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Oral Glucose Gel:
Low Cost, Quick and Effective Management of
Neonatal Hypoglycemia
In a continuous endeavor to maintain best practice for neonatal
care, increasing and maintaining exclusive breastfeeding rates
stays at the forefront of our perinatal department’s agenda. With
the intention to lower the rate of separation of mom’s and babies,
and positively impact breastfeeding we joined forces. In
collaboration with all perinatal areas, lactation, pediatrics,
neonatology, information systems and the families we serve, in
July 2017 we launched the use of oral glucose gel for treatment of
neonatal hypoglycemia. Evidence was presented to all staff
(Harris,etal, 2013)( AAP, 2011 ). Following AAP guidelines an
algorithm was established, policy and practice were updated and
the staff trained one on one. Through two quarters we fine-tuned
our data collection, adjusted to the unexpected new glucometers,
and managed to drop our rate of admission to NICU with a primary
diagnosis of hypoglycemia from 12% to 3% of all hypoglycemic
neonates born at our community NICU.
INTRODUCTION
OBJECTIVES
A Gap analysis early in the project revealed a general lack of knowledge,
absence of dextrose Gel in the institution, and a clear ordering method. As
the project was adopted by the Pediatric committee and the unit based
nurse committees from Couplet Care, the NICU and lactation teams, the
need for a strong multilevel education plan became clear. All stakeholders
including the pharmacy and information technology team would be
involved. A GANNT chart kept us abreast of our progress, and leaders
from every area kept the conversation alive with monthly updates avoiding
a surprise practice change for all staff involved.
Major Goals Met- 15 months
1. Buy in from Neonatology
2. Creating a Policy: Many revisions
3.Add 40% Dextrose Gel to formulary
a) Pricing
b) Stock in medication dispensing machine
c) Documentation in EMR
d) Multi-dose tube scanned with every administration
4. New order: added to hypoglycemia order set
a) Originally not pre-checked
b) Pre-checked as Physician confidence grew
c) Originally physician notification with every dose
5. Staff Training:
a) New algorithm
b) Pharmacy training
c) Medicine: 95% communication by phone with pediatricians
d) Neonatology: awareness of process and availability of product in
nursery
e) IT: Training all users to utilize the order
f) Nursing: Gel administration, 1:1 hands on training, blood sugar
follow up, and team communication and support
METHODS AND MATERIALS CONCLUSIONS & DISCUSSION
The use of oral Dextrose Gel is a viable, cost effective method of treating
neonatal hypoglycemia. Within 3 fiscal quarters, the rate of babies with
hypoglycemia admitted to NICU dropped from 12% to 3%. However, the
target is moving and difficult to stay ahead of. With differing
recommendations for “normal blood Sugars”, and the pressing issue of
exclusive breastfeeding this algorithm remains a hot topic.
• With the First two patients receiving gel, the second blood sugar
remained below 30 mg dL, thirty minutes after the dextrose gel dose.
They were taken to NICU for IV Dextrose, but blood sugar in NICU
was> 60 g/dL, the baby went back to the mother, and we lengthened the
interval between dose and recheck of blood sugar.
• The first ever dose of glucose gel given was on a weekend. It was
requested by a pediatrician. The staff were annoyed that it was so hard
to obtain- because go live was not until Monday. The pharmacist found
it and a dose was given, keeping the baby with the mother. Go Live that
Monday, took care of that.
• Originally, Staff needed to notify the pediatrician for an order prior to
every dose. This generated too many calls and the algorithm was
adjusted
REFERENCES
AAP (2011). Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics 3
(127). Retrieved from http://pediatrics.aappublications.org/content/127/3/575.short
Bennett, Fagan, Chaharbakhshi E, Zamifirova, & Flicker (2016). Implementing a protocol
using glucose gel to treat neonatal hypoglycemia, Nursing and Women’s Health. 2016 Feb-
Mar;20(1):64-74.doi: 10.1016/j.nwh.2015.11.001 Epub, 2016 Feb 12.
Cochrane Review, (2016). Oral dextrose gel for treatment of newborn infants with low blood
glucose levels. Retrieved from: http://www.cochrane.org/CD011027/NEONATAL_oral-
dextrose-gel-treatment-newborn-infants-low-blood-glucose-levels
Harris DL, Weston PJ, Signal M, Chase JG, & Harding JE ( 2013). Dextrose gel for neonatal
hypoglycemia randomized, double blind, placebo-controlled trial. Lancet. 2013
Dec.21;38(9910):2077-83. doi: 10.1016/S0140-6736(13)61645-1
Office of the surgeon General (2011). The surgeon general’s call to action to support
breastfeeding. Publications and reports of the surgeon General. Retrieved from:
https://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
WHO (2010). Health Topics: Breastfeeding. Retrieved from:
http://www.who.int/topics/breastfeeding/en/
ACNOWLEDGEMENTS AND CONTACT
Sharon McMahon APRN, CNS- [email protected]
Mary Beth Sweet, IBCLC- [email protected]
Mary Welch, BSN, RNC-NIC [email protected]
Sally McGann, Director, HMNH Perinatal, [email protected]
Newborn Pediatric Committee HMNH
It has been amply demonstrated that exclusive breastfeeding positively
impacts the health of both mothers and babies (USDHHS, 2011).
In our community hospital, while approximately 400 bedside neonatal
blood sugars per month are checked secondary to risk factors for
hypoglycemia or demonstrations of symptoms of low blood sugar (AAP,
2013), only about 10 % of those patients are admitted to NICU for
hypoglycemia. These newborns are separated from their family negatively
impacting their ability to establish exclusive breastfeeding during the
newborn inpatient stay. In an effort to keep mothers and babies together
and allow optimal opportunities for skin to skin, preservation of the family
unit, and unlimited access to breastfeeding, oral Dextrose gel for treatment
of neonatal hypoglycemia was implemented.
Henry Mayo Newhall Hospital
Sharon McMahon APRN, CNS NICU Mary Beth Sweet, IBCLC
Addressing Barriers to Exclusive Breastfeeding
Keeping Moms and Babies Together: Dextrose Gel and Neonatal Hypoglycemia
Evidence
HMNH ALGORITHM
RESULTS
Within 3 fiscal quarters, the rate of admission to NICU for hypoglycemia
dropped from 12% to 3%.
The total number of necessary blood sugars for newborn nursery and
NICU combined dropped 20%.
DOSE: 0.2 grams Glucose / kg / dose
(D10W = 0.1 gram / mL) Glutose Gel = 0.4 gram / mL
STAFF EDUCATIONAL POSTER
- -
Dextrose is Glucose is Dextrose
Weight in
kg
Dose of 40%
Oral Gucose Gel
in grams
Volume, mL
2 0.4 1
2.5 0.5 1.25
3 0.6 1.5
3.5 0.7 1.75
4 0.8 2
4.5 0.9 2.25
5 1 2.5
Asymptomatic with Risk FactoRS:
Infant of Diabetic Mother (IDM)
Large for Gestational Age (LGA) or BW ≥ 4000 grams
Small for Gestational Age (SGA) or BW ≤ 2500 grams
Late preterm: 35 0/7 – 36 6/7 weeks gestation
Symptomatic Any Time During Stay:
Jittery, tremors, seizures
Lethargy, poor feeding
Apnea, respiratory distress
Hypotonic, floppy, irritable
Exaggerated Moro
High pitched, feeble cry
BIRTH Immediate Skin-to-Skin and Assist with Breastfeeding
POCT #1 After Breastfeeding, within 1 hour of birth
Immediately upon demonstration of symptoms
RESULTS: Bedside glucose
check = POCT Encourage mom to hand express and feed back any available EBM
in Addition to any other feeding orders
Less than 30 mg /dL
Give a dose of Oral Glucose Gel 0.5 mL/kg per policy
Give supplemental formula feeding 15-30 mL Keep baby Skin-to-Skin, continue assisting with breastfeeding,
hand expression and feeding back any EBM
or 31 – 39 mg / dL
Give a dose of Oral Glucose Gel 0.5 mL/kg per policy Keep baby Skin-to-Skin and continue assisting with breastfeeding,
AND hand express and feedback any EBM
or Greater than 40 mg/dL
Continue feeding every 2-3 hours
and check blood sugar before every feed for 24 hours
Continue feeding every 2-3 hours and
check blood sugar before every feed until 3 consecutive results are greater than 45 mg/dL
POCT #2 1 hour after last POCT-at least 45 minutes after gel dose Less than 30 mg / dL
Give a dose of Oral Glucose Gel 0.5 mL/kg per policy
Give supplemental formula feeding 15-30 mL Keep baby Skin-to-Skin, continue assisting with breastfeeding,
hand expression and feeding back any EBM If this is the second sugar <30, Notify MD and consider transfer to NICU
or 31 – 39 mg / dL
Give dose of Oral Glucose Gel 0.5 mL/kg per policy Keep baby Skin-to-Skin, continue assisting with breastfeeding,
And hand express and feedback EBM
or Greater than 40 mg/dL
Continue feeding every 2-3 hours
and check blood sugar before every feed for 24 hours
Continue feeding every 2-3 hours and
check blood sugar before every feed until 3 consecutive results are greater than 45
mg/dL
POCT #3 1 hour after the last POCT- at least 45 min after gel dose
Less than 30 mg / dL
Immediately Give a dose of Oral Glucose Gel 0.5 mL/kg per policy with supplemental formula feeding 15-30 mL
Keep baby Skin-to-Skin and continue assisting with breastfeeding
If this is the second sugar <30, Notify MD and consider transfer to NICU
or 31 – 39 mg / d
Give a dose of Oral Glucose Gel 0.5 mL/kg per policy
Keep baby Skin-to-Skin, continue assisting with breastfeeding, hand expression and feeding back any EBM
(Up to 6 doses of Glucose Gel may be given within the first 48 hours of life)
or Greater than 40 mg/dL
Continue feeding every 2-3 hours
and check blood sugar before every feed for 24 hours
Continue feeding every 2-3 hours and
check blood sugar before every feed until 3 consecutive results are greater than 45
GEL+
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