Identification and management of Hypoglycaemia in term (>= 37 weeks) and late preterm (33-36 weeks) newborns on postnatal wards and transitional care

Publication: 30/06/2007  --
Last review: 28/02/2019  
Next review: 28/02/2022  
Clinical Guideline
CURRENT 
ID: 1149 
Supported by: Maternity Services Clinical Governance Forum (MSCGF)
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Identification and management of Hypoglycaemia in term (≥37 weeks) and late preterm (33-36 weeks) newborns on postnatal wards and transitional care

  1. Background
  2. Identifying babies at risk
  3. Prevention
  4. Management
  5. Monitoring
  6. Feeding support
  7. Investigations

1. Background

Hypoglycaemia accounts for around 10% of admissions of term babies to NNUs.  Many of these admissions may be avoidable, with judicious management.
For most babies, good thermoregulation and feeding support are all that is required assist transition to normal glucose homeostasis.  However, occasionally hypoglycaemia may be persistent or severe enough to result in brain damage and neurological impairment. 
Management must therefore strike a careful balance between avoiding separating mothers and babies unduly, and preventing the severe hypoglycaemia associated with poor long-term outcomes.

Aims:

  • Identify - ‘at risk’ babies as early as possible
  • Prevent  - Implement preventative measures
  • Diagnose - Accurately measure blood glucose
  • Treat - Instigate prompt and effective management
  • Avoid - Unnecessary separation of mothers and babies

Scope:

  • Term (³37/40) babies with risk factors for  or confirmed hypoglycaemia on PNW
  • Moderate to late preterm infants  (33-36/40) being cared for on transitional care.
  • The management of hypoglycaemia in unwell or preterm babies (<33/40), is beyond the scope of this guideline.
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2. Identifying babies at risk

  • Babies may be identified at any point, and level of risk may change – vigilance is key
  • As soon as risk is identified, parents should receive written information explaining why their baby requires additional monitoring and blood tests (Appendix 4).  This may be given antenatally or postnatally. The final version will be available online shortly.

Antenatal identification:

  • Infants of diabetic mothers
  • Maternal PET on beta blockers (e.g. labetalol) in 3rd trimester / at time of delivery
  • Low Estimated Fetal Weight

At delivery:

  • Preterm <37/40
  • Significant resuscitation at birth (Cord / infant pH <7.1 & BEx > -12mmol/L)
  • Birth weight ≤2nd centile (Table 1) 

Later:

  •  
    • Cold babies – temp <36.5
    • ANY symptoms suggestive of hypoglycaemia (Table 2)

Other groups to consider, but not to routinely monitor if no clinical concerns:

  • Babies born by LSCS, particularly emergency deliveries
  • Babies with suspected sepsis
  • Birth weight >90th centile
  • FHx of metabolic disorders associated with neonatal hypoglycaemia

Gestation
age/weeks

Boys
(weight kg)

Girls
(weight kg)

 

 

 

33

1.30

1.25

34

1.50

1.40

35

1.70

1.65

36

1.85

1.80

37

2.10

2.00

38

2.30

2.20

39

2.50

2.45

40

2.65

2.60

41

2.80

2.75

42

2.90

2.85

Table 1. 2nd centile weights for boys and girls by week of gestation.

Signs / symptoms of hypoglycaemia

Hypothermia <36.6, not explained by environment

Cyanosis

Seizures

Lethargy

Hypotonia

High pitched cry

Apnoea

Jittery movements*

Abnormal feeding behaviour**

Table 2. Signs / symptoms of hypoglycaemia

*Jittery movements are common, and alone do not warrant checking blood glucose – look for other signs / evidence in the history.

** Abnormal feeding behaviour – (not waking for feeds, not sucking effectively, appearing unsettled, and demanding very frequent feeds), especially after a period of feeding well, may be indicative of hypoglycaemia, and warrants paediatric review and consideration of blood glucose measurement.   

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3. Prevention

Antenatal considerations

  • Parent information leaflet should be given at the earliestt opportunity (Appendix 4)
  • Antenatal expression of breast milk from 36-37/40 should be considered in mothers whose babies are likely to be at risk of hypoglycaemia. Refer to trust SOP on antenatal expressing (Link) detail.aspx?ID=4706
    , and supporting leaflet (Link).
  • Contraindications to antenatal expression include:
    • History of threatened / actual premature labour
    • Cervical incompetence / cervical suture in situ
    • History of antepartum hemorrhage or placenta praevia

Thermoregulation at delivery

  • Pre-warm towels & hats available at delivery
  • Minimise draughts in delivery area – limit open windows etc.
  • Dry baby thoroughly
  • Hat on immediately
  • Skin to skin with warm towel on top

Consideration of where babies should be cared for

  • Care should take place in the safest clinical setting
  • Refer to TCU / NNU admission criteria for guidance (link)
  • However, if a baby can be looked after safely with its mother, deviating from this guidance, but avoiding separation, this should be supported.
  • If transitional care admission is planned, aim to transfer mother and baby together if clinically safe. This maximises the opportunities for skin to skin contact, helping with thermoregulation and early feeding.
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4. Management

  • All babies at risk of hypoglycaemia should be managed as per Flowchart A

In general, the following treatment thresholds apply:

  • No action beyond feeding support is required if blood glucose is:

    ≥ 2.0mmol/L

    Blood glucose monitoring can stop when TWO x consecutive measurements ≥2.0mmol are obtained. Observe feeding for further 24 hours.

  • Prompt action is required if blood glucose is:

    1.0 – 1.9mmol/L and asymptomatic see Flowchart B

  • Urgent action is required if blood glucose is:

<1.0mmol/L at any time
<2.0mmol/L on 3 or more occasions in first 48hrs regardless of clinical signs
<2.6mmol/L with abnormal clinical signs
see Flowchart C

  • Reluctant feeders, with no risk factors and who are otherwise clinically well, should be managed as per Flowchart D

Note: In some situations, different treatment thresholds apply:

Blood Glucose <2.6 mmol/L for preterm or unwell babies on NNU
see: detail.aspx?ID=524

<2.6mmol/L in babies >72 hours old
<3.0mmol/L if hyperinsulinism suspected
<3.0mmol/L in HIE

40% Dextrose gel

  • Safe first line treatment in asymptomatic babies with blood glucose 1.0 – 1.9mmol/l
  • MUST be used in conjunction with feeding plan to be effective
  • Can be given twice by midwives (with feeds) prior to seeking neonatal review, as long as baby remains well
  • Requirement of a third dose should prompt urgent neonatal review, regardless of symptoms
  • Emergency administration at blood glucose levels <1.0mmol/L is appropriate if no IV access, but should always be accompanied by urgent neonatal review and a plan for urgent iv access (escalation to senior)
  • See Appendix 1 for further details
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5. Monitoring

  • Accurate identification of hypoglycaemia is essential, and consideration should be given to the method of analysis when interpreting a blood glucose level
  • Only those devices conforming to the ISO15197:2013 standard should be used
  • Bedside glucometers in LTHT have demonstrated good accuracy but are not as reliable when blood glucose <2.0 mmol/L. Therefore:
    • If capillary glucose is <2 mmol/L, repeat capillary measurement to confirm, and take a fluoride sample at the same time
    • If the repeat capillary glucose is <2 mmol/L, treat the patient as above and send the fluoride sample to the lab
  • Recurrent (3 capillary readings <2.0mmol/L) or severe (any capillary <1.0mmol/L) hypoglycaemia, should be cross checked by sending a lab sample. (Appendix 2)
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6. Feeding support

Where the intention is to breast feed

  • Breast milk is the best fuel to maintain good glycaemic control and optimize metabolic adaptation, by improving the availability of alternative cerebral fuels.
  • Offer support aimed at increasing milk production and achieving exclusive breast feeding.
  • If difficulty is experienced, offer the following support:
    • Encourage uninterrupted skin-to-skin
    • Offer the breast in response to feeding cues (Table 3)
    • Feed as often as possible and at least 3 hourly
    • Ensure mothers confident with hand expressing
    • Support expressing 8-10 x per day
    • Give expressed colostrum as soon as it is available, by whichever method parents prefer e.g. cup / syringe
  • Be judicious when advising formula top-ups, as these can disrupt glycaemic control, and may impact milk supply.
  • If colostrum not available despite the above measures, consider supplementing with formula milk (10-15ml/kg per feed) until it is available.

Where the intention is to formula feed

  • Exclusive formula feeding is associated with lower availability of alternative cerebral fuels. It is therefore more important to focus on the volumes these babies consume, than it is in exclusively breast-fed babies, where the fuel has very different properties.
  • Feed 10-15ml/kg in response to feeding cues (Table 3) and at least every 3 hours until glycaemic control is achieved.

Feeding cues

Rapid eye movements under the eyelids

Mouth and tongue movements

Body movements and sounds

Fist sucking

Crying is a LATE sign of hunger

Table 3. Feeding cues

  • Babies who are reluctant to feed, but remain well, can be managed as per Flowchart D
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7. Investigations

  • Not usually required, unless severe, recurrent or symptomatic hypoglycaemia.
  • MUST be done during the period of hypoglycaemia, but NEVER delay management
  • Consider further investigation for underlying metabolic abnormalities / hyperinsulinaemia if blood glucose:
    • <2.0mmol/L on ≥3 occasions within first 48hours of life
    • <1.0mmol/L at any time
    • <2.6mmol/L with symptoms of hypoglycaemia
    • <2.6mmol/L at >72 hours of life
  • See Appendix 2 for details of hypoglycaemia screen
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Audit and monitoring compliance

Audit and monitoring of this guidance will take place within the first year after implementation. Subsequent audit will be guided by this but will take place no less than every three years.

Audit results will be presented to the neonatal and maternity audit meeting, which will agree actions arising from the recommendations, and monitor the progress of the actions.

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APPENDIX 1: Use of 40% Glucogel

Indications

  • Blood glucose 1.0-1.9mmol/l in infant with no abnormal clinical signs
  • Blood glucose <1.0mmol/l – only as an interim measure, whilst arranging urgent neonatal review and treatment, or if delay in establishing IV access.
  • Infants ≥ 35/40, and 48 hours old.

Notes

  • Must be used in conjunction with a feeding plan
  • Any more than 1 dose should be discussed with neonatal team
  • Advisable that neonatal review takes place if a 3rd dose is required

Dose

  • 40% Dextrose gel 200mg/kg (Glucogel 40% 0.5ml/kg)
  • Up to two doses given 30 minutes apart per episode of hypoglycaemia
  • Maximum of six doses in 48 hours

Weight of baby (kg)

Volume of gel (ml)

1.5-1.99

1

2.0-2.99

1.5

3.0-3.99

2.0

4.0-4.99

2.5

5.0-5.99

3.0

6.0-6.99

3.5

Method of administration

  • Draw up correct volume using 2.5 or 5ml enteral syringe
  • Dry oral mucosa with gauze, gently squirt gel with syringe (no needle) onto the inner cheek and massage gel into the mucosa using latex-free gloves#
  • Offer a feed (effective breast feed / EBM / 10-15ml/kg formula) immediately after administering dextrose gel
  • Repeat blood sugar measurement as per Flowchart B
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APPENDIX 2: Investigations for persistent / severe hypoglycaemia

Indications

Further investigations should be performed during the period of hypoglycaemia if:

  • Blood glucose <1.0mmol/l at any time
  • ≥ measurements <2.0mmol/l during the first 48hours of life
  • Symptoms of hypoglycaemia with a blood glucose <2.6mmol
  • Blood glucose <2.6mmol in babies >72 hours old

Hypoglycaemia Screen
Blood glucose must be <2.6mmol/L for all samples to be processed

A hypoglycaemia “grab bag” is available on L43 / J01, with all required equipment.  ICE has a “hypoglycaemia in the newborn” button to ease requesting / printing

Lab Glucose
Lactate
Free fatty acids
3-OH butyrate

Grey fluoride tube, 2ml

On ice

Plasma amino acids
Cortisol
Insulin
C-peptide
Growth Hormone
Ketone bodies

 


Green Lithium Heparin tube, 2ml

Ammonia

Green Lithium Heparin tube, 1ml

Must reach lab within 30 mins, on ice
Phone lab and porters to collect by hand

Carnitine
Acylcarnitines

1 spot on newborn screening card

Urine Ketones
Urine organic acids
Urine Reducing substances

White universal container – 1st urine after hypoglycaemic episode

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APPENDIX 3: Calculating IV glucose delivery

Flow rate of 10% Dextrose (ml/kg/day)

Infusion rate (mg/kg/min)

40

2.77

60

4.16

90

6.25

120

8.33

150

10.42

165

11.45

How to calculate mg/kg/min from ml/kg/day for any concentration of glucose:
Rate (ml/kg/day) / 144 x glucose % = mg/kg/min

How to make up any concentration of glucose in any volume:
HV = V (D-L) / (H-L)
LV = V – HV

HV = volume of higher concentration glucose to add (ml)
V = desired total volume (ml)
D = desired final concentration of glucose (%)
L = lower concentration of glucose (%)
H = higher concentration of glucose (%)
LV = volume of lower concentration of glucose to add (ml)
Add HV and LV together to get the final desired volume (ml) and concentration (%) of glucose.

Example:
Make up 500mls of 15% Glucose from 50% Glucose and 10% Glucose

D = 15%
V = 500mls
L = 10%
H = 50%

HV = 500 (15 – 10) / (50 – 10) =        62.5mls of 50% Glucose
LV = 500 – 62.5 =                              437.5mls of 10% Glucose

So;
62.5mls of 50% Glucose + 437.5mls of 10% Glucose = 500mls of 15% Glucose

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APPENDIX 4: Parent Information Leaflet

Provenance

Record: 1149
Objective:

The objective of the guideline is to identify those babies at risk of hypoglycaemia, and give standards of care to minimise risk of hypoglycaemia in at risk babies.

Clinical condition:

Hypoglycaemia of the newborn

Target patient group: Newborn babies
Target professional group(s): Health Visitors
Primary Care Nurses
Primary Care Doctors
Secondary Care Doctors
Secondary Care Nurses
Midwives
Adapted from:

Evidence base

  1. Identification and Management of Neonatal Hypoglycaemia in the Full Term Infant: A Framework for Practice. British Association of Perinatal Medicine, 2017.
  2. Harris DL, Weston PJ, Signal M, Chase JG, Harding JE. Dextrose gel for treating neonatal hypoglycaemia: A randomised placebo-controlled trial (The Sugar Babies Study). Lancet. 2013;382(9910):2077–83.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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