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Hypoglycaemia Management and Prevention in Neonates Guideline

Hypoglycaemia Management and Prevention in Neonates Guideline v2.1 of 17

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Title


Author

Author’s job title Senior Neonatal Staff Nurse and Educator

Directorate Medical

Department SCU

Version Date Issued Status Comment / Changes / Approval

0.1 August 2015

Draft Initial version by SN Deborah Malpass and Dr Ragavendra Subba-Rao for comments.

0.2 November 2015

Draft Extensive editing following comments. Changes to format and order. Further changes to condense and simplify contents.

1.0 November 2015

Final draft Final draft for comments.

1.1 February 2016

Revision Changes after comments from Dr Selter and Sara Wright.

2.0

November 2016

Final Amendments made following comments from midwifery staff.

2.1 September 2017

Revision Feeding chart added to appendices

Main Contact Special Care Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 322610 Tel: Internal – 2610

Lead Director Medical Director

Superseded Documents None

Issue Date November 2016

Review Date November 2019

Review Cycle Three years

Consulted with the following stakeholders:

Paediatrics consultant group

Neonatal nurses Head of midwifery / midwives

Approval and Review Process

Group/Committee

Local Archive Reference G:\ Paediatric Resources/Neonates/Neonatal Guidelines/previous versions of guidelines Local Path G:\ Paediatric Resources/Neonates/Neonatal Guidelines Filename Hypoglycaemia Management and Prevention in Neonates Guideline v2.1



Policy categories for Trust’s internal website (BOB) Neonatal, Neonatal Nursing, Neonates, Paediatric

Tags for Trust’s internal website (Bob) Blood Glucose, Blood Sugar, Newborn, Infant, Jittery



CONTENTS

Document Control........................................................................................................................ 1

1. Purpose ................................................................................................................................ 3

2. Definitions............................................................................................................................ 4

3. Responsibilities .................................................................................................................... 4

4. Introduction and Definition................................................................................................... 4

5. Pathophysiology ................................................................................................................... 5

6. Measurement of glucose ...................................................................................................... 5

7. Risk Factors for hypoglycaemia ............................................................................................. 6

8. Possible symptoms of hypoglycaemia in the newborn ........................................................... 6

9. Management of newborn infants to prevent hypoglycaemia ................................................. 7

10. Management of hypoglycaemia ............................................................................................ 7

11. SCBU management of infants ................................................................................................ 9

12. Process for Implementation and Monitoring Compliance and Effectiveness ........................... 10

Appendix 1 - Flowchart for the management of infants at risk of hypoglycaemia ........................ 11

Appendix 2 ................................................................................................................................ 12

Appendix 3 ................................................................................................................................ 13

Appendix 4 ................................................................................................................................ 13

Appendix 5 Feeding Chart .......................................................................................................... 14

13. References ......................................................................................................................... 16

14. Associated Documentation ................................................................................................. 17

1. Purpose

The purpose of this document is to give guidance on the management and prevention of hypoglycaemia in neonates on the post-natal ward, special care baby unit and paediatric ward if applicable.

This guideline applies to midwives and maternity care assistants on Delivery Suite and Bassett Ward, registered nurses and Health Care Assistants on the Special Care Unit and Caroline Thorpe paediatric ward and all paediatric doctors.

Implementation of this policy will ensure that:

The risks to neonates associated with hypoglycaemia are minimised.



2. Definitions

3. Responsibilities

Role of all clinical staff including nurses, midwives and doctors who care for neonates:

To act in accordance with this guideline

To minimise the risks to neonates associated with hypoglycaemia

4. Introduction and Definition

This document highlights the importance of blood glucose levels in neonates within the first few days of life and explores best practice in relation to the management of hypoglycaemia in order to prevent harm to the neonate. The exact definition of neonatal hypoglycaemia is unclear, and the definition of clinically significant hypoglycaemia remains “one of the most confused and contentious issues in contemporary neonatology” (Cornblath et al, 2000). However, commonly defined and accepted normal blood sugar limits for neonates are 2.6mmol/L to 7mmol/L (Koh et al, 1988, Lucas et al, 1988, Bowell, 2010). Therefore, in neonates blood glucose of less than 2.6mmol/L is defined as hypoglycaemia (WHO, 1997).

EBM Expressed breast milk mmol/l millimole per litre ˃ Greater than ˂ Less than ≥ Greater than or equal to



5. Pathophysiology

Glucose is transferred to the foetus by facilitated diffusion from the maternal circulation. In the first two hours after birth the blood glucose levels fall rapidly. In a healthy term infant the brain is protected by elevated levels of lactate and ketones, with an enhanced ability to use these metabolites. As a healthy term infant it is normal for the blood glucose level to fall and then rise again in the next few hours, either spontaneously or after feeding. Healthy asymptomatic term babies’ blood glucose levels may be normally low in the first few days of life, but this does not seem to have any adverse consequences. Glucose supply is essential, more so when there are conditions associated with high energy demands, such as the exhaustion of glycogen stores caused by birth asphyxia, or the increased metabolic rate caused by sepsis or hypothermia. Preterm infants are at high risk of neonatal hypoglycaemia due to decreased stores of glycogen and fat, poor feed tolerance and impaired hormonal responses. They are also at risk of hypothermia, which can then cause hypoglycaemia. Infants who have been Intra-Uterine Growth Restricted (IUGR) are also at increased risk due to the same reasons. Infants of diabetic mothers are at an increased risk of hypoglycaemia following birth due to the hyperinsulinaemic environment in-utero (Boxwell, 2010).

6. Measurement of glucose

Blood glucose measurement should be carried out using the Roche Performa ‘AccuCheck’ Blood Glucose Meter as screening tool

If AccuCheck reading is below 1.5 mmol/L send sample for laboratory testing for confirmation, but treat immediately

Always ensure ‘AccuCheck’ equipment is maintained and calibrated as per manufacturer’s instructions and that clinical staff are trained in use and signed-off as competent

Biochemistry laboratory using a paediatric grey bottle

Blood gas machine using a capillary tube or blood gas syringe



7. Risk Factors for hypoglycaemia

1. Infants of diabetic mothers (including gestational diabetes)

2. Preterm infants (<37 weeks)

3. Infants Small for Gestational Age (SGA) Or Intra-Uterine Growth Restricted

(IUGR), (ie. <2.5kg and/or <2nd centile)

(see web link here for WHO 0-4 years Boys and Girls Growth Charts)

4. Infants of macrosomic appearance (large for gestational age)

5. Maternal medication (ie. beta blocker therapy, insulin)

6. Hypothermia

7. Haemolytic Disease of the Newborn (bilirubin approaching exchange

transfusion line)

8. Moderate to severe birth asphyxia (requiring admission)

9. Sepsis

10. Seizures

11. Poor feeding (As defined in Appendix F of Newborn Infant Feeding policy)

8. Possible symptoms of hypoglycaemia in the newborn

Tremors and jitteriness

Seizures

Apnoea

Lethargy

Hypotonia

Poor feeding

Weak or high pitched cry

“Jitteriness” alone is not a definitive sign of hypoglycaemia. Many babies will appear

jittery on handling, jitteriness is defined by UNICEF (2013) as “Excessive repetitive

movements of one or more limbs, which are unprovoked and usually relatively fast. It is

important to be sure that this movement is not simply a response to stimuli.”

http://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/uk-who-growth-chart-resources-0-4-years/uk-who-0



9. Management of newborn infants to prevent hypoglycaemia

Encourage skin to skin contact – a warm environment and early feed are the best

ways to prevent hypoglycaemia for all babies.

Early feed - Feed within an hour of birth if possible, and at least 3 hourly thereafter.

If baby not interested in first feed, make sure they have some expressed colostrum

and are fully assessed for signs or ill health and hypoglycaemia. If baby is well check

a blood glucose at least 2 hours after birth. If baby is unwell or symptomatic of

hypoglycaemia this can be done sooner. Follow guidance in Appendix F of Newborn

Infant Feeding policy.

Teach mother how to recognise feeding cues and how to hand express if

breastfeeding.

Monitor baby’s well being - All ‘at-risk’ infants must have an accurate up-to-date

feed chart and prior to feeds check the wellbeing of the baby, considering the infants

level of consciousness, tone, temperature, respiration, colour/perfusion (Unicef,

2013). This can be documented using the NEWS observation chart.

If a baby is less than the 10th centile on a GROW chart, then the weight should be

plotted on a WHO 0-4 years Boys or Girls Growth Chart to establish if they are below

the 2nd centile, and therefore at risk.

10. Management of hypoglycaemia

Blood glucose levels should be checked on all infants who have any risk factors.

Blood glucose should also be checked in infants who exhibit symptoms of

hypoglycaemia and a paediatrician should be informed.

Records of blood glucose measurements, treatment, response to treatment and the management decisions made as a result should be documented accurately in the baby’s purple post-natal notes or care plan and feed chart.

Hypoglycaemia should be treated with an immediate enteral feed, even if the baby is

asymptomatic. This should be the most appropriate method to gestation and clinical

status.

Expressed breast milk will be used for breast fed babies wherever possible.

Supplements with infant formula will be required only when the blood glucose is

below 2.5 mmols and breastfeeding has not been successful and the amount of

Expressed Breast Milk is insufficient to increase blood glucose.

Infants of women with diabetes should not be discharged home to community care until they at least 24 hours of age and have been seen by a medical professional who is satisfied they are feeding well and maintaining their blood glucose level ≥2.6 mmol/l (NICE, 2008).

http://www.northdevonhealth.nhs.uk/new/wp-content/uploads/2016/02/Newborn-Infant-Feeding-Policy-and-Guidelines-PDF-V2.0-03FEB16.pdf

http://www.northdevonhealth.nhs.uk/new/wp-content/uploads/2016/02/Newborn-Infant-Feeding-Policy-and-Guidelines-PDF-V2.0-03FEB16.pdf

http://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/uk-who-growth-chart-resources-0-4-years/uk-who-0



Infants of women with diabetes who are hypoglycaemic with symptoms should also have blood testing for polycythaemia, hyperbilirubinaemia, hypocalcemia and hypomagnesia. (NICE, 2008).

If the blood glucose of at ‘at-risk’ infant being tested is ≥ 2.6 mmol/l, the blood glucose should be checked before subsequent feeds. Stop monitoring when 3 successive pre-feed blood glucose levels are ≥ 2.6 mmol/l.

Feeding should be ‘baby-led’ as per Newborn Infant Feeding Policy, but with a maximum interval of 3 hours between feeds. Prior to feeds check the wellbeing of the baby, considering the infants level of consciousness, tone, temperature, respiration, colour/perfusion (Unicef, 2013).

All stages apply to the first blood sugar result, if the next result (the

second) remains <2.6 mmol/l, this should be discussed with a paediatrician

Blood glucose 1.5 mmol/l to 2.5 mmol/l

Give breastfeed with top-up of expressed breast milk or appropriate formula top-up, or if formula feeding give a full 3 hourly amount of first infant formula at 8-12ml/kg.

If baby reluctant to feed (even with top-up) follow the guidance in Appendix F of the ‘Newborn Infant Feeding policy’ and ask for paediatric review

Inform Paediatric SHO or Registrar to make them aware and discuss plan

Check blood glucose 1 hour post-feed If the second result remains <2.6 mmol/l, this should be discussed again with a paediatrician

Blood glucose <1.5mmol/l

Send blood glucose sample for laboratory testing

Give breastfeed and a full feed top-up of 8-12ml/kg, or a 3 hourly amount of appropriate

formula top-up at 8-12ml/kg each feed.

Inform Paediatrician and arrange to attend and clinically review infant

Consider admission to SCBU if feeds poorly tolerated, and consider 2.5ml/kg Dextrose bolus

over 5 minutes and/or intravenous 10% Dextrose infusion as per SCBU maintenance fluid

regime

If intravenous access is difficult consider use of Dextrose Gel 40% 0.5ml/kg massaged onto

the buccal membranes or Glucagon 0.1 mg/kg IM (maximum of 1mg).

Check blood glucose 1 hour-post feed / change

If the second result remains <2.6 mmol/l, this should be discussed with a paediatrician

˂1.0mmol/l or unreadable

Admit to SCBU and consider feeding interval or volume changes

If feeds poorly already tolerated consider intravenous bolus of 10% Dextrose at 2.5ml/kg

and/or commencing infusion as per SCBU maintenance fluid regime

Re-check blood glucose after 30 minutes



11. SCBU management of infants

(for infants who are symptomatic, or high-risk infants where enteral feeds are contra-indicated, or infants who’s blood glucose remains low after intervention):

- Consider admission to SCBU

- Consider changing feed interval to more frequent ie. 1 or 2 hourly feeds

- Consider increasing fluid intake to next day mls/kg on SCBU maintenance

fluid regime

- Consider an intravenous Dextrose bolus at 2.5mls/kg

- Consider increasing intravenous 10% Dextrose infusion up to a maximum of

90ml/kg/day if newborn and monitor serum sodium levels to prevent

hyponatraemia

- If blood glucose still low, ensure Paediatric consultant has been informed,

and once up to 90mls/kg/day of intravenous 10% Dextrose, increase the

concentration rather than volume appropriately, up to 12.5% then 15% if

necessary. (If > 12.5% Dextrose is used, this must be given via a central line

to avoid complications - See appendix 3 for how to prepare).

- Infants over a few days old will need fluid maintenance volumes managed on

an individual basis

- If intravenous access is difficult ask for senior help and consider use of

Dextrose gel 40% 0.5ml/kg using an enteral syringe to draw up and then

massage onto the buccal membranes OR glucagon (Gluca-gen HypoKit in

fridge on SCBU) 0.1 mg/kg IM (maximum of 1.0mg)

- Investigations: When hypoglycaemia is persistent (glucose <2.2 mmol/L for

more than 72 hours) in the absence of clearly identifiable risk factors, further

investigation should be undertaken (as in appendix 2).

- Investigations for CRP, FBC and blood cultures and treatment with antibiotics

should be considered if sepsis is suspected.

-If repeated blood glucose is ≥ 2.6 mmol/l or rapidly rising and infant is on intravenous Dextrose,

re-start enteral feeds and titrate with Dextrose as tolerated and as per Paediatrician’s advice



- Consider testing Calcium levels if infant is jittery

12. Process for Implementation and Monitoring Compliance and Effectiveness

Implementation of this guideline not required, as this practice is already in place in

all applicable areas.

Staff are informed of revised documentation. There is an expectation that staff are

responsible to keep updated on any improvements to practice and deliver care

accordingly.

Non-adherence to the guideline is reported by use of the Datix system. Incidents are

monitored and reviewed by the neonatal governance team and action plans made if

required. Individual cases are discussed at handover, on ward rounds and weekly on

grand rounds and are used for learning in safeguarding supervision.

Further discussion and reviews occur at Directorate meetings, Neonatal/Paediatric

Governance meetings Maternity Patient Safety Meetings and locally at Ward

meetings. Learning and action plans are cascaded at these meetings and

improvements implemented. Key findings and learning points will be disseminated

to relevant staff.



Appendix 1 - Flowchart for the management of infants at risk of

hypoglycaemia

No

Yes

Care at birth to include:

• Dry baby, keep warm, initiate skin-to-skin contact

• First feed as soon as possible, always within the first hour; observation of wellbeing

Fed effectively?

Ongoing management to include:

* Review

Baby-led feeds (but at least 3 hourly)

Encourage mother to observe feeding

cues

Keep baby warm

Pre-feed blood glucose monitoring,

(initially prior to 2nd

feed), then stop when

level is normal x3

Blood glucose measurement above 2.6 mmol/l

Blood glucose measurement between 1.5 and 2.6 mmol/l

Proactive management:

Ongoing observation

Give breast or formula feed

If breastfeeding, hand express and give EBM (if not available continue expressing hourly)

Ongoing skin contact/ temperature maintenance

Newborns at risk of hypoglycaemia:

Infants of diabetic mothers Pre-term infants (<37 weeks) Low birth weight (<2.5 kgs or <2

nd centile)

Infants of macrosomic appearance Maternal medications Hypothermia Haemolytic Disease of Newborn Mod. or Sev. Birth Asphyxia Sepsis Seizures Poor feeding (See Appendix F Newborn Infant Feeding guideline)

Within 3-4 hours of age:

Review

Pre-feed glucose

measurement

*Review

Prior to feeds check:

Level of

consciousness

Tone

Temperature

Respirations

Colour

Inform paediatrician

Breastfeed followed by EBM or formula

full top-up by cup or nasogastric tube/

Formula feed full 3 hourly amount by

bottle or nasogastric tube

Repeat blood glucose in 1 hour

Blood glucose above 2.6 mmol/l

Blood glucose below 2.6 mmol/l

Symptomatic hypoglycaemia:

Apnoea Cyanosis Jitteriness Convulsions Or blood glucose below 1.5 mmol/l at any stage:

Refer baby to paediatrician

Blood glucose measurement below 1.5mmol/L

Refer to paediatrician, consider SCBU

Management’



Appendix 2 Investigations recommended in significant persistant hypoglycaemia

Test Volume Colour of

Specimen

bottle

Sample Note

Laboratory

Glucose

0.5mLs Grey Capillary or venous

blood

Insulin 1mL (Full Paed

bottle)

Purple

Venous blood Serum (not haemolysed)

to lab within 20

minutes. (To RD&E)

Growth

hormone

0.6mLs (Full Paed

bottle)

Yellow Venous blood (To BRI)

Cortisol 0.6mLs (Full Paed

bottle)

Yellow Venous blood

Free fatty acids 1mL Grey Venous blood (To Southmead)

β-hydroxybutyrate 1mL Grey Venous blood (To Southmead)

Urinary ketones 3mLs White

topped

Urine Next urine voided after

hypoglycaemic episode

(Use bedside ketone

meter if possible).

Other (non-urgent) investigations should include:

Test Volume Colour of

specimen bottle

Capillary/

Venous

Note

TFT’s (TSH, T4)

LFT’s and U+E’s

Full Yellow Venous blood

Ammonia 1mL (Full Paed

bottle)

Purple

Venous blood To lab within 15 mins

on ice.

Acylcarnitine

profile

N/A N/A Capillary or

venous blood

2 spots on Newborn

Bloodspot card

Plasma amino

acids

0.6mLs (Full Paed

bottle)

Yellow Capillary or

venous blood

(To Southmead)

Lactate and blood

gas

0.5mLs Capillary tube Capillary or

venous blood

Use blood gas

machine

Urinary organic

acids

5mLs White topped Urine (To Southmead)

Also consider CRP, FBC and blood cultures if sepsis is suspected, and antibiotic treatment if necessary.

Contact Biochemistry: i) via phone within working hours: ex. 2419 (biochemist) or ex. 2345 (lab); ii) via bleep 031 'out of hours'



Appendix 3

Volume of dextrose concentrations and infusion rates for glucose infusion:

Table 1: preparation of higher dextrose concentration for fluids in 500mls

Infusion concentration Volume of 10% dextrose Volume of 50% glucose

12.5% 465mls 35mls

15.0% 440mls 60mls

17.5mls 405mls 95mls

20% 375mls 125mls

Table 2: preparation of higher dextrose concentration for fluids in 50mls

Infusion concentration Volume of 10% glucose Volume of 50% glucose

12.5% 46.5mls 3.5mls

15.0% 44.0mls 6.0mls

17.5% 40.5mls 9.5mls

20% 37.5mls 12.5mls

Appendix 4

To calculate an infant’s glucose requirement:

Glucose rate (mg/kg/min) = Dextrose concentration x Volume infused in ml/kg/day 144

Infants requiring ˃10mgs/kg/day of glucose usually have a pathological basis for their hypoglycaemia, and

treating the cause is as important as correcting the low glucose level



Appendix 5 Feeding Chart

Gestation Additional Information

E.g. IVABs, tongue-tie, centile

Birth Weight

Feeding Management Plan

Date Day Weight Milk Type / Method

Frequency If top up required: mls / feed

Total expected Daily Input

Total 24 hour input

Discussed with mother

Comments Initials

Date Time

Start/Finish Milk Type / Method

Pre/Post BM

Total Taken

Passed Urine

Stools Colour

Additional Information Initials

Please review for jaundice at each feed if possible, and comment under ‘Additional Information’

Patient Identification Label



Feeding Management Plan

Date Time

Start/Finish Milk Type / Method

Pre/Post BM

Total Taken

Passed Urine

Stools Colour

Additional Information Initials



13. References

Adamkin, D. H. (2009) Late preterm infants: severe hyperbilirubinemia and postnatal glucose homeostasis. Journal of Perinatology (29) 12-17. Boxwell, G. (2010) Neonatal Intensive Care Nursing, 2nd Edition. Routledge, New York. Cornblath, M. Hawdon, J. and Williams, A. (2000) Controversies regarding definition of neonatal hypoglycaemia: suggested operational thresholds. Paediatrics (105) 1141-1145. Cornblath, M, Schwartz, R. (1993) Hypoglycaemia in the neonate. Journal of Paediatric Endocrinology. (6) 113-129. Cornblath, M. and Ichord, R. (2000) Hypoglycaemia in the neonate. Seminars in Perinatology (24) 136. CEMACH (2007) Diabetes in pregnancy: caring for the baby after birth. Findings of a national enquiry. Hawdon, J. M., Ward-Platt, M. P., Aynsley-Green, A. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week. Archives of Disease in Childhood (67) 357-365. Hay, Jr. W., Faju, T., Higgins, R. D., Kalhan, S. C., Devaskar, S. U. (2009) Knowledge gaps and research needs for understanding and treating neonatal hypoglycemia: workshop report from Eunice Kennedy Shriver National Institute of Child Health and Human Development. Journal of Pediatrics, 155 (5) 612-7. Koh, T. H. H. G., Aynsley-Green, A., Tarbit, M. et al. (1998) Neural dysfunction during hypoglycaemia. Archives of Disease in Childhood (63)1353-1358. Lucas, A., Morley, R., Cole, T. J. (1988) Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia. British Medical Journal, 297 (6659):1304-8. National Institute for Health and Clinical Excellence (2008) Diabetes in pregnancy. Management of diabetes and its complications from pre-conception to the postnatal period London: NICE. [Available on-line at: www.nice.org.uk] Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007) Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London RCOG Press [Available on-line at: www.rcog.org.uk] Rozance, P. J. and Hay, W. W. (2010) Neonatal Hyperglycaemia. American Academy of Pediatrics. 11 (11) 632-640. Stenninger, E., Flink, R., Eriksson, B. and Sahlen, C. (1998) Long-term neurological dysfunction and neonatal hypoglycaemia after diabetic pregnancy. Archives of Disease in Children and Foetal and Neonatal Education, 79 (3) 174-9.

http://www.nice.org.uk/

http://www.rcog.org.uk/



UNICEF UK Baby Friendly Initiative (2007). Guidance on the development of policies and guidelines for the prevention and management of Hypoglycaemia of the Newborn. UNICEF. [Available on-line at www.babyfriendly.org.uk]

14. Associated Documentation

NDHT Newborn Infant Feeding policy and guidelines

NDHT Care of the Newborn Immediately After Birth guideline

NDHT Thermal Care of the Neonate guideline

http://www.northdevonhealth.nhs.uk/wp-content/uploads/2016/02/Newborn-Infant-Feeding-Policy-and-Guidelines-PDF-V2.0-03FEB16.pdf

http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2013/09/Care-of-Newborn-immediately-after-birth-guidelines-V5.0-29Jan14.pdf

http://www.northdevonhealth.nhs.uk/wp-content/uploads/2016/07/Thermal-care-of-the-Neonate-V1.0-May15.pdf

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