Hyperglycaemia - Management of Neonatal Hyperglycaemia

Publication: 01/09/2005  --
Last review: 05/09/2017  
Next review: 05/09/2020  
Clinical Guideline
CURRENT 
ID: 631 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

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.

Management of neonatal hyperglycaemia

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Aim

  • To streamline the management of neonatal hyperglycaemia.
  • To prevent complications of hyperglycaemia (fluid and electrolyte imbalance with dehydration)
  • To administer continuous insulin infusion safely to maintain normoglycaemia (7 to 10 mmol/l) and adequate calorie intake.

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Definition

There is no established definition of neonatal hyperglycaemia.  However blood sugar levels >12 mmol/L accompanied by severe (+++) glycosuria may warrant treatment especially in sick preterm infants.
If the blood sugar is > 10 mmol/l, it is prudent to calculate the glucose delivery rate (see below).

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Aetiology

Hyperglycaemia can occur in between 45% and 80% of preterm infants who survive the first week of life 1,2  and is seen most frequently in very low birth weight infants.

Risk factors

  • Sepsis
  • Pain
  • Respiratory distress
  • Equipment failure
  • Administrator error
  • Steroids

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Prevention

To identify underlying aetiology (remember infection, stress response and glucose overload) and treat treatable conditions.
Check fluid rates and equipment prior to starting fluid infusions. Recheck fluids/rates at each shift change.

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Management:

  1. Confirm the diagnosis by repeating blood glucose on the gas machine, and send true glucose sample to lab.

DO NOT WAIT FOR THIS RESULT

  1. Monitor urine for glycosuria and urine volume (mL/kg/hr) to ensure adequate fluid balance. If baby needs additional fluids to counter renal and extrarenal losses (phototherapy) consider using 5% glucose or 0.45% saline
  2. Check the administration equipment. Ensure that the fluid the baby has received is being administered at the correct rate and volume.
  3. Take down TPN if the blood sugar is greater than 20mmol/ and replace fluids with appropriate ward stock fluid. Store TPN that has been taken down for analysis
  4. Review babies’ drug chart to confirm no medication is being administered that may cause hyperglycaemia e.g. corticosteroids.
  5. Treat serious underlying disorders especially infection (septic screen and antibiotics).
  6. Calculate glucose delivery rateRemember to include all infusions with glucose
Glucose Infusion Rate (mg/kg/min)

EITHER

=

% glucose x Fluid Rate (ml/kg/day)
144

OR

=

% glucose x ml/hr
6 x body weight (kg)

or use hyperlink to calculate NICU Tools: Paediatric Calculators



Whenever possible maintain the delivery of intravenous nutrition (TPN) and reduce glucose in all other infusions. If this does not bring down the blood glucose consider reducing TPN (e.g. half the infusion rate) and replacing the remainding fluid allowance with fluid with a lower concentration of glucose e.g. 5% dextrose.

  1. If glucose delivery rate is >10 mg/kg/min, decrease glucose in increments to 6 to 10 mg/kg/min. If on TPN, 8 to 10 mg/kg/min is acceptable
  2. If glycosuria and hyperglycaemia > 12 mmol/l persists, despite an appropriate glucose infusion rate, change fluids to 5 % glucose at same rate.
  3. If hyperglycaemia persists and blood sugar not decreasing  after 1 hour, commence insulin via separate venous access (peripheral or central). See attached chart for details.
  4. Monitor Blood sugar hourly initially then according to blood glucose stability.
  5. If hyperglycemia persists or there is an ongoing insulin requirement for several days and other causes have been excluded consider the diagnosis of neonatal diabetes mellitus and contact the children's diabetes consultant for further advice

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Provenance

Record: 631
Objective:

To streamline the management of neonatal hyperglycaemia

Clinical condition:

Neonatal Hyperglycaemia

Target patient group: Babies
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

N/A


Evidence base

Optimal nutritional intake in sick and preterm infants has been shown to result in better growth, both early on and at discharge from hospital 3 . Active management strategies in the absence of evidence-based publications include carbohydrate restriction or intravenous insulin infusion.  There is some data that suggests controlled insulin infusion improves and sustains glucose tolerance, facilitates provision of calories, and enhances weight gain in glucose-intolerant premature infants but study numbers are small 4. Potential hazards of insulin infusion are hypoglycaemia and hypokalaemia.  Potential hazards of carbohydrate restriction include a reduction in total energy intake to a level, which may lead to a catabolic state at a critical stage of development.  Recent evidence from the Nirture trial suggests that early insulin infusion to tightly control blood glucose does not confer benefits on premature infants in the first week of life but does increase the incidence of hypoglycaemia the long term effect of which is yet to been reported.

Consensus achieved with
Neonatal clinical governance team including neonatal consultants, registrars, neonatal nurses and pharmacists.
Compliance to be checked with audit after implementation of guideline.

REFERENCES

  1. Louik C, Mitchell AA, Epstein MF, Shapiro S. Risk factors for neonatal hyperglycemia associated with 10% dextrose infusion.Am J Dis Child.  1985;139:783-6
  2. Dweck HS, Cassady G. Glucose intolerance in infants of very low birth weight.Incidence of hyperglycemia in infants of birth weights 1,100 grams or less. Pediatrics. 1974;53:189-95.
  3. Wilson DC, Cairns P, Halliday HL, Reid M, McClure G, Dodge JA. Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight   infants  Arch. Dis. Child. Fetal Neonatal Ed., Jul 1997;77:4-11
  4. Collins JW Jr, Hoppe M, Brown K, Edidin DV, Padbury J, Ogata ES. A controlled trial of insulin infusion and parenteral nutrition in extremely low birth weight infants with glucose intolerance.  J Pediatr. 1991;118:921-7.
  5. Beardsall K, Yuen K, Williams R, Dunger D Applied physiology of glucose control Current Paediatrics 2003;13: 543-548
  6. Beardsall K, Vanhaesebrouck S et al. Early Insulin Therapy in Very-Low-Birth-Weight Infants. NEJM 359;18:1873-84

Document history

LHP version 1.0

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