One of the most essential lessons in medical training is learning how to distinguish the “sick” from the “not sick.”
Pediatricians become experts in differentiating between the noisy and congested breathing of a child with a viral URI and the increased work of breathing that raises concern for impending respiratory failure. We learn to reassure parents that the splotchy red bumps covering their baby’s skin are actually a benign rash with an alarming name (erythema toxicum) and that a small, seemingly innocuous vesicular lesion on a baby requires immediate evaluation. As we continue in our training, we also quickly learn that medicine is full of gray areas, where the line between the “sick” and “not sick” is hard to define.
In this month’s Pediatrics in Review, the “Neonatal Hypoglycemia” review article addresses a topic that is both common and often confusing for the general pediatrician. As the article points out, there are many unknowns when it comes to defining what constitutes clinically meaningful hypoglycemia in a well-appearing baby.
The association between the degree and duration of low blood glucose concentrations and the risk of neurodevelopment impairment is not well understood. Many infants will have transiently low blood sugar values but never go on to develop severe or prolonged hypoglycemia. This article does an excellent job of reviewing the physiology of “normal” transitional hypoglycemia and the risk factors associated with more significant congenital hypoglycemia that require an in-depth evaluation.
Thompson-Branch and Havranek also provide a useful summary (see Figure) of the slightly differing clinical guidelines from the AAP and the Pediatric Endocrine Society that many pediatricians use to direct their management of neonatal hypoglycemia.
Figure. Pediatric Endocrine Society (PES) and American Academy of Pediatrics (AAP) neonatal hypoglycemia guidelines in the first 48 hours after birth and beyond.
Whenever we encounter an area of medicine where the line between “sick” and “not sick” is unclear, we run the risk of over-testing, over-diagnosing, and over-treating. When it comes to neonatal hypoglycemia, this leads to unnecessary separation of infants from their mothers, numerous painful heel sticks/venipunctures, and undue stress for new parents.
This month’s review article is a worthwhile read that will help pediatricians develop a reasoned approach to identifying the minority of neonates who fall into the truly “sick” category of pathologic hypoglycemia.