Title Hypoglycaemia Management and Prevention in Neonates Guideline. Author s job title Senior Neonatal Staff Nurse and Educator Directorate Medical

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1 Document Control Title in Neonates Guideline Author Author s job title Senior Neonatal Staff Nurse and Educator Directorate Medical Department SCU Version Date Issued Status Comment / Changes / Approval 0.1 August 2015 Draft Initial version by SN Deborah Malpass and Dr Ragavendra Subba-Rao for comments. 0.2 November 2015 Draft Extensive editing following comments. Changes to format and order. Further changes to condense and simplify contents. 1.0 November Final draft Final draft for comments February Revision Changes after comments from Dr Selter and Sara Wright November 2016 Final Amendments made following comments from midwifery staff. 2.1 September Revision Feeding chart added to appendices 2017 Main Contact Special Care Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Medical Director Superseded Documents None Issue Date November 2016 Review Date November 2019 Consulted with the following stakeholders: Paediatrics consultant group Neonatal nurses Head of midwifery / midwives Approval and Review Process Group/Committee Tel: Direct Dial Tel: Internal 2610 Review Cycle Three years Local Archive Reference G:\ Paediatric Resources/Neonates/Neonatal Guidelines/previous versions of guidelines Local Path G:\ Paediatric Resources/Neonates/Neonatal Guidelines Filename in Neonates Guideline v2.1 in Neonates Guideline v2.1 Page 1 of 17

2 Policy categories for Trust s internal website (BOB) Neonatal, Neonatal Nursing, Neonates, Paediatric Tags for Trust s internal website (Bob) Blood Glucose, Blood Sugar, Newborn, Infant, Jittery in Neonates Guideline v2.1 Page 2 of 17

3 CONTENTS Document Control Purpose Definitions Responsibilities Introduction and Definition Pathophysiology Measurement of glucose Risk Factors for hypoglycaemia Possible symptoms of hypoglycaemia in the newborn Management of newborn infants to prevent hypoglycaemia Management of hypoglycaemia SCBU management of infants Process for Implementation and Monitoring Compliance and Effectiveness Appendix 1 - Flowchart for the management of infants at risk of hypoglycaemia Appendix Appendix Appendix Appendix 5 Feeding Chart References Associated Documentation Purpose The purpose of this document is to give guidance on the management and prevention of hypoglycaemia in neonates on the post-natal ward, special care baby unit and paediatric ward if applicable. This guideline applies to midwives and maternity care assistants on Delivery Suite and Bassett Ward, registered nurses and Health Care Assistants on the Special Care Unit and Caroline Thorpe paediatric ward and all paediatric doctors. Implementation of this policy will ensure that: The risks to neonates associated with hypoglycaemia are minimised. in Neonates Guideline v2.1 Page 3 of 17

4 2. Definitions EBM mmol/l Expressed breast milk millimole per litre Greater than Less than Greater than or equal to 3. Responsibilities Role of all clinical staff including nurses, midwives and doctors who care for neonates: To act in accordance with this guideline To minimise the risks to neonates associated with hypoglycaemia 4. Introduction and Definition This document highlights the importance of blood glucose levels in neonates within the first few days of life and explores best practice in relation to the management of hypoglycaemia in order to prevent harm to the neonate. The exact definition of neonatal hypoglycaemia is unclear, and the definition of clinically significant hypoglycaemia remains one of the most confused and contentious issues in contemporary neonatology (Cornblath et al, 2000). However, commonly defined and accepted normal blood sugar limits for neonates are 2.6mmol/L to 7mmol/L (Koh et al, 1988, Lucas et al, 1988, Bowell, 2010). Therefore, in neonates blood glucose of less than 2.6mmol/L is defined as hypoglycaemia (WHO, 1997). in Neonates Guideline v2.1 Page 4 of 17

5 5. Pathophysiology Glucose is transferred to the foetus by facilitated diffusion from the maternal circulation. In the first two hours after birth the blood glucose levels fall rapidly. In a healthy term infant the brain is protected by elevated levels of lactate and ketones, with an enhanced ability to use these metabolites. As a healthy term infant it is normal for the blood glucose level to fall and then rise again in the next few hours, either spontaneously or after feeding. Healthy asymptomatic term babies blood glucose levels may be normally low in the first few days of life, but this does not seem to have any adverse consequences. Glucose supply is essential, more so when there are conditions associated with high energy demands, such as the exhaustion of glycogen stores caused by birth asphyxia, or the increased metabolic rate caused by sepsis or hypothermia. Preterm infants are at high risk of neonatal hypoglycaemia due to decreased stores of glycogen and fat, poor feed tolerance and impaired hormonal responses. They are also at risk of hypothermia, which can then cause hypoglycaemia. Infants who have been Intra-Uterine Growth Restricted (IUGR) are also at increased risk due to the same reasons. Infants of diabetic mothers are at an increased risk of hypoglycaemia following birth due to the hyperinsulinaemic environment in-utero (Boxwell, 2010). 6. Measurement of glucose Blood glucose measurement should be carried out using the Roche Performa AccuCheck Blood Glucose Meter as screening tool If AccuCheck reading is below 1.5 mmol/l send sample for laboratory testing for confirmation, but treat immediately Always ensure AccuCheck equipment is maintained and calibrated as per manufacturer s instructions and that clinical staff are trained in use and signed-off as competent Biochemistry laboratory using a paediatric grey bottle Blood gas machine using a capillary tube or blood gas syringe in Neonates Guideline v2.1 Page 5 of 17

6 7. Risk Factors for hypoglycaemia 1. Infants of diabetic mothers (including gestational diabetes) 2. Preterm infants (<37 weeks) 3. Infants Small for Gestational Age (SGA) Or Intra-Uterine Growth Restricted (IUGR), (ie. <2.5kg and/or <2 nd centile) (see web link here for WHO 0-4 years Boys and Girls Growth Charts) 4. Infants of macrosomic appearance (large for gestational age) 5. Maternal medication (ie. beta blocker therapy, insulin) 6. Hypothermia 7. Haemolytic Disease of the Newborn (bilirubin approaching exchange transfusion line) 8. Moderate to severe birth asphyxia (requiring admission) 9. Sepsis 10. Seizures 11. Poor feeding (As defined in Appendix F of Newborn Infant Feeding policy) 8. Possible symptoms of hypoglycaemia in the newborn Tremors and jitteriness Seizures Apnoea Lethargy Hypotonia Poor feeding Weak or high pitched cry Jitteriness alone is not a definitive sign of hypoglycaemia. Many babies will appear jittery on handling, jitteriness is defined by UNICEF (2013) as Excessive repetitive movements of one or more limbs, which are unprovoked and usually relatively fast. It is important to be sure that this movement is not simply a response to stimuli. in Neonates Guideline v2.1 Page 6 of 17

7 9. Management of newborn infants to prevent hypoglycaemia Encourage skin to skin contact a warm environment and early feed are the best ways to prevent hypoglycaemia for all babies. Early feed - Feed within an hour of birth if possible, and at least 3 hourly thereafter. If baby not interested in first feed, make sure they have some expressed colostrum and are fully assessed for signs or ill health and hypoglycaemia. If baby is well check a blood glucose at least 2 hours after birth. If baby is unwell or symptomatic of hypoglycaemia this can be done sooner. Follow guidance in Appendix F of Newborn Infant Feeding policy. Teach mother how to recognise feeding cues and how to hand express if breastfeeding. Monitor baby s well being - All at-risk infants must have an accurate up-to-date feed chart and prior to feeds check the wellbeing of the baby, considering the infants level of consciousness, tone, temperature, respiration, colour/perfusion (Unicef, 2013). This can be documented using the NEWS observation chart. If a baby is less than the 10 th centile on a GROW chart, then the weight should be plotted on a WHO 0-4 years Boys or Girls Growth Chart to establish if they are below the 2 nd centile, and therefore at risk. 10. Management of hypoglycaemia Blood glucose levels should be checked on all infants who have any risk factors. Blood glucose should also be checked in infants who exhibit symptoms of hypoglycaemia and a paediatrician should be informed. Records of blood glucose measurements, treatment, response to treatment and the management decisions made as a result should be documented accurately in the baby s purple post-natal notes or care plan and feed chart. Hypoglycaemia should be treated with an immediate enteral feed, even if the baby is asymptomatic. This should be the most appropriate method to gestation and clinical status. Expressed breast milk will be used for breast fed babies wherever possible. Supplements with infant formula will be required only when the blood glucose is below 2.5 mmols and breastfeeding has not been successful and the amount of Expressed Breast Milk is insufficient to increase blood glucose. Infants of women with diabetes should not be discharged home to community care until they at least 24 hours of age and have been seen by a medical professional who is satisfied they are feeding well and maintaining their blood glucose level 2.6 mmol/l (NICE, 2008). in Neonates Guideline v2.1 Page 7 of 17

8 Infants of women with diabetes who are hypoglycaemic with symptoms should also have blood testing for polycythaemia, hyperbilirubinaemia, hypocalcemia and hypomagnesia. (NICE, 2008). If the blood glucose of at at-risk infant being tested is 2.6 mmol/l, the blood glucose should be checked before subsequent feeds. Stop monitoring when 3 successive pre-feed blood glucose levels are 2.6 mmol/l. Feeding should be baby-led as per Newborn Infant Feeding Policy, but with a maximum interval of 3 hours between feeds. Prior to feeds check the wellbeing of the baby, considering the infants level of consciousness, tone, temperature, respiration, colour/perfusion (Unicef, 2013). All stages apply to the first blood sugar result, if the next result (the second) remains <2.6 mmol/l, this should be discussed with a paediatrician Blood glucose 1.5 mmol/l to 2.5 mmol/l Give breastfeed with top-up of expressed breast milk or appropriate formula top-up, or if formula feeding give a full 3 hourly amount of first infant formula at 8-12ml/kg. If baby reluctant to feed (even with top-up) follow the guidance in Appendix F of the Newborn Infant Feeding policy and ask for paediatric review Inform Paediatric SHO or Registrar to make them aware and discuss plan Check blood glucose 1 hour post-feed If the second result remains <2.6 mmol/l, this should be discussed again with a paediatrician Blood glucose <1.5mmol/l Send blood glucose sample for laboratory testing Give breastfeed and a full feed top-up of 8-12ml/kg, or a 3 hourly amount of appropriate formula top-up at 8-12ml/kg each feed. Inform Paediatrician and arrange to attend and clinically review infant Consider admission to SCBU if feeds poorly tolerated, and consider 2.5ml/kg Dextrose bolus over 5 minutes and/or intravenous 10% Dextrose infusion as per SCBU maintenance fluid regime If intravenous access is difficult consider use of Dextrose Gel 40% 0.5ml/kg massaged onto the buccal membranes or Glucagon 0.1 mg/kg IM (maximum of 1mg). Check blood glucose 1 hour-post feed / change If the second result remains <2.6 mmol/l, this should be discussed with a paediatrician 1.0mmol/l or unreadable Admit to SCBU and consider feeding interval or volume changes If feeds poorly already tolerated consider intravenous bolus of 10% Dextrose at 2.5ml/kg and/or commencing infusion as per SCBU maintenance fluid regime Re-check blood glucose after 30 minutes in Neonates Guideline v2.1 Page 8 of 17

9 -If repeated blood glucose is 2.6 mmol/l or rapidly rising and infant is on intravenous Dextrose, re-start enteral feeds and titrate with Dextrose as tolerated and as per Paediatrician s advice 11. SCBU management of infants (for infants who are symptomatic, or high-risk infants where enteral feeds are contraindicated, or infants who s blood glucose remains low after intervention): - Consider admission to SCBU - Consider changing feed interval to more frequent ie. 1 or 2 hourly feeds - Consider increasing fluid intake to next day mls/kg on SCBU maintenance fluid regime - Consider an intravenous Dextrose bolus at 2.5mls/kg - Consider increasing intravenous 10% Dextrose infusion up to a maximum of 90ml/kg/day if newborn and monitor serum sodium levels to prevent hyponatraemia - If blood glucose still low, ensure Paediatric consultant has been informed, and once up to 90mls/kg/day of intravenous 10% Dextrose, increase the concentration rather than volume appropriately, up to 12.5% then 15% if necessary. (If > 12.5% Dextrose is used, this must be given via a central line to avoid complications - See appendix 3 for how to prepare). - Infants over a few days old will need fluid maintenance volumes managed on an individual basis - If intravenous access is difficult ask for senior help and consider use of Dextrose gel 40% 0.5ml/kg using an enteral syringe to draw up and then massage onto the buccal membranes OR glucagon (Gluca-gen HypoKit in fridge on SCBU) 0.1 mg/kg IM (maximum of 1.0mg) - Investigations: When hypoglycaemia is persistent (glucose <2.2 mmol/l for more than 72 hours) in the absence of clearly identifiable risk factors, further investigation should be undertaken (as in appendix 2). - Investigations for CRP, FBC and blood cultures and treatment with antibiotics should be considered if sepsis is suspected. in Neonates Guideline v2.1 Page 9 of 17

10 - Consider testing Calcium levels if infant is jittery 12. Process for Implementation and Monitoring Compliance and Effectiveness Implementation of this guideline not required, as this practice is already in place in all applicable areas. Staff are informed of revised documentation. There is an expectation that staff are responsible to keep updated on any improvements to practice and deliver care accordingly. Non-adherence to the guideline is reported by use of the Datix system. Incidents are monitored and reviewed by the neonatal governance team and action plans made if required. Individual cases are discussed at handover, on ward rounds and weekly on grand rounds and are used for learning in safeguarding supervision. Further discussion and reviews occur at Directorate meetings, Neonatal/Paediatric Governance meetings Maternity Patient Safety Meetings and locally at Ward meetings. Learning and action plans are cascaded at these meetings and improvements implemented. Key findings and learning points will be disseminated to relevant staff. in Neonates Guideline v2.1 Page 10 of 17

11 Appendix 1 - Flowchart for the management of infants at risk of hypoglycaemia Care at birth to include: Dry baby, keep warm, initiate skin-to-skin contact First feed as soon as possible, always within the first hour; observation of wellbeing Newborns at risk of hypoglycaemia: Infants of diabetic mothers Pre-term infants (<37 weeks) Low birth weight (<2.5 kgs or <2 nd centile) Infants of macrosomic appearance Maternal medications Hypothermia Haemolytic Disease of Newborn Mod. or Sev. Birth Asphyxia Sepsis Seizures Poor feeding (See Appendix F Newborn Infant Feeding guideline) Fed effectively? Yes Ongoing management to include: * Review Baby-led feeds (but at least 3 hourly) Encourage mother to observe feeding cues Keep baby warm Pre-feed blood glucose monitoring, (initially prior to 2 nd feed), then stop when level is normal x3 No Proactive management: Ongoing observation Give breast or formula feed If breastfeeding, hand express and give EBM (if not available continue expressing hourly) Ongoing skin contact/ temperature maintenance Within 3-4 hours of age: Review Pre-feed glucose measurement Symptomatic hypoglycaemia: Apnoea Cyanosis Jitteriness Convulsions Or blood glucose below 1.5 mmol/l at any stage: Blood glucose measurement above 2.6 mmol/l Blood glucose measurement between 1.5 and 2.6 mmol/l Blood glucose measurement below 1.5mmol/L *Review Refer baby to paediatrician Prior to feeds check: Inform paediatrician Breastfeed followed by EBM or formula full top-up by cup or nasogastric tube/ Formula feed full 3 hourly amount by bottle or nasogastric tube Repeat blood glucose in 1 hour Level of consciousness Tone Temperature Respirations Colour Blood glucose above 2.6 mmol/l Blood glucose below 2.6 mmol/l Refer to paediatrician, consider SCBU in Neonates Guideline v2.1 Page 11 of 17

12 Appendix 2 Investigations recommended in significant persistant hypoglycaemia Test Volume Colour of Specimen bottle Sample Note Laboratory Glucose Insulin Growth hormone Cortisol 0.5mLs Grey Capillary or venous blood 1mL (Full Paed bottle) 0.6mLs (Full Paed bottle) 0.6mLs (Full Paed bottle) Purple Venous blood Serum (not haemolysed) to lab within 20 minutes. (To RD&E) Yellow Venous blood (To BRI) Yellow Venous blood Free fatty acids 1mL Grey Venous blood (To Southmead) β-hydroxybutyrate 1mL Grey Venous blood (To Southmead) Urinary ketones 3mLs White topped Urine Next urine voided after hypoglycaemic episode (Use bedside ketone meter if possible). Other (non-urgent) investigations should include: Test Volume Colour of specimen bottle Capillary/ Venous TFT s (TSH, T4) Full Yellow Venous blood LFT s and U+E s Ammonia Acylcarnitine profile 1mL (Full Paed bottle) Note Purple Venous blood To lab within 15 mins on ice. N/A N/A Capillary or venous blood 2 spots on Newborn Bloodspot card Plasma amino acids 0.6mLs (Full Paed bottle) Yellow Capillary or venous blood (To Southmead) Lactate and blood gas 0.5mLs Capillary tube Capillary or venous blood Use blood gas machine Urinary organic acids 5mLs White topped Urine (To Southmead) Also consider CRP, FBC and blood cultures if sepsis is suspected, and antibiotic treatment if necessary. Contact Biochemistry: i) via phone within working hours: ex (biochemist) or ex (lab); ii) via bleep 031 'out of hours' in Neonates Guideline v2.1 Page 12 of 17

13 Appendix 3 Volume of dextrose concentrations and infusion rates for glucose infusion: Table 1: preparation of higher dextrose concentration for fluids in 500mls Infusion concentration Volume of 10% dextrose Volume of 50% glucose 12.5% 465mls 35mls 15.0% 440mls 60mls 17.5mls 405mls 95mls 20% 375mls 125mls Table 2: preparation of higher dextrose concentration for fluids in 50mls Infusion concentration Volume of 10% glucose Volume of 50% glucose 12.5% 46.5mls 3.5mls 15.0% 44.0mls 6.0mls 17.5% 40.5mls 9.5mls 20% 37.5mls 12.5mls Appendix 4 To calculate an infant s glucose requirement: Glucose rate (mg/kg/min) = Dextrose concentration x Volume infused in ml/kg/day 144 Infants requiring 10mgs/kg/day of glucose usually have a pathological basis for their hypoglycaemia, and treating the cause is as important as correcting the low glucose level in Neonates Guideline v2.1 Page 13 of 17

14 Appendix 5 Feeding Chart Patient Identification Label Gestation Additional Information E.g. IVABs, tongue-tie, centile Please review for jaundice at each feed if possible, and comment under Additional Information Birth Weight Feeding Management Plan Date Day Weight Milk Type / Method Frequency If top up required: mls / feed Total expected Daily Input Total 24 hour input Discussed with mother Comments Initials Date Time Start/Finish Milk Type / Method Pre/Post BM Total Taken Passed Urine Stools Colour Additional Information Initials in Neonates Guideline v2.1 Page 14 of 17

15 Feeding Management Plan Date Time Start/Finish Milk Type / Method Pre/Post BM Total Taken Passed Urine Stools Colour Additional Information Initials in Neonates Guideline v2.1 Page 15 of 17

16 13. References Adamkin, D. H. (2009) Late preterm infants: severe hyperbilirubinemia and postnatal glucose homeostasis. Journal of Perinatology (29) Boxwell, G. (2010) Neonatal Intensive Care Nursing, 2 nd Edition. Routledge, New York. Cornblath, M. Hawdon, J. and Williams, A. (2000) Controversies regarding definition of neonatal hypoglycaemia: suggested operational thresholds. Paediatrics (105) Cornblath, M, Schwartz, R. (1993) Hypoglycaemia in the neonate. Journal of Paediatric Endocrinology. (6) Cornblath, M. and Ichord, R. (2000) Hypoglycaemia in the neonate. Seminars in Perinatology (24) 136. CEMACH (2007) Diabetes in pregnancy: caring for the baby after birth. Findings of a national enquiry. Hawdon, J. M., Ward-Platt, M. P., Aynsley-Green, A. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week. Archives of Disease in Childhood (67) Hay, Jr. W., Faju, T., Higgins, R. D., Kalhan, S. C., Devaskar, S. U. (2009) Knowledge gaps and research needs for understanding and treating neonatal hypoglycemia: workshop report from Eunice Kennedy Shriver National Institute of Child Health and Human Development. Journal of Pediatrics, 155 (5) Koh, T. H. H. G., Aynsley-Green, A., Tarbit, M. et al. (1998) Neural dysfunction during hypoglycaemia. Archives of Disease in Childhood (63) Lucas, A., Morley, R., Cole, T. J. (1988) Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia. British Medical Journal, 297 (6659): National Institute for Health and Clinical Excellence (2008) Diabetes in pregnancy. Management of diabetes and its complications from pre-conception to the postnatal period London: NICE. [Available on-line at: Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007) Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London RCOG Press [Available on-line at: Rozance, P. J. and Hay, W. W. (2010) Neonatal Hyperglycaemia. American Academy of Pediatrics. 11 (11) Stenninger, E., Flink, R., Eriksson, B. and Sahlen, C. (1998) Long-term neurological dysfunction and neonatal hypoglycaemia after diabetic pregnancy. Archives of Disease in Children and Foetal and Neonatal Education, 79 (3) in Neonates Guideline v2.1 Page 16 of 17

17 UNICEF UK Baby Friendly Initiative (2007). Guidance on the development of policies and guidelines for the prevention and management of Hypoglycaemia of the Newborn. UNICEF. [Available on-line at Associated Documentation NDHT Newborn Infant Feeding policy and guidelines NDHT Care of the Newborn Immediately After Birth guideline NDHT Thermal Care of the Neonate guideline in Neonates Guideline v2.1 Page 17 of 17