Care Process Model

APRIL

2012

GUIDELINES FOR MANAGEMENT OF

Neonatal Hypoglycemia
2012 update
These guidelines were prepared by Larry Eggert, MD, in consultation with Intermountain Healthcares (Intermountains) Well Newborn Development Team and NICU Development Team, under the guidance of Intermountains Women and Newborns Clinical Program. The guidelines are derived from analysis of the literature and expert consensus.

The problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 General recommendations . . . . . . . . . . . . . . . 1 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ALGORITHM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

THe PROBLeM
Hypoglycemia in the newborn is not a medical condition in itself, but can be a symptom of underlying disease. Prolonged or recurrent low glucose levels may lead to long-term neurodevelopmental sequelae. Unfortunately, the exact parameters of normal blood glucose in the neonate remain controversial. Although neonates have a lower normal blood glucose range than older infants, a blood glucose level that requires intervention in every newborn has not been defined and appears to be dependent on birth weight, gestational age, feeding method, and postnatal age in hours. Also uncertain are the level and duration of hypoglycemia that cause damage and the vulnerability, or lack thereof, of the brains of infants of differing gestational ages. Because of the lack of clear definition of safe neonatal blood glucose levels, knowing when and how to screen and intervene can be difficult. Based on analysis of the literature, clinical experiences, and expert consensus, these guidelines promote a pragmatic approach that provides a wide safety margin.

R EFE R EN C ES
1. Canadian Paediatric Society. Screening guidelines for newborns at risk for low blood glucose. Paediatr Child Health. 2004;9(10):723-729. http://www.cps. ca/english/statements/fn/fn04-01.htm. Accessed March 28, 2012. 2. Chan SW. Neonatal hypoglycemia. UpToDate Online. Waltham, MA: 2010. http://www.utdol.com/online/ content/topic.do?topicKey=neonatol/5898&select edTitle=1%7E38&source=search_result. Accessed March 28, 2012. 3. Cornblath M, Hawdon, JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics [serial online]. 2000;105(5):1141-1145. http://pediatrics.aappublications.org/cgi/content/ full/105/5/1141?ck=nck. Accessed March 28, 2012. 4. New Zealand Ministry of Health. Auckland District Health Board. Newborn Services Clinical Guideline. Guidelines for the Management of Hypoglycaemia. 2004 July. http://www.adhb.govt.nz/newborn/ guidelines/nutrition/HypoglycaemiaManagement. htm. Accessed March 28, 2012. 5. Newborn Nursery QI Committee. Neonatal hypoglycemia: initial and follow up management. Portland (ME): The Barbara Bush Childrens Hospital at Maine Medical Center; 2004 Jul. http://www. guideline.gov/summary/summary.aspx?ss=15&doc_ id=7180&nbr=4293. Accessed March 28, 2012. 6. Volpe JJ. Neurology of the Newborn. 5th ed. Pennsylvania, PA: Saunders/Elsevier; 2008. 7. Wight N, Marinelli KA, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #1: guidelines for glucose monitoring and treatment of hypoglycemia in breastfed neonates. Breastfeed Med. 2006;1(3):178-184. http://www.guideline.gov/ summary/summary.aspx?doc_id=11218&nbr=0058 65&string=neonatal+AND+hypoglycemia. Updated January 25, 2010. Accessed March 28, 2012. 8. World Health Organization. Hypoglycaemia of the Newborn, Review of the Literature: 1997. http://www.who.int/maternal_child_adolescent/ documents/chd_97_1/en/index.html . Accessed March 28, 2012.

GeNeRAL ReCOMMeNdATiONs
The following are generally recommended principles; detailed recommendations are given in the algorithm on page 2 of this document.

1 Initiate feeding. Feeding should be initiated for all neonates as soon as the infant is ready, preferably within 1 hour of birth. Neonates who are not fed will have a physiologic drop in blood glucose, with a low at 1 to 1.5 hours of age. The feeding should be breast milk (colostrum) or infant formula NOT dextrose-water. Colostrum, if available, is preferred to formula. 2 Assess risk factors and symptoms. All neonates with risk factors or major symptoms should have blood glucose checked. 3 Screen and manage based on initial feeding and assessment. If the neonate is symptomatic or blood glucose level is less than 45 mg/dL, notify a LIP while proceeding with management steps outlined in the algorithm on page 2.
New in the 2012 update: Our process algorithm now supports the use of the Nova StatStrip Glucose Monitoring System at the bedside for verification of initial low glucose-screening results. This modification follows from direct comparisons of various testing methods by Intermountain nursing, laboratory, and medical experts. Also, consistent with current practice and science, this updated algorithm simplifies the IV infusion recommendations and suggests a lower initial IV infusion rate.

G u i d e l i n e s f o r m a n a G e m e n t o f n e o n ata l h y p o G ly c e m i a

a p r i l 2012

ALGORiTHM: MANAGeMeNT OF NeONATAL HYPOGLYCeMiA

1 Initiate feeding for all neonates as soon as infant is ready, preferably within 1 hour of birth.
2 Assess the neonate for presence of the following risk factors and symptoms.
Feed breast milk/colostrum or infant formulaNOT dextrose-water. Colostrum, if available, is preferred to formula.

Risk factors:
Prematurity (age <37 weeks) or LBW (<2500 gm) SGA or IUGR (<10th percentile for weight) Intrapartum depression (5 min Apgar <7) Infant of a diabetic mother (IDM) LGA (>90th percentile for weight) Hypothermia (<36.5C axillary after stabilization) Polycythemia (central Hct >65) Microphallus or midline defect Maternal terbutaline, beta-blocker, or oral hypoglycemic agent during L&D

Major symptoms:
Stupor, hypotonia Jitteriness, irritability, high-pitched cry Seizures Apnea, cyanosis Irregular rapid breathing >1 hour grunting, retractions, RR >60

Asymptomatic WITHOUT risk factors

No further action necessary

Asymptomatic WITH risk factors

Symptomatic

Check blood glucose at least 30 minutes after conclusion of feeding, but no later than 4 hours of age. (If baby wasnt interested in feeding right after birth, check blood glucose within 2-3 hours after birth.)

Check blood glucose immediately.

Glucose >45 Some at-risk babies may develop late hypoglycemia, often between 12 and 24 hours of age. Follow clinically and recheck glucose about every 6 hours, before feeding, for the first 24 hours of life.

Glucose 30 - 44

Glucose <30

Glucose <45

Glucose 45 Notify LiP. Search for other etiology.

Breastfeed, or feed expressed breast milk or formula (10 ml/kg) by mouth or gavage.

Notify LIP while proceeding with algorithm. Retest glucose at bedside using Nova StatStrip (venipuncture) or i-STAT (heel-stick or venipuncture); send for STAT lab glucose only if bedside retesting cant be done as described. If glucose is >45, return to appropriate box above. Otherwise, proceed with algorithm.

Recheck glucose 30 minutes after conclusion of feeding

Give minibolus D10W @ 2 ml/kg IV push Then start D10W @ 80 ml/kg/day Recheck glucose in no more than 30 minutes Repeat minibolus D10W @ 2 ml/kg IV push Increase rate of D10W to 100 ml/kg/day For glucose <30, now or later, notify LIP to request STAT Neonatology consult. Recheck glucose in no more than 30 minutes

Glucose 45?

no

yes
Continue feeding. Monitor glucose before feeding until stable (>45 x 2). Some at-risk babies may develop late hypoglycemia, often between 12 and 24 hours of age. Follow clinically and recheck glucose about every 6 hours, before feeding, for the first 24 hours of life.

Glucose 45?

no yes

yes
Once glucose is >45, screen every 1-2 hours until stable (>45 x 2)

Glucose 45?

no
Repeat minibolus D10W @ 2 ml/kg IV push

Continue IV and wean as tolerated. Some at-risk babies may develop late hypoglycemia, often between 12 and 24 hours of age. Follow clinically and recheck glucose about every 6 hours, for the first 24 hours of life.

no

Symptoms?

Increase rate of D10W to 120 ml/kg/day

yes
Notify LIP. Search for other etiology.

Recheck glucose in no more than 30 minutes

If glucose remains <45, notify LIP to request Neonatology consult. Discuss further therapy and discuss transport/transfer to a higher-level neonatal unit.

yes no

Glucose 45?

2010-2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. PATIENT AND PROVIDER PUBLICATIONS 801.442.2963 CPM011 - 4/12

page 2 of 2