Screening and Management of Neonatal Hypoglycemia Page 2 of 7
Policy Statement: Infants at risk for hypoglycemia will be properly assessed and managed to prevent adverse, preventable outcomes related to neonatal hypoglycemia.
Purpose: Identification and management of the term and late preterm (34 0/7 to 36 6/7 weeks gestation) infant at high risk for hypoglycemia. This is a suggested treatment guideline based on current evidence and consensus. It does not represent an exclusive course of management.
Key point: Glucose is the major energy source for the fetus and neonate. Risk indicators and algorithms have been provided in this instruction for screening and follow-up. Regardless of screening or current status of algorithm treatment, if a newborn has symptoms consistent with hypoglycemia, blood glucose should be immediately obtained and treatment based upon the results of this value.
Definitions:
Term Infant: Gestation that has been completed through 37 weeks or greater
Late Preterm Infant: Gestation that has been completed through 34 week to 36 6/7 weeks
SGA: Small for gestational age. Birth weight below the 10th percentile using Fenton growth curve. This definition does not make a distinction among SGA infants who are constitutionally normally small from those who are growth-restricted and small.
IUGR: Intrauterine growth restriction. Infants that did not achieve the expected in utero growth potential due to genetic or environmental factors. May be larger than 10th percentile.
Symmetric IUGR: Infants with symmetric IUGR have reductions in all measurements with the weight, head, and length proportionally affected. Symmetric IUGR begins early in gestation and usually is caused by intrinsic factors such as congenital infections or chromosomal abnormalities. However, decreased nutrient supply early in development can also restrict growth of all organs. Also referred to as growth restriction with microcephaly.
Asymmetric IUGR– Infants with asymmetric IUGR have disproportionate growth restriction in which head circumference is preserved, length is somewhat affected, and weight is compromised to a greater degree. As a result, the normal-sized head appears relatively large compared with the size of the body. Abnormal growth typically begins in the late second or third trimesters and results from reductions in fetal nutrients that limit glycogen and fat storage, yet allow continued brain growth. Also referred to as growth restriction with head sparing.
LGA: large for gestational age, above the 90th percentile – can be caused by genetic or maternal factors (notably diabetes).
IDM: Infant of diabetic mother. Includes infants born to mothers with either pre-existing Type 1 or 2 diabetes as well as those born to mothers with gestational diabetes
Background:
In preparation for extrauterine life the fetus stores glucose in the form of glycogen. Glucose is the major energy source for the fetus and neonate. The only source of glucose available to the fetus is through placental transfer from maternal circulation. Blood glucose concentrations in the fetus is typically ¾ of that in the mother’s blood. In utero the fetus is unable to convert glycogen to glucose and thus receives most of the glucose it requires from the placenta. Glycogen is stored in the liver, heart, lungs and skeletal muscle, with the majority of storage occurring during the final trimester. Alternate fuels (ketones, lactate) are produced in very low quantities. The usual rate of utilization of glucose in an infant is 4-8 mg/kg/min. The glucose regulatory mechanisms at birth are sluggish. Thus, the infant is susceptible to hypoglycemia when glucose demands are increased or when exogenous or endogenous glucose supply is limited. Severe or prolonged hypoglycemia may result in long term neurologic damage.
Neonatal hypoglycemia most commonly occurs in infants with impaired gluconeogenesis, brought about by excess insulin production, altered counter-regulatory hormone production, or an inadequate substrate supply.
At risk infants that will undergo routine screening:
· SGA or LGA (based on Fenton growth curve)
· IUGR (by provider determination, e.g. SGA or other growth failure based on serial ultrasounds)
· Prematurity including late preterm infants (e.g. all infants <37+0 weeks gestation)
· IDM
· Maternal oral hypoglycemic medication use
· Maternal antenatal steroids (i.e. betamethasone) administration within 2 weeks of delivery
· Maternal intrapartum tocolysis (e.g. terbutaline, propranolol, or nifedipine)
· Perinatal asphyxia (Apgar < 7 at 5 minutes)
· Discordant twins (>20% by birth weight)
Additionally screening to be considered in the following non-specific clinical circumstances:
· Jitteriness
· Poor feeding
· Poor thermoregulation (cold stress/hypothermia or hyperthermia)
· Sweating
· Undergoing sepsis evaluation
· Tachypnea or increased work of breathing (grunting, flaring, retractions)
· Polycythemia
· Irritability
· Poor tone, lethargy
· Weak or high pitched cry
· Apnea or periodic breathing
· Micropenis or other dysmorphology
· Poor color (cyanosis)
· Maternal anti-depressant medication use
Instructions:
Newborn Nursery:
*** If the at risk infant is symptomatic at any time, immediately check the glucose ***
1. Initiate feeding within 20 minutes after delivery for all well newborns.
· Facilitate breastfeeding ensuring audible swallowing for at least 15 minutes. Document first latch, refer to Breastfeeding the Newborn, for further information.
· If breastfeeding is not available due to maternal condition, seek consent for donor milk use. Provide 1-5mL/kg of warmed donor milk. Infant may take more if desired.
Refer to Bottle feeding the Newborn.
· If donor milk is declined, utilize standard concentration formula
2. Infants that meet blood glucose screening criteria will have a screening glucose checked 30 minutes after initiation of feeding (or within one hour after delivery) and every 3 to 4 hours subsequently, prior to feeds until criteria for discontinuation are met.
Sustained skin to skin contact is preferred while performing laboratory draw, to support bonding, breastfeeding and newborn thermoregulation.
3. Obtain iSTAT glucose using glucose cartridge located in refrigerator. Ensure cartridge is not expired prior to use. (These must sit at room temperature for 5 minutes prior to using.) If no iSTAT available please utilize serum glucose levels as glucometers do not provide accurate readings for newborns.
4. Warm heel with hospital approved heel warmer for approximately 15 min prior to obtaining sample. Warming the heel will prevent venous stasis which may underestimate glucose level, increase blood flow, and prevent bruising of the heel.
5. Screening Results Management:
· If glucose is less than 45 mg/dL and infant is symptomatic, infant is to be transferred to the NICU for intravenous dextrose fluids. Send serum glucose level for confirmation, but do not wait for results to initiate treatment.
· If the result reads “ *** ” then the iSTAT cannot read the sample and a serum blood sample should then be sent to the lab for confirmation. The most common reason for this reading is that the infant’s HCT is too high. Do not wait for results prior to notifying the provider.
· For the asymptomatic infant with glucose level ≤ 25 mg/dL, infant is to be transferred to the NICU for IV Glucose.
· For the asymptomatic infant with glucose levels > 25 mg/dL and ≤ 45 mg/dL
- The infant is to be fed immediately. If infant has been breastfeeding then obtain consent from parent for either donor milk or formula of parents’ choice
(Donor Breast Milk Consent Form)
- If the infant is being breastfed, suggest alternate method for feeding including supplemental nursing system (i.e. SNS, tube at breast), finger feeding, or cup feeding. Preferred feeding substrate options:
a) 1st choice: Mother’s EBM
b) 2nd choice: Donor Milk, refer to Donor Breast Milk, at least 1-5 mL/kg. Infant may take more if desired.
c) 3rd choice: standard formula concentration, at least at least 1-5 mL/kg. Infant may take more if desired.
Link to Bottle-feeding the Newborn
· For the asymptomatic infant with glucose levels 25 mg/dL but to ≤ 45 mg/dL,
40% dextrose gel can be also considered to achieve euglycemia at provider’s order.
To administer: Gently rub gel into the hypoglycemic infant's buccal mucosa.
Appropriate dose 0.5mL/kg (200 mg/kg).
This treatment intervention should not be repeated for follow up low or equivocal results more than twice.
Note: Other concentrations of oral sucrose (24%, i.e. Sweet-Ease) or glucose water should NOT be utilized enterally to increase an infant’s blood glucose levels.
· Within 45 minutes of feeding a follow up glucose to be obtained. If the glucose remains less than 45 mg/dL, the provider is to be notified and NICU transfer is to be considered.
Additional glucose screening is indicated prior to the following feeding.
· Transferring infants to NICU for intravenous fluids
- Indicated for any of the following:
a) All symptomatic infants with screening glucose < 45 mg/dL
b) Infants with any screening glucose ≤ 25 mg/dL
c) Infants with 2 or more screening glucoses ≤ 35 mg/dL
d) Infants with 3 or more screening glucoses ≤ 45
e) Provider discretion
- Infants receiving intravenous fluids are cared for in the NICU.
- Provider caring for infant on FBC to be notified by FRC RN. FBC RN to document provider notified, time of notification, and orders received.
- At transfer, FBC RN to document time of transfer, identify NICU RN assuming care, and NICU room number.
- Communication regarding infants transferred to the NICU
a) The provider will contact a NICU provider to assume care OR
b) If the provider has NICU privileges, the provider will either place NICU admission, evaluation, and treatment orders or call the NICU RN assuming care of the infant to give verbal orders.
6. Discontinuation of screening.
IDM may develop asymptomatic hypoglycemia as early as 1 hour after birth and typically do so by 12 hours of age. By contrast, SGA infants may develop hypoglycemia by 3 hours of age and may be at risk for up to 10 days after birth. At-risk infants should be screened with a frequency and duration related to risk factors specific to the individual infant.
Recommendations for discontinuation:
· At provider discretion, by order.
· LGA / IDM infants: routine prior-to-feed screening among at risk infants may be discontinued if an infant remains asymptomatic, if feeding has been established, and two glucose screens are > 45 mg/dL in first 24 hours following birth.
· SGA/IUGR infants: routine prior-to-feed screening among at risk infants may be discontinued if an infant remains asymptomatic, if feeding has been established, and three glucose screens are > 45 mg/dL in first 24 hours following birth.
· At risk infants will have a screening glucose at 24 hours of age obtained with their Oregon State newborn screen and routine bilirubin sampling. Repeated screening before feedings should be continued if plasma glucose concentrations remain lower than 45 mg/dL.
· After the initial 24 hours following birth, glucose levels > 50 mg/dL are the target level.
Management of hypoglycemia past the initial 24 hrs from birth is out of the scope of this guideline. Considerations for supplementation, caloric fortification, thermoregulation strategies, and neonatology consultation may be warranted.
References:
Harris, Deborah L et al. Dextrose gel for neonatal hypoglycemia (the Sugar Babies Study): a randomized, double-blind, placebo-controlled trial. The Lancet, Volume 382, Issue 9910, 2077 - 2083
Mosalli, R. (2014). Dextrose Gel is Superior to Feeding Alone in Neonatal Hypoglycemia.Journal of
Clinical Neonatology,3(1), 10–11.
Besuner, P. (2011). Protocols and Procedures for Maternity Services, 3rd ed.
Postnatal Glucose Homeostasis in Late-Preterm and Term Infants Committee on Fetus and Newborn,
Pediatrics Mar 2011, 127 (3) 575-579; DOI: 10.1542/peds.2010-3851
Neonatal Glycemia and NeurodevelopmentalOutcomes at 2 Years N Engl J Med 2015;373:1507-18.
Karlsen, K. (2013). The STABLE Program; Guidelines for Neonatal Healthcare Providers, 5 ed. Salt
Hume R, McGeechan A, Burchell A. Failure to detect preterm infants at risk of hypoglycemia before discharge. J Pediatr. 1999; 134(4):499 –502
Aziz, K et al. Screening guidelines for newborns at risk for low blood glucose. Canadian Paediatric Society Fetus and Newborn Committee. Paediatr Child Health 2004;9(10):723-9. Reaffirmed: 2016
Wight, W et al. The Academy of Breastfeeding Medicine. ABM Clinical Protocol #1: Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycemia in Term and Late-Preterm Neonates, Revised 2014. BREASTFEEDING MEDICINE Volume 9, Number 4, 2014
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