Neonatal hypoglycaemia and blood glucose level monitoring Clinical Guideline Education Package 30 minutes Towards your CPD Hours.

Neonatal hypoglycaemia and blood glucose level monitoring

Clinical Guideline Education Package

30 minutes

Towards your CPD Hours

Pre-test• Have you completed the

pre-test?– If not, please complete a pre-

test and return it to the designated box

• Don’t forget to complete, tear off and return the small card on top of the paper

• Contact your Champion if you require help

Objectives

• Become familiar with the Neonatal hypoglycaemia and blood glucose level monitoring Clinical Guideline

• Develop an understanding of the key recommendations

• Increased knowledge of good clinical care provision for babies ‘at risk’ of neonatal hypoglycaemia

Introduction• At birth babies must initiate glucose

production and absorption to maintain their blood glucose levels (BGL)

• Some babies may be unable to make the metabolic adaptation to extra uterine life– These babies are ‘at risk’ of severe or

persistent hypoglycaemia

Definitions• Hypoglycaemia is:

• a BGL < 2.6 mmol/L

• Severe hypoglycaemia is:• a BGL < 1.4 mmol/L or• a BGL < 2.6 mmol/L despite greater than 10 mg/kg/min

of glucose being administered

• Persistent or recurrent hypoglycaemia:– Definition is controversial, two options for practice:

• any 3 BGLs < 2.6 mmol/L• hypoglycaemia persisting/recurring after 72 hrs

Equipment• A BGL may be measured using:

• a bedside glucometer» using only glucometers that use the glucose oxidase

test strip with electrochemical sensor

• a blood gas machine

• the biochemical laboratory

• Confirm any BGL < 2.0 mmol/L by blood gas machine or laboratory testing

Babies at risk

Risk factors for neonatal hypoglycaemia may be due to maternal or neonatal

factors

Babies at riskMaternal factors

• Maternal diabetes mellitus• risk correlates with quality of control during

pregnancy more than category of diabetes

• Intrapartum administration of glucose

• Maternal drug therapy including:• β-blockers• oral hypoglycaemic agents• cipramil• terbutaline• valproate

Babies at riskNeonatal factors

Prematurity less than 37 weeks Intrauterine growth restriction

Macrosomia Perinatal hypoxic-ischaemic insult

Respiratory distress Sepsis

Hypothermia Polycythaemia

Congenital cardiac abnormalities Neonatal hyperinsulinism

Endocrine disorders Inborn errors of metabolism

Rhesus haemolytic disease Erythroblastosis fetalis

Obvious syndromes– with midline defects (e.g. cleft palate)– Beckwith-Weidemann syndrome

Iatrogenic– intravenous (IV) cannula infiltrated– inadequate feeding

Management of babies at risk

• Basic management principles:

– prevent babies from becoming hypoglycaemic

– detect those babies that are hypoglycaemic– treat those babes that are hypoglycaemic– find a cause if the hypoglycaemia is severe,

persistent or recurrent

Management of babies at riskPrevention

• Initiate skin to skin to avoid hypothermia• if gestation and condition allow• nurse in an incubator if required

• Provide energy:• initiate early feeds within 30 – 60 min of birth

– breastfeed or– give expressed breast milk (EBM), if baby reluctant or not

appearing to feed well– formula if mother plans to artificially feed– gavage feeds of EBM and/or formula (with maternal consent)

if baby is less than 35 weeks gestation• commence IV therapy 10% Dextrose at 60 mL/kg/day, if

enteral feeding not possible

• If feeding, continue 3 hrly oral feeds or more frequently if baby is demanding

Management of babies at riskDetection

It is not necessary to screen asymptomatic, appropriately grown term babies that do not have

risk factors

Management of babies at riskDetection

• The clinical signs of hypoglycaemia are neither sensitive nor specific

• Any baby that is unwell or who has signs that cannot be readily explained should have their BGL checked

• Babies with signs specific for hypoglycamia require urgent paediatric review and management with IV therapy

Management of babies at riskDetection

• Hypoglycaemic babies may show any of the following signs:

• tremors / jitteriness• pallor• poor feeding / intolerance after feeding well• irritability• hypothermia• high pitched cry• diaphoresis (sweating)• temperature instability• tachycardia• apnoea with cyanotic episodes• hypotonia• changes in level of consciousness• seizures

Management of babies at riskDetection

• Babies should have blood glucose screens if:

– they have any risk factors (one or more)– they are unwell– they have any unexplained abnormal signs that may

be due to hypoglycaemia

• When sampling for BGL, ensure the baby receives appropriate analgesia according to local policy– Oral sucrose is not contraindicated in babies of

diabetic mothers

Antenatal CareBirth Mode

• Decision about birth mode after a previous CS should consider:

• Maternal preferences and priorities• Facility capabilities• Maternal and perinatal risks and benefits of VBAC

and elective repeat CS– considered in the context of the woman’s individual

circumstances– refer to VBAC Guideline for recommendations

Management of babies at riskDetection

• Well babies with risk factors:– the timing of checking BGLs remains controversial

for this group of babies

• Options for practice are:– at 1, 2 and 4 hrs of age then every 4 – 6 hrs until

monitoring is ceased OR– pre second feed. This should be within 3 hrs of

birth, then check pre-feeds until monitoring ceases

• Practice in accordance with your local hospital policy

Management of babies at riskDetection

• Unwell babies with/without risk factors:

– check BGL immediately, repeat BGL checks regularly while the baby is unwell (at least 6 hrly)

• Confirm any glucometer BGL less than 2 mmol/L by blood gas machine or laboratory analysis

• However, do not wait for this confirmation before starting the appropriate treatment

Management of babies at riskTreatment

• Well babies with no clinical signs:– if a baby has one abnormal BGL, continue to monitor

until normal for 24 hrs (at least 6 hrly)

• BGL 1.5-2.5 mmol/L– maintain close surveillance– feed or offer another feed immediately

• give additional EBM if available, formula if not• give formula if mother plans to artificially feed

– recheck BGL after 30-60 min– if BGL does not increase after a feed, commence IV

10% Dextrose at 60 mL/kg/day– IV therapy is indicated for BGL persistently < 2.0 mmol/L

Management of babies at riskTreatment

• BGL 1.0-1.4 mmol/L– commence IV 10% Dextrose at 60 mL/kg/day– consider IM glucagon 200 microgram/kg, if IV

access is delayed– recheck BGL after 30 min

• therapeutic goal is greater than or equal to 2.6 mmol/L– adjust IV therapy to achieve therapeutic goal

Management of babies at riskTreatment

• BGL < 1.0 mmol/L or unrecordable– urgent treatment with IV therapy – do not wait for confirmation of low BGL before

commencing IV therapy– commence IV 10% Dextrose at 60-75 mL/kg/day– consider 2 mL/kg bolus of 10% Dextrose

– consider IM glucagon 200 microgram/kg if IV delay– recheck BGL after 30 min

• the therapeutic goal is ≥ 2.6 mmol/L– adjust IV therapy to achieve therapeutic goal

NEVER give a bolus of dextrose without also increasing the background rate or concentration of IV Dextrose infusion

Management of babies at riskTreatment

• Cease BGL monitoring:

– in babies that are well and have not required IV therapy once BGLs have been ≥ 2.6 mmol/L for 24 hrs

– only applies to babies who are not found to have an underlying cause for the hypoglycaemia

Management of babies at riskTreatment

• Unwell babies with/without clinical signs

• Intervention is required:

– commence IV 10% Dextrose 60 mL/kg/day

– recheck BGL after 30 min• adjust IVT to achieve a therapeutic BGL of ≥ 2.6 mmol/L

Management of babies at riskTreatment

• Intravenous Therapy

• Indicated for babies who:– have BGLs persistently < 2.0 mmol/L– have a BGL < 1.5 mmol/L– are unwell– are not tolerating enteral feeds

Management of babies at riskTreatment

• Once IV treatment commenced– check BGL hrly until ≥ 2.6 mmol/L– then continue 4 hrly

Note: inadequate dextrose infusion rates are a common cause of ongoing hypoglycaemia

• If BGL remains > 2.6 mmol/L– increase Dextrose concentration– increase rate– consider increasing concentration and rate in

combination

Management of babies at riskTreatment

• Considerations:– be cautious of fluid overload – if rate >100 mL/kg/day on day 1 of life,

consider increasing concentration instead of rate

– concentrations of Dextrose ≥ 12% should be delivered via a central or umbilical line

– pharmacological intervention may be required– refer to Table 1 in Guideline for recommendations

Management of babies at riskTreatment

• Breastfeeding is not contraindicated while baby is receiving IVT as long as baby is well

• Mother may need extra reassurance– Consider referral to a midwife or lactation

consultant for support

Management of babies at riskTreatment

• Decrease IVT:– once BGL stable for 12 hrs– do not decrease abruptly– reduce gradually– increase volume of enteral feeds concurrently

Management of babies at riskSevere, persistent, recurrent hypoglycaemia

• These babies are at risk of developing neurological morbidity

• Hypoglycaemia is an important marker for a number of serious diseases

• Further investigation is required– refer to page 12 of the Guideline for recommendations

• Non Level 3 Neonatal units should consider discussing such babies with a Neonatologist

Management of babies at riskSevere, persistent, recurrent hypoglycaemia

• Hypoglycaemia screen to be done:– while the baby is hypoglycaemic– before giving any Dextrose treatment

• If there is difficulty collecting samples, treatment should commence without delay

– refer Table 2 & 3 in Guideline for test recommendations

• Practice Tip: prepare a ‘hypoglycaemia screen kit’ to help reduce delays in sample collection

• Consider the need for transfer to a higher level facility for ongoing management

Inter-hospital transfer

• Arrange according to local policy

• Coordinated by Retrieval Services Queensland

Follow up

• Follow up depends on severity and duration of hypoglycaemia

• Discuss with Neonatologist

Post-test

• Please complete the Post-Test (Education) and return it to the designated box

• Don’t forget to complete, tear off and return the small card on top of the test paper

References• Statewide Maternity and Neonatal Clinical Guidelines Program, 2010. Maternity and Neonatal

Clinical Guideline: Neonatal hypoglycaemia and blood glucose level monitoring, Queensland Health, Brisbane, Queensland.

Contact DetailsJacinta LeeA/Manager

Queensland Maternity and Neonatal Clinical Guidelines ProgramTranslating evidence into best clinical practice

GPO Box 48 Brisbane QLD 4001P: (07) 3131 6777M: 0407 922 760E: [email protected]

Visit our website:http://www.health.qld.gov.au/cpic/resources/mat_guidelines.asp