Neonatal Hypoglycemia

By: Alli Chulada, Alyssa Breda, Henry Chouinard, and Katelyn bouchardWildcat Hospital Neonatal Hypoglycemia PolicyContentsBackgroundPathophysiologyPurposeApplicationsSigns and SymptomsScreening and ManagementSources

BackgroundBlood sugars measured since 1911Policies from WDH, CMC, Southern, and EHCompared and Reviewed National GuidelineCreated our own policy for Wildcat Hospital

PathophysiologyLoss of continuous transplecental infusion of glucoseInadequate glycogen production/storageEndocrine disorders cortisol, GH, epinephrineDiabetic mother hyperinsulinism PurposeProvide standardized guidelines for screening and management of newborns at risk or showing signs and symptoms of hypoglycemia.ApplicationsAt risk for hypoglycemia:Preterm or post-term infant (less than 37 weeks or greater than 42 weeks)Small for gestational ageLarge for gestational ageInfant of diabetic motherInfant of mother treated with oral hypoglycemic agents or beta adrenergic medications Sick or stressed infants Intrauterine Growth Restriction

Signs and SymptomsJitterinessTremorsHypotoniaChanges in LOC [irritability, lethargy, stupor, seizure]Weak or high pitched cryPoor sucking or feedingApneaHypothermiaTachypnea Cyanosis

Screening and ManagementInfants showing signs and symptomsObtain blood glucose (BG) immediately via heel stick. If BG is less than 40 mg/dL, send blood sample to lab for confirmation. Start treatment immediately; do not wait for laboratory confirmation.

Screening and ManagementInitiate IV glucose therapyBolus infusion: D10W at 200mg/kg (dextrose 10%) over 1 minute. Check BG 20 minutes after bolus infusion, adjust IV infusion rate as needed IV infusion: D10W at 6-8mg/kg/min. Check BG every shift while infant is receiving continuous infusion.In infants with persistent hypoglycemia seek further evaluation to determine the cause.

Screening and Management For all infants at risk who are asymptomaticBirth to 4 hours of ageInitiate feeding within 1st hour of lifeIf newborn is unable to feed, notify the physician for possibly of gavage feedings.

Screening and ManagementScreen for blood glucose within the first 30min after the feedingIf BG is less than 40 mg/dL, send blood sample to lab for confirmation. Start treatment immediately; do not wait for laboratory confirmation. If BG is greater than 25mg/dL begin scheduled feedings every 2-3 hours. Check blood glucose after 1 hour of feeding.If BG is between 25-40mg/dL notify the provider to either repeat feeding with formula or initiate IV glucose therapy.

Screening and ManagementIf BG is less than 25mg/dL notify the physician and repeat feeding. Recheck BG in 1 hour.If BG remains less than 25mg/dL notify the physician prior to initiating IV glucose therapy Bolus infusion: D10W at 200mg/kg (dextrose 10%) over 1 minute. Check BG 20 minutes after bolus infusion, adjust IV infusion rate as needed IV infusion: D10W at 6-8mg/kg/min. Check BG every shift while infant is receiving continuous infusion.Goal: target range of BG 40-50mg/dL. At 1st 24 hour of IV therapy, target glucose screen greater than 45mg/dL.

Screening and ManagementIf BG is between 25-40mg/dL, repeat feeding and recheck blood glucose in 1 hour. Notify the physician to consider IV glucose therapyIf BG is greater than 40 mg/dL begin scheduled feedings every 2-3 hours. Check blood glucose prior to each feed.Screening and Management4-24 hours of age

Continue feeds every 2-3 hours, screen glucose before each feed. If BG is less than 35mg/dLRepeat feeding immediately and recheck BG in 1 hour. If BG is less than 35mg/dL, notify the provider before initiating IV glucose therapy

Screening and ManagementBolus infusion: D10W at 200mg/kg (dextrose 10%) over 1 minute. Check BG 20 minutes after bolus infusion, adjust IV infusion rate as needed IV infusion: D10W at 6-8mg/kg/min. Check BG every shift while infant is receiving continuous infusion.Goal: target range of BG 40-50mg/dL. At 1st 24 hour of IV therapy, target glucose screen greater than 45mg/dL.

Screening and ManagementIf BG is between 35-45mg/dL, notify physician to repeat feeding or consider initiating IV glucose therapy. If BG is greater than 45mg/dL continue feedings every 2-3 hours and screen prior to feedings.

Screening and ManagementWeaning of IV glucoseIf newborn is being managed on continuous IV glucose therapy without bolus dose or increasing of IV infusion rate can maintain a blood glucose between 40-50mg/dL and a target glucose screen greater than 45mg/dL after 1st 24 hours of infusion and prior to feedsScreening and ManagementNewborn is able to maintain thermoregulation Newborn is able to maintain respiratory rate less than 60 breaths/minuteNewborn is breastfeeding well or feeding at least 10mL/kg of formula every 3 hoursDecrease IV glucose therapy rate of D10W by 25% of original rate every 3-6 hours PRN

Screening and ManagementContinue with feedings after 2-3 hours and assess blood glucose prior to feeds. Notify physician if infant is not tolerating weaning process or begins to decline in status. Convert IV to saline lock when weaning is complete. Refer below to discontinuation of blood glucose screening.

Screening and ManagementDiscontinuation of blood glucose screeningContinue screening through 1st 12 hours of infants of diabetic mothers and infants LGA. Continue screening through 1st 24 hours of infants SGA and late-preterm. To discontinue testing newborn must maintain normal glucose concentrations (greater than 50mg/dL) during three consecutive routine feedings. If blood glucose is less than 50mg/dL after 24 hours, notify physician to consider alternative causes of hypoglycemia. Possible Endocrinologist consult.SourcesChan, S. W. (n.d.). Neonatal hypoglycemia. Neonatal hypoglycemia. Retrieved March 19, 2014, from http://www.uptodate.com/contents/neonatal-hypoglycemiaCornblath, M. (n.d.). Result Filters. National Center for Biotechnology Information. Retrieved March 19, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/9200872 Questions?