Controversies and Consensus in the Management of Neonatal Hypoglycemia: A Review of Current Guidelines and Evidence

Neonatal hypoglycemia is a common and serious metabolic disorder, affecting up to 15% of newborns and a higher proportion of those with risk factors. Severe or prolonged episodes can cause lasting neurodevelopmental impairment, including cerebral palsy and developmental delay. Management remains complex due to the absence of a universal definition, standardized screening methods, and treatment protocols, resulting in significant variation across major pediatric guidelines. This review summarizes current evidence and guidelines on the management of neonatal hypoglycemia, emphasizing the ongoing debate over its definition – particularly the traditional threshold of <2.6 mmol/L versus the higher, age-specific targets recommended by the Pediatric Endocrine Society for improved neuroprotection. Management focuses on proactive screening of at-risk infants, including those born to diabetic mothers and preterm infants. Treatment follows a stepwise approach, with 40% buccal dextrose gel as an effective, non-invasive first-line therapy that reduces the need for intravenous glucose, which is reserved for severe, symptomatic, or persistent cases. Long-term studies indicate that even treated hypoglycemia may be associated with later neurodevelopmental challenges, underscoring the importance of prevention. Although management of neonatal hypoglycemia has advanced with the adoption of less invasive approaches such as buccal dextrose gel, the lack of a universal definition remains a major challenge. Future research should aim to harmonize international guidelines, integrate tools such as continuous glucose monitoring, and explore preventive strategies to enhance neurodevelopmental outcomes in at-risk newborns. The overarching goal remains the prompt identification, screening, and treatment of vulnerable infants.