Management and TREATMENT of neonatal HYPOGLYCEMIA

What defines hyperglycemia and how do we manage it? If you haven't watched the first video on what causes low sugars and its symptoms, then go back and watch that first. And remember, if you want the PDF summary of this video, then subscribe to our newsletter. Hello, I'm Dr. Tala, and I've been a neonatologist for about 16 years now. And I'm sure like a lot of you, I don't think I've spent a single day in the unit where I don't have to correct somebody's low blood sugars. So this is a very clinically important video. Also make sure that you watch until the end for your little homework assignment. Let's get straight into it. One, what defines hyperglycemia? Well, this is the huge controversial question. And depending on where you live, you will get a different answer because different professional organizations in different countries have all determined that there are different levels of sugar that should be considered hyperglycemia, which I always find very interesting because they're all looking at exactly the same studies and exactly the same research, but coming up with slightly different algorithms and protocols. In the references under the video, we've included a brilliant article, a review article, where they basically go over all the different policies and recommendations from six different international professional organizations. So the one from the US, the AAP in Canada, and then UK, Australia, and the Endocrinological Society as well. So I would highly recommend that you look through that. It summarizes everything so beautifully. Okay, so back to the age old question, what do we consider to be a low glucose? And I know that I've said something about this before, but again, in medicine, we only care about an abnormal number if it is affecting the baby now, or it is going to be affecting the baby in the future. Otherwise, we don't really care what the number is. So logically, if a baby has clinical symptoms of hyperglycemia, so that means that it is affecting the baby right now, then logically, we should probably have a higher threshold to actually treat that hyperglycemia. And all the professional organizations agree on this. If a baby has clinical symptoms, you are much more likely to treat that baby. In the AAP report on postnatal glucose homeostasis, which was published in 2011, and it hasn't actually been reviewed since then, but they recommended that if any baby has clinical symptoms of hyperglycemia and a blood glucose level of less than 40 milligrams per deciliter, which is 2.2 millimoles per liter, then that baby should be treated with IV dextrose. This was instituted before kind of glucose gels were used more regularly. Whereas other organizations use even slightly higher thresholds to automatically treat babies. So 45 or 47 mg per deciliter, which is 2.5 or 2.6 millimoles per liter. I'm also just gonna bring this up really quickly. Some countries use the unit of milligrams per deciliter for the glucose, and other countries use millimoles per liter. Basically, the conversion is you multiply the millimoles times 18 to get the milligrams per deciliter, because the molar weight of glucose is 180. Remember, C6H12O6 and oxygen is 16 and carbon is 12 or whatever, not important. And then you're also accounting for the fact that it's a deciliter and a liter. So in summary, multiply by 18 or divide by 18 to get the millimoles. Now you know. Okay, so that was the treatment of symptomatic infants. What about asymptomatic infants with low blood glucoses? Well, the first thing that you should know is that most professional organizations do not recommend routinely testing all babies for a glucose level. So basically, the only way that we're going to know if a baby does have a glucose level is if we are picking certain babies to screen for hyperglycemia on. And logically, these organizations all have recommendations in place for which babies we should be screening. For example, the AAP recommends that we screen at-risk babies for hyperglycemia. So who's at risk? So preterm babies, if you're born less than 37 weeks, SGA babies, small for gestational age babies, so your weight is less than 10th percentile, LGA babies, so your birth weight is above 90th percentile or large for gestational age, as well as infants of diabetic mothers. They also recommend that if the baby is exhibiting very poor feeds or just subjectively the baby isn't feeding well at all, then those are babies we should be checking as well. And this goes without saying, if a baby has any symptoms of hyperglycemia, then obviously we should be checking the glucose level then as well. Now the question is, when do we check that first glucose level? Again, every organization recommends something different. Some of them recommend before the second feed, so at kind of two to four hours of life. The AAP recommends checking the first blood glucose level about half an hour after the first feed, which they recommend happening within the first hour or so. So basically the AAP wants you to check that sugar by the time the baby's about two hours old. And then how long do you screen asymptomatic newborns for? Again, different policy statements everywhere, somewhere between six to 24 hours. So make sure that you familiarize yourself with a professional organization in your country, as well as the individual hospital that you work in, because they also may have interpreted those recommendations differently. So everybody in your hospital should at least be treating low glucose levels in the same way. Okay, so what should we consider hyperglycemia in an asymptomatic neonate? So a baby that doesn't have any symptoms. Again, almost impossible to pinpoint a number, but if you are going to remember one number, then remember 47 milligrams per deciliter or 2.6 millimoles per liter. So if the baby's blood glucose level is consistently staying below 47, then according to the Canadian, the UK and the Australian organizations, that is their definition of hyperglycemia. And by the way, that seemingly very random specific number came from two studies in the 1980s. The first one showed that if a baby had a blood sugar level of less than 47 for three days in a row, then they had increased chance of developmental delays. And the other study used sensory evoked potentials like at different blood glucose levels to also make that same determination. So old studies, but we're saying 47. That's kind of when the baby's a little bit older, because understand in the first few hours of life, the baby's blood sugar may be lower than that and still be acceptable. Like we said, that a lot of babies, their blood sugar can fall to 30 in one to two hours after birth before it starts naturally coming back up again. So this is the algorithm recommended by AAP in the first few hours of life. So a sugar in the first four hours of life needs to be above 40. If it stays below 25, then the baby needs IV glucose. After four hours, we're looking for sugars above 45. But if it stays below 35, again, the baby needs IV glucose. Again, just to remind you all that this protocol was written before the huge availability of glucose gels. In the UK, the BAPM recommended that there were three different levels of glucose that you needed to be aware of so that you could then escalate care, whether that was escalate treatment or further evaluation or whatever. And the three critical numbers for them was one, any blood glucose below one millimole per liter or 18 milligrams per deciliter, two, a blood glucose less than 45 or 2.5 in a baby with clinical signs, and three, a blood glucose of less than two or 36 on a repeat test with a baby with risk factors. Generally, as we're managing the hyperglycemia, we want those sugars to go up to the 40s and 50s. And then again, the different organizations have recommendations of how high the sugar should be for a baby to be able to be discharged, to go home. And depending on where you live, those numbers for discharge can be anywhere between 45 and 70. The 70 number comes from the Pediatric Endocrinological Society, and that seems ridiculously high, but they want a blood sugar consistency of 70 in babies that are known to have risk factors for having hypoglycemia. So this is like persistent hypoglycemia for a long period of time in babies that have some sort of congenital issue where we know that they are predisposed to get hyperglycemia. So if a baby is healthy and they've kind of gained weight, we're in their unit, they're no longer preterm or the insulin levels have normalized, then even if the sugar drops a little bit, they should have all the right machinery in place to be able to get their sugars back up again. But if we know that the infant has issues, whether it's a organic acidemia or something, then we want those sugars to stay at a higher level because those are the babies that the sugars can go from like 50 all the way down to zero and the baby isn't able to get it back up again. Two, how do we manage hyperglycemia? And you're going to be surprised or not at all, a lot more greenness here as well. So first of all, let's go through all the different things we have to consider when we're choosing what treatment to give babies, if any. So these are all the things that you should consider as you're trying to decide how aggressively you should treat the baby. One, how old the baby is in hours. So like we said, the sugar soon after birth, like less than four hours, we expect it to be a little bit lower than after four hours and then after 24 hours and after 48 hours. So definitely a 38 at 48 hours of life is pretty concerning, whereas a 38 in the first four hours of life isn't as concerning. So how old the baby is. Two, is the baby feeding? Obviously, if the baby is in the NICU and has a gastroschisis and the baby's NPO, then we're not going to increase the sugar by giving the baby a feed. We're not even gonna give a glucose gel if we're really strictly trying to keep the baby NPO. In this case, we would have to give IV dextrose. Three, does the baby have symptoms? Again, if the baby has symptoms, obviously you're more likely to treat, but you're also more likely to treat with IV dextrose rather than with increased feeds or a glucose gel or whatever. Four, how low is the number? Again, the lower it is, the more aggressive you're going to be in trying to get the sugar up. If a baby's sugar is 39 at 24 hours of life, you're probably not going to start by admitting the baby to the unit and starting IV fluids. Whereas if it's less than 10, then you are going to admit that baby and give IV fluids. How sick is the baby? If the baby is septic or has HIE or is really acidotic, we're already really worried about the status of the brain. We definitely don't want to add hyperglycemia on top of that. So again, we're probably going to make sure that we are treating that low glucose a little bit more aggressively. What is causing the hyperglycemia? And I really want to say a few words about this because it really can affect the baby's management and treatment strategies. So for example, let's say that you've got a 36 week AGA baby that's in term nursery and the baby's sugars have just been borderline, kind of low 40s, high 30s. They get a little bit better with the feeds but then fall back down again. How aggressively do we have to treat this baby? Well, we can assume that the reason why this baby's sugars are borderline is because the baby probably isn't eating great because it's late preterm and also because the baby doesn't have as much stores because it's a late preterm baby of the different substrates, the glycogen or whatever. And that's why the baby can't quite get its sugars just high enough. So this is a baby that there's a good chance with a little bit of extra feeds, whether that's encouragement or feeding more often or maybe even gavage feeds, maybe even a glucose gel, this baby's sugars could be okay. If this baby does end up going to the unit, then it probably won't take a lot of IV glucose to get this baby's sugars normalized because it's not like this baby has a huge demand for sugars. It's just not quite getting enough. Now let's say that same baby is also hypothermic. So the baby came from newborn nursery and the baby's cold or the baby's septic. At that point, the baby is going to need slightly more energy to help warm the baby up or to help the baby fight an infection. So this is going to need a little bit more IV glucose or a higher GIR. Then what about if we have an infant of a diabetic mother, which like we already said, these babies have high levels of insulin circulating around their bodies. So what did we say that insulin does? It basically sucks up all the glucose from the blood into the cells. So it doesn't leave enough glucose circulating in the blood to reach the brain. So if a baby in the term nursery has a low sugar and the baby's mother was diabetic, so it's an infant of a diabetic mother, I'm thinking this baby is way more likely to need admission because even if this baby is eating enough, the insulin in the body is sucking up that glucose and not leaving enough glucose in the blood. Often it's the IDN babies that we end up admitting to the NICU and we have to carry on giving them higher and higher glucose concentrations. So we're creeping up on the GIR, D10, D12.5, D15, whatever, because all the glucose that we're giving is just being pulled into the cells really rapidly by the insulin. Obviously the same goes for other causes of hyperglycemia. If the baby has a metabolic disorder, then obviously that's going to be something that we treat differently. For example, if the baby has an error in breaking down fatty acids, so the baby's lacking an enzyme and is unable to use the fatty acids as an energy source, then those are babies that we don't want fasting at all. So these are babies that we would be feeding really often to make sure that the glucose never plummets. So obviously the cause of the hyperglycemia is going to determine your overall management. And like we've been saying, treatment is also going to depend on where you live, because like we keep saying, all these different professional organizations have slightly different protocols and algorithms for hyperglycemia. And you should be following those in whatever hospital that you work in, because as we all know, consistency in the NICU is so important. And a lot of those hospital algorithms are going to depend on the hospital itself. Do you have gel available? Can you do an IV and the baby still stays with the mother? Is there a really high breastfeeding rate? All these other things are going to kind of like influence what the hospitals end up doing in their own protocols. But now let's go over all the different treatment options we have for babies with hyperglycemia. Not all of them, I'm not gonna go through all the organic acidemias and whatever else. One, good feeds, obviously an important source of sugar. So if the baby, for example, is 12 hours old and literally never latched or has a very weak latch and baby hasn't really eaten anything at all, then that baby is going to need help with feeds. Hopefully there's a specialist that can kind of help with the breastfeeding itself, or that baby needs to be supplemented with donor breast milk or formula if donor breast milk or whatever isn't available. Sometimes we even can gavage babies, preferably when they're still with mommies, just so that we don't have to separate them. As we all know, good feedings, consistently good feedings, every kind of two to three hours, as well as keeping the baby warm, are very good preventative strategies to prevent the babies from actually developing hyperglycemia. So hopefully your hospitals have lactation specialists in place or a team of nurses or a professional organization that can really help mother with the breastfeeding or just with feeding generally, and just encourage her and remind her that this has to happen frequently in those first couple of days of life. And let me just emphasize here that good feeds, unless you have a super low glucose, are always going to be the ideal treatment for babies with hyperglycemia. It is the most natural way to get that glucose up. And if you're just feeding the baby to increase the glucose, then you're not going to be at risk of suddenly increasing that glucose by a good amount. And sudden increases in glucose have also been implicated with potentially bad outcomes in the future. So obviously, if we can go with feeds, go with feeds. Two, glucose gels. And we've only started using glucose gels in the last five to 10 years. And really, we only use it in babies that are above 35 weeks. Glucose gels were initially introduced and tested upon and everything, with the hopes that it would encourage the mothers to carry on breastfeeding the babies. It wouldn't kind of interrupt that good breastfeeding by giving formula feeds or taking the babies to the unit or whatever. And one study called the Sugar Babies, what a perfect name for a study, compared giving hyperglycemic babies a placebo gel or a glucose gel. And it found that the babies that got the glucose gel had fewer admissions to the NICU, it was also cost-saving, and those babies were less likely to be on formula at two weeks of age. Having said that, the follow-up of these Sugar Babies at four years of age showed no difference in developmental outcomes. If anything, the babies that had received the glucose gel had slightly worse visual processing scores, but they were taller and they weighed more. The other things that we worry about when we give glucose gels are that one, it may have additives in it that are not ideal, and two, that it may also alter the microbiota in the gut. So as we've talked about before, you know that in the gut, there's a very careful balance of kind of good bacteria, the commensal bacteria, and the bad pathogenic bacteria. And people are concerned that maybe by giving glucose gels, we're encouraging the wrong type of development of bacteria and you're predisposing your gut to more of an inflammatory state. Having said that, so far, the small studies that have been done have been reassuring about that kind of shifting microbiota. Anyway, I'm sure a lot of you use glucose gels. We use glucose gels, and for us, they have been very successful in keeping the babies with the mothers. But just to let you know, there's going to be a lot more to discuss on this topic moving forward. But just so that you know these basics about glucose gel, generally, we're using 40% glucose gel, and the dose is 0.5 milliliters per kilo, which ends up with that percentage and everything being 200 milligrams per kilo. And it's given into the buccal mucosa, into the mucosa around the mouth. So basically, you should dry the buccal mucosa with some gauze, and then you're giving 0.5 milliliters that you're kind of massaging into the mucosa, so it's all being absorbed through that until the full dose is being given. Gels should be given at least 30 minutes apart. Again, that depends on what your hospital does. And obviously, if the sugar is really, really low, then the gel should only be given kind of as a bandage until you can get some good IV fluids going. Different hospitals allow different numbers of gels to be given on the floor before the baby's automatically admitted to the NICU. Usually, it's somewhere between three to six different gel doses. Three, a dextrose IV bolus. So obviously, a baby's gonna need an IV for this. Sometimes you can do the IV on the floor. Most of the time, a baby isn't being admitted to the NICU for an IV bolus dose. And the standard dose of this, if you are going to remember one dose in all of neonatology, then this is what you should remember. The standard dose is two milliliters per kilo, which in a D10W IV ends up being 200 mgs per kg, which is exactly the same dose that we're trying to give when we give the glucose gels. Just as an aside, other professional organizations can go up to 2.5 mls per kilo. Remember that this really is just a Band-Aid. If a baby has a low sugar and you just bolus them with a glucose gel or with a D10 bolus, then what's gonna happen to the baby? Immediately, their insulin level might spike a little bit. So if you don't do anything else apart from just give the bolus or just give the gel, then that sugar may end up being even lower afterwards. So if you are giving the equivalent of a bolus, make sure that you're doing something else as well, increasing the feeds or running IV fluids or whatever. Four, IV dextrose infusion. So for pretty much any time you're giving this, this baby is being taken to the NICU. So the first thing that you have to realize is when you're starting the IV infusion, then automatically you're separating the baby from his mother and you're increasing the mother's anxiety, you're interrupting breastfeeding. So that's why it's not like we want to rush towards this at all. So usually we start IV dextrose in a baby where the sugars are staying really low or we've tried gels and increased feedings a few times and the sugars are still low. So we'll admit them to the NICU and start IV dextrose. So usually we start with D10W running through a peripheral IV. And usually we start at about 60 to 80 milliliters per kilo per day. So with D10W, that ends up being a GIR between about 4.2 and 5.5. If you can't remember what a GIR is, then go back and watch the previous video that we made. It really is critical that you understand what a GIR is when we're treating hypoglycemia. If the sugars are staying low, then you can start creeping up on the GIR. So logically, you can either go up on the rate or the total volume you're giving the baby. So you can go up to 100 or 120 mLs per kilo per day. Remember, you really don't want to fluid overload the baby, especially in the beginning of the life. That's not good at all either. The other thing that you can do is go up on the concentration of the glucose. So you can go 10, D10, D12.5, D15, D20, any number in between. Just remember though that many institutions max out the concentration of glucose that they're giving through a peripheral IV at D12.5. So if you, in many hospitals, if you're giving more than D12.5, then generally you're going to have to obtain central access whether it's an umbilical vein or a PIC or a Broviac or whatever. By the way, this D12.5 really isn't based on solid evidence. So if anybody is looking for a very interesting and helpful research study, then maybe add to the data that it would be acceptable to infuse D15, for example. If you do have central access, then you can carry on creeping up on the dextrose concentration. So to D15 or D20, some places will go up to D25. So obviously you can give a lot more sugar in a smaller volume if the concentration is higher, which brings us to our next point. If you are going up on the dextrose, always calculate the GIR. So you're actually comparing apples to apples. If somebody comes and tells you, oh, my baby's not doing well, he's on 100 mLs per kilo per day, that doesn't really mean a lot. Is it D10? Is it D20? That's a huge difference in how much glucose that baby is getting. Another important aspect of calculating the GIR is as that's going up, then you should be more concerned that you are missing something or you should be starting additional therapies. So really once the GIR is going above eight mgs per kg per minute or 10 mgs per kg per minute, then maybe start thinking, do I need to be doing something else? The vast majority of the time when you're needing a really high GIR, it's because the baby has a high circulating level of insulin and whatever glucose we're giving the baby is getting sucked up into those cells almost immediately. Five, what other therapies can we use? And I'll list some other medications briefly because these are all things that we use in the unit, but I'm not going to go into great detail about them. The first one and a medication that I have come to love in just about all causes of hyperglycemia is glucagon. So this can be given IM. In fact, one of the professional organizations recommends that if you can't get IV access and the baby isn't feeding enough and the sugar is low, you can give an IM dose of glucagon. Or more usually we're giving an IV bolus or in our institution, we're normally giving an IV infusion. Glucagon, like we said in the previous video, is really good at making glucose. So gluconeogenesis, glycogenesis, and it's very good at increasing the glucose levels. Usually we're starting the glucagon infusion when the GIR is above about 10 mgs per kg per minute. If a baby has high insulin levels and you've documented that the baby has high insulin levels, then you could give diazoxide. This is a potassium channel activator and it works directly to inhibit the pancreatic secretion of insulin. So basically diazoxide decreases insulin secretion. This can be helpful in those IDM babies that have just that lingering IV fluids need. So you can't get them off the glucose infusion for just days and days. You just can't get them over the hump. So diazoxide is a good medication for those cases. Steroids are another medicine that is sometimes used. And like we all know, when we give steroids, the sugars generally do go up. It's very much a blanket treatment, just like really all the times that we're giving steroids. We don't really know what we're treating. We're just making the numbers better. Whether that's better for the kids in the long run, we don't know. You could also use another medication, which is octreotide, which is a somatostatin analog. So like a man-made form of the somatostatin. And basically that decreases really everything coming out of the pancreas, including the insulin. It's been shown that this can be associated with an increased risk of neck. And honestly, if you're reaching octreotide, you should definitely be doing this in conjunction with a pediatric endocrinologist. It's not really recommended in all babies for the sole purpose of treating hyperglycemia. So in continuing our general management guidelines, at what point should we be investigating the hyperglycemia further? Like, okay, you've admitted a baby, you put them on a bit of IV fluids, they're probably getting better, then you probably don't need to investigate that further. Well, when do you need to investigate it further? So the first thing is, is if you don't find any reason for why the baby has hyperglycemia. So say you have a term AGA baby in the newborn nursery, the mother reports the baby's been eating really well, so do the nurses, but you can't seem to get the sugars out of the 20s. That is concerning. Something else is going on that we're missing. Generally in these situations, I start by going through the mother's chart. Are we missing something with her? Is she really a gestational diabetic? Or maybe she never got the diagnosis, but she failed her one hour glucose test, but never ended up doing the three hour glucose test. Maybe even though she didn't have the diagnosis, all her sugars since admission have been really high. Maybe she doesn't have the diagnosis, but her last baby was five kilos. Also a little bit suspicious that she may have had gestational diabetes. Is there something else that we're missing? Does the mother have any prenatal infections? Does the mother have syphilis, for example, which notoriously produces low glucoses in babies? Or am I missing something with the baby? Is the baby sick? Does the baby have an infection? Does the baby have polycythemia? So a really, really high red blood cell count, which can lower the glucose just because they're kind of gobbling up all that glucose. And by the way, anytime I end up admitting a baby with hyperglycemia to the NICU, I will at least get a CBC and differential just to make sure I'm not missing an infection. And I also want to check the hematocrit to make sure the baby doesn't have polycythemia. Once we go past kind of the initial more common things, you have to start looking for zebras. Does the baby have any dysmorphic features? Are we missing a syndrome? Is it possible that the baby has some sort of metabolic disease? Clearly something is going on that we're missing here and it really does warrant further investigation. Two, we also need to investigate further if the baby just doesn't seem to be getting better. So for example, the baby gets admitted with low sugars. We have a reason for the low sugars, but even after we have the baby on IV fluids, we continue have to giving the IV fluids for a lot longer than we think we would, so days, or we keep having to go up on the GIR and we don't really have a great explanation for it. So one of the first things that we do when the amount of sugar that we're giving seems out of proportion to the baby's glucose levels is we will check hormone levels on the babies. So we'll check TSH, GH or thyroid stimulating hormone, growth hormone and cortisol. So all of those hormones should be involved with actually raising the baby's sugars. So if the baby is deficient in any of those hormones, we would expect the glucoses to be low. Ideally, you want to check those hormones when the baby's glucose is at a low point. So if the baby's glucose is less than 35, then we would definitely expect all those hormones to be elevated because they're reacting to the low sugar. So it's kind of more sensitive to get all those lab levels when the baby's glucose is low. So that would be a situation where you'd put in a conditional lab. If the sugar falls below 35, then get these hormones. You'd probably also want to check the insulin levels. If the sugar is low, then the insulin level should be really, really low because the body doesn't want to make the sugar any lower. So if the insulin is at all present or elevated, then that is concerning for hyperinsulinism in the face of hyperglycemia. So normal insulin levels in a newborn baby are about 10. But if they're about 10 when the sugar is 30, then that is way too high. Really, you want the insulin to be unreadable when there is hyperglycemia. Really, if it's anywhere above one, then probably this insulin is too high, inappropriately high, and you can label it hyperinsulinism. If the level of insulin is really high, so 15, 20, 50, then at that point you have to be concerned that maybe something is going on with the pancreas and it's just secreting a lot of insulin, maybe there is a tumor or something there, or some weird cause of really high transient hyperinsulinism. This is an aside if anybody loves crime shows. So when the body releases insulin, a byproduct is also C-peptide. So if you happen to check the insulin level and it's really high, and you also check the C-peptide level, but the C-peptide is really low, it means that it's not the baby that's actually producing the insulin, it means that somebody is exogenously administering insulin. So somebody is inappropriately giving this baby insulin, making the sugars low. Hopefully none of us are ever going to see this, but it's an interesting fact. Then in addition to those hormone studies, if the baby appears sick, then so many other things could be going on, including, like we keep saying, an inborn error of metabolism. And good screening tests for that would be checking a gas, so checking the metabolic acidosis of the baby, maybe checking a lactate, as well as checking an ammonia level. And then obviously a bunch of other tests. At that point, you should probably be getting a metabolic specialist involved. And really the third point of management is if the baby is getting better, then how do we wean off the IV fluids and how do we send the baby home? Well, for weaning, normally what we do is we put some sort of weaning order in place. So for example, we would say, if the blood glucose level is above 60 or 65, then wean the IV fluids by one ml an hour until you're off. Different places will do it differently, different providers will do it differently, but really you want some sort of consistent plan so the baby's slowly working to coming off the IV fluids. Once off the IV fluids or having not given glucose gel or whatever, every different professional organization recommends a different number of normal glucose checks before the baby can go home. For example, the AAP wants three normal glucose checks without obviously any fluids or any gels or anything being given before the baby can go. Normally when the baby's in the NICU, normally we watch the baby for about 24 hours off the IV fluids before we send the baby home. Okay, I think we're gonna stop here. There's so much information on hyperglycemia. I really edited this out. There was so much more I wanted to say, but I really just wanted to include the really important points. But here is your homework assignment for you. One, name three possible treatments for babies with hyperglycemia. Two, name five possible tests that you might want to get in a baby that you have in the NICU with hyperglycemia. And three, name three different ways in which the cause of hyperglycemia may then affect your management plans. I hope you learned something from this video. If you reached this far, then please like it and subscribe to this channel if you're interested in neonatal education. Thank you so much for being here.