= 1.85,
p = 0.173
diagnoses in
hypoglycaemic and non-hypoglycaemic
χ
2
4 (50.0)
4 (50.0)
8
= 0.47,
neonates. Hypoglycaemia
was significantly more
Grandmultipara
p = 0.492
+
frequent among preterm
babies (p = 0.006) and those
16 (26.2)
45 (73.8)
61
χ
2
Inborn (WGH)
= 1.94,
who were
small-for-gestational age (p = 0.022).
Referred
33 (37.1)
56 (62.9)
89
p = 0.164
Table 3: Comparison
of Diagnoses
on Admission
in
Keys:
Babies with and without
Hypoglycaemia.
The 150 babies were
delivered by 136 mothers
Babies
Yates correction
applied
with
Babies
Wk=weeks
Diagnoses* on
without
χ
2
admission
hypoglycae
Total
mia No.
Hypoglycae
p value
(%)
mia No. (%)
Clinical
features
Preterm
30 (61.2)
38 (37.6)
68
7.42
0.006
Birth asphyxia
19 (38.8)
36 (35.6)
55
0.14
0.709
Septicaemia
8 (16.3)
24 (23.8)
32
1.0\9
0.297
The distributions of
the clinical features among
Neonatal
babies with and without
hypoglycaemia are
jaundice
4 (8.2)
19 (18.8)
23
2.12
0.145**
compared in Table 2.
Twenty-nine (59.2%) of the 49
Severe
anaemia
6 (12.2)
10 (9.9)
16
0.19
0.663
babies with
hypoglycaemia were symptomatic
Polycythaemia
7 (14.3)
6 (5.9)
13
2.90
0.088
compared with 28
(27.7%) of the 101 babies without
SGA
8 (16.3)
4 (4.0)
12
5.28
0.022**
hypoglycaemia (p =
0.000). The mean plasma
LGA
2 (4.1)
4 (4.0)
6
0.00
1.000**
glucose of asymptomatic
babies was slightly less
Tetanus
1 (2.0)
4 (4.0)
5
0.02
0.897**
than that of
symptomatic babies (1.47 ± 0.57 versus
Rhesus
Iso-
0 (0.0)
2 (2.0)
2
0.05
0.816**
1.51 ± 0.64) but the
difference was not statistically
immunisation
significant (p =
0.823). The rectal temperature of
babies with
hypoglycaemia ranged between 33.70
* = Many babies had
more than one diagnoses
and 38.70 C with a mean
(SD) of 35.70 (1.10) C.
o
o
**=Yates' correction
applied
There was a
significantly higher prevalence of
Figures in parenthesis
are percentages of total babies
hypoglycaemia among
babies with hypothermia (χ
2
with and without
hypoglycaemia
= 10.31, p = 0.001).
Floppiness, poor suck, cyanosis
SGA= Small for
gestational age
and respiratory
distress were the commonest clinical
LGA= Large for
gestational age
93
Outcome
figures of 38 percent
was reported from Nepal, an
Asian country and 38.4
percent Lahore in
Pakistan.
10,11
The outcome of study
subjects is presented in Table
4. The prevalence of
motor deficit among discharged
However, one major
reason that may partly account
hypoglycaemic babies
(all spastic) was about ten
for the higher
prevalent rates of NNH in the present
times that in other
babies (p = 0.009). There were a
study is the use of
higher plasma glucose level in the
total of 35 (23.3%)
deaths among the 150 babies
definitions of NNH. For
example, using cut-off blood
glucose levels of 1.1
mmol/L or 1.7 mmol/L, will
5
studied. Mortality rate
was higher among
hypoglycaemic babies
but the difference was not
give lower prevalent
rates than using blood glucose
levels of 2.2
mmol/L
6-8
statistically
significant (p = 0.060).
or plasma level of 2.5
mmol/
L. Even in the same
population using lower glucose
10
Table 4: Comparison
of Outcome
among Babies
levels will exclude
babies with higher plasma glucose
with and without
Hypoglycaemia.
levels making fewer
babies being diagnosed as
Babies with
Babies without
Total
having hypoglycaemia.
Another possible reason for
Outcome
hypoglycaemia
hypoglycaemia
No.
χ2
No. (%)
No. (%)
(%)
value
the difference between
the prevalent rates of
Discharged
hypoglycaemia may be in
the selection of the babies
without
106
studied. Whilst in the
present study high-risk babies
motor
27 (55.1)
79 (78.2)
(70.7)
8.51
0.004
deficit
who required
hospitalisation for major illnesses were
Discharged
5.09
0.024*
studied, the Nepalese
study recruited apparently
with motor
5 (10.2)
1 (1.0)
6 (4.0)
healthy babies from a
post-natal ward within the first
deficit
Discharged
0.00
1.000
50 hours of life while
Hamid et
al in Lahore, Pakistan
against
recruited neonates with
known risk factors or
suggestive clinical
feature.
10,11
medical
1 (2.0)
1 (1.0)
2 (1.3)
advice
Referred
0 (0.0)
1 (1.0)
1 (0.7)
0.00
1.000
The relatively higher
blood glucose cut-off value
used in the present
study has the advantage of
Died
16 (32.7)
19 (18.8)
35
3.53
0.060
(23.3)
providing management
opportunities for many more
Total
49 (100)
101 (100)
150
(100)
babies who were at risk
of hypoglycaemia. This is
clinically beneficial
in view of the damaging effect of
Figures in parenthesis
are percentages of total in
symptomatic
hypoglycaemia on the brain and the fact
each column
that the critical blood
glucose level at which damage
χ= 13.0,
df =
4, p
= 0.01
2
can occur has not been
clearly defined.
2,12
Koh
et al
12
*WithYates's
correction
showed reversible
disturbances in evoked potentials
at glucose level below
2.6 mmol/L in asymptomatic
term babies, although
no similar studies have been
reported from
Nigeria.
Discussion
Findings of higher
proportion of babies with
hypoglycaemia among
referred babies than inborn
The point-of-admission
prevalence of neonatal
babies in the present
study is in agreement with the
hypoglycaemia in the
present study was 32.7
previous reports of
Njokanma and Fagbule. This
6
percent. This was high,
especially when compared
could partly be
explained on the basis of delay in
with the 6.6 percent
reported in 1977 by Omene from
arrival of referred
high-risk babies to the hospital; for
Benin,
5
Mid-western Nigeria and
9.5 percent
example, the mean age
of outborn babies with
reported in 1994 by
Njokanma and Fagbule in
hypoglycaemic was
significantly higher when
Sagamu. Sagamu, like
Ilesa, is located in South-
6
compared with that of
the inborn babies with
western Nigerian. The
prevalence observed in the
hypoglycaemia. Very ill
babies while waiting to be
present study was also
higher than the 20.6 percent
referred or during
transfer are hardly fed adequately,
reported by Sexson from
the USA and 23.0 percent
7
if at all fed. Such
babies are usually subjected to cold
reported by Osier et
al from Kenya, an East African
8
injury (from lack of
transfer incubators or proper
country. The earlier
cited Nigerian reports of 1977
wrappings)
and
may
therefore
develop
and 1994 would suggest
a rise in prevalence of NNH
hypoglycaemia.
Moreover, the high index of
and the later works
from Kenya and USA, though
suspicion and better
high-risk neonate identification
from different
populations give credence to this
and interventions may
be contributory to the lower
trend. The difference
between the observed
prevalent rate of
hypoglycaemia among inborn
prevalence in the
present study and the values cited
babies.
from the more recent
USA and Kenyan studies may
Although, hypoglycaemia
is a common finding
among infants of
diabetic mothers (IDM), none of
13
also be a reflection of
higher predisposing factors to
NNH in the locality in
which the present study was
the two infants of
diabetic mothers seen in the present
done as suggested by
Koh et al. Indeed, much higher
9
study developed
hypoglycaemia, a finding consistent
94
with that of another
Nigerian study. However, the
5
The high prevalent rate
of NNH and high mortality
number of infants of
diabetic mothers in this study is
rate among babies with
NNH in the present study is
too small to have a
meaningful conclusion.
an indication that
blood glucose estimation should be
The proportion of
babies with symptomatic
routine in the care of
high-risk neonates. Where
hypoglycaemia in the
present study was higher than
standard laboratory
facilities are sparse, cheap but
35.7 percent previously
documented in Benin and
5
sensitive and reliable
strip methods of glucose
40.2 percent in India.
The comparison of occurrence
14
estimation may be used.
Most of the major risk
of symptoms and signs
suggestive of NNH between
factors for NNH in the
present study like LBW,
studies is rather
difficult since these features are not
hypothermia, birth
asphyxia, septicaemia and
specific for
hypoglycaemia and different blood
polycythaemia are
highly preventable and treatable.
glucose levels have
been used to define
Effort to reduce these
factors must be pursued
hypoglycaemia. However,
babies with features
vigorously. There is
need to train and re-train health
suggestive of
hypoglycaemia such as hypothermia,
workers, particularly
those in the lower tiers of health
cyanosis, convulsion,
refusal to suck, and non-
care system on the
prevention of NNH. Public
anaemic pallor deserve
prompt estimation of blood
awareness on the
immediate post-delivery care of the
glucose. Empirical
treatment for hypoglycaemia is
newborn and provision
of suitable transfer medium
advised if estimation
of blood glucose is not available
for referred babies
should also be intensified to
or likely to be
delayed.
reduce the burden of
NNH among out-born babies.
About a third of the
babies with hypoglycaemia in the
Affordable and easily
accessible maternal and child
present study died.
This was almost twice the
health services with
improved referral facilities for
mortality rate in
non-hypoglycaemic babies. The
high-risk pregnancies
will prevent most of the co-
implication is that
hypoglycaemia to some extent
morbidities and
therefore reduce the high morbidity
contributes to neonatal
mortality.
and mortality rates
reported in the present study.
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