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

2. 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

3. 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

4. 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

5. 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

6. 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

7. Babies at risk Risk factors for neonatal hypoglycaemia may be due to maternal or neonatal factors

8. Babies at risk Maternal 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

9. Babies at risk Neonatal factors Prematurity less than 37 weeksIntrauterine growth restriction MacrosomiaPerinatal hypoxic-ischaemic insult Respiratory distressSepsis HypothermiaPolycythaemia Congenital cardiac abnormalitiesNeonatal hyperinsulinism Endocrine disordersInborn errors of metabolism Rhesus haemolytic diseaseErythroblastosis fetalis Obvious syndromes – with midline defects (e.g. cleft palate) – Beckwith-Weidemann syndrome Iatrogenic – intravenous (IV) cannula infiltrated – inadequate feeding

10. 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

11. Management of babies at risk Prevention 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

12. Management of babies at risk Detection It is not necessary to screen asymptomatic, appropriately grown term babies that do not have risk factors

13. Management of babies at risk Detection 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

14. Management of babies at risk Detection 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

15. Management of babies at risk Detection 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

16. Antenatal Care Birth 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

17. Management of babies at risk Detection 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

18. Management of babies at risk Detection 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

19. Management of babies at risk Treatment 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

20. Management of babies at risk Treatment 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

21. Management of babies at risk Treatment 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

22. Management of babies at risk Treatment 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

23. Management of babies at risk Treatment 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

24. Management of babies at risk Treatment 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

25. Management of babies at risk Treatment 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

26. Management of babies at risk Treatment 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

27. Management of babies at risk Treatment 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

28. Management of babies at risk Treatment Decrease IVT: –once BGL stable for 12 hrs –do not decrease abruptly –reduce gradually –increase volume of enteral feeds concurrently

29. Management of babies at risk Severe, 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

30. Management of babies at risk Severe, 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

31. Inter-hospital transfer Arrange according to local policy Coordinated by Retrieval Services Queensland

32. Follow up Follow up depends on severity and duration of hypoglycaemia Discuss with Neonatologist

33. 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

34. 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.

35. Contact Details Jacinta Lee A/Manager Queensland Maternity and Neonatal Clinical Guidelines Program Translating evidence into best clinical practice GPO Box 48 Brisbane QLD 4001 P: (07) 3131 6777 M: 0407 922 760 E: Jacinta_Lee@health.qld.gov.auJacinta_Lee@health.qld.gov.au Visit our website: http://www.health.qld.gov.au/cpic/resources/mat_guidelines.asp