Clinical Director for Women s and Children s Directorate

Transcription

1 TREATMENT OF NEONATAL HYPOGLYCAEMIA IN THE HIGH RISK INFANT CLINICAL GUIDELINES Register No: Status: Public Developed in response to: Intrapartum NICE Guidelines RCOG guideline Contributes to CQC Regulation 12 Consulted With Post/Committee/Group Date Anita Rao/ Alison Cuthbertson Alison Cuthbertson Madhu Joshi Dr. Lim Chris Berner Tony Laing Sarah Moon Dora Bergman Clinical Director for Women s and Children s Directorate Head of Midwifery/ Nursing for Women s and Children s Services Consultant for Obstetrics and Gynaecology Consultant Paediatrician Maternity Risk Management Neonatal Lead Nurse Specialist Midwife for Guidelines and Audit Specialist Midwife for Infant Feeding January 2016 Professionally Approved By Dr Hassan Consultant Lead for Risk Management January 2016 Version Number 2.0 Issuing Directorate Women s and Children s Ratified By Document Ratification Group Ratified On 25 th February 2016 Trust Executive Board Date March 2016 Implementation Date 1 st March 2016 Next Review Date February 2019 Contact for Information Sarah Moon, Specialist Midwife for Guidelines & Audit Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians Distribution Method Intranet & Website. Notified on Staff Focus Related Trust Policies (to be read in conjunction with) Standard Infection Prevention Hand Hygiene Guideline for Maternity Record Keeping including Documentation in Handheld Records Management of Breast Feeding in the Postnatal Period Prevention and management of Neonatal Hypothermia Document history Review No Reviewed by Review Date 1.0 Sharon Pilgrim September Denise Gray clarification to 8.0 March Dr Hassan, Paediatric Consultant 1 st March

2 INDEX 1. Purpose 2. Equality and Diversity 3. Definition and Incidence 4. Babies Clinically at Risk of Hypoglycaemia 5. Prevention 6. Symptoms 7. Equipment 8. Treatment of Asymptomatic at Risk Infants 9. Symptomatic Infants 10. Failure to Respond 11. Further Investigation 12. Staff and Training 13. Supervisor of Midwives 14. Infection Prevention 15. Audit and Monitoring 16. Guideline Management 17. Communication 18. References Appendices A. Appendix A - Management of at Risk Infants B. Appendix B - Making up Varying Concentrations of Glucose C. Appendix C - Carbohydrate Requirement in Hypoglycaemic Infants D. Appendix D - Neonatal Blood Glucose Observation Chart 2

3 1.0 Purpose 1.1 To identify those infants at risk of neonatal hypoglycaemia and develop a coordinated treatment strategy to optimize care and outcome. 2.0 Equality and Diversity 2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Definition and Incidence 3.1 The blood glucose concentration at which hypoglycaemia exists is not known and this may not reflect neuroglycopaenia. 3.2 The biological effects of hypoglycaemia vary according to the availability of alternate fuels e.g. ketone bodies, lactate, amino acids and according to the presence of other compounding clinical factors like hypoxia, hypercarbia, polycythemia and hypocalcaemia. 3.3 In a well term infant, appropriate for gestational age babies, a transient drop in blood sugar is commonly seen after birth as part of the physiological adaptation to postnatal life. There is no evidence that this is in anyway harmful and they do not require glucose monitoring due to their ability to utilize ketones as alternative fuel. 3.4 Breast fed term infants may have lower concentrations of blood glucose but higher concentration of ketone bodies than term babies on formula feeds. (Refer to guideline entitled Management of breast feeding in the postnatal ward register number 09110) 3.5 Preterm and small for gestational age infants are defined as vulnerable and do not have the ability to utilize ketones and therefore require glucose monitoring. 3.6 In the vulnerable infant hypoglycaemia is defined as a blood glucose level of < 2.6mmols 4.0 Babies Clinically at Risk of Hypoglycaemia 4.1 Increased demand/ reduced supply: Preterm <37 weeks gestation Intrauterine Growth Restriction (IUGR) Infection Intrapartum asphyxia Hypothermia (< 36 C) Small for gestational age (birth weight < 2 nd centile for ) Maternal beta blockers e.g. Labetalol Family history of MCADD - medium-chain acyl-coa dehydrogenase deficiency Macrosomia birth weight >91 st centile for gestational age) Polycythaemia (Haematocrit >70%) 3

4 4.2 Hyperinsulinism: Maternal diabetes mellitus or impaired maternal glucose tolerance Persistent hyperinsulinaemic hypoglycaemia of infancy Beckwith Weidman Syndrome Islet cell adenoma Transient neonatal hypoglycaemia 4.3 Other conditions include: Endocrinopathies i.e. pituitary, growth hormone deficiency Carbohydrate metabolism disorders i.e. galactosaemia Organic acidaemias Fat oxidation defects i.e. MCAD 5.0 Prevention 5.1 Keep all infants warm; axilla temperature should be maintained between degrees centigrade. (Refer to the guideline entitled Prevention and management of Neonatal Hypothermia ; register number 09128) 5.2 Feed all high risk infants within 2 hours of birth if possible. 6.0 Symptoms 6.1 Specific symptoms Seizures Coma 6.2 Non Specific Apnoea Hypotonia Jittery Irritability Abnormal cry Feeding problems Pallor 7.0 Equipment 7.1 Blood glucose is measured by using a 15 second glucometer suitable for neonatal use. Prior to carrying out the procedure, it is essential to check the expiry dates of the testing strips. 8.0 Treatment of Asymptomatic at Risk Infants 8.1 Infants can have low glucose levels and be completely asymptomatic 8.2 If the blood meter reading is <2.6 mmols but >1.5mmol: 4

5 Feed immediately Check the blood glucose levels 30 minutes after the feed. All readings should be recorded on the neonatal blood glucose observation chart and documented accurately in the Postnatal Care Record booklet If >2.6 then the baby should stay on the Postnatal Ward with its mother Feed every 3 hours, preferably at the breast, or with expressed breast milk however if these are unsuccessful, infant formula may need to be considered. If the mother wishes to formula feed then it should be at the correct mls/kg/day which may be increased to the next day on the neonatal feeding regime i.e. from 40mls/kg on day 1 to 60mls/kg Consider feeding more frequently Infant should not be increased by more than one day ahead without consulting a Paediatric Registrar due to risk of fluid overload Pre-feed blood glucose tests should be performed until there have been 2 readings >2.6mmol If post feed the blood glucose is still low, the Paediatric team should be informed If post feed the blood glucose remains < 2.0 mmol, even if the infant is asymptomatic admission will be required to the Neonatal Unit (NNU) and a further laboratory tested blood glucose should be obtained 8.3 If blood glucose mmol and baby is not symptomatic: Check laboratory tested blood glucose result Increase the volume and frequency of enteral feeds Consider intravenous (IV) glucose if infant is unable to increase/tolerate feed frequency or volume or Intensive feeding does not produce normoglycaemia Enteral feeding should be continued during IV infusion If infant develops symptoms or becomes profoundly hypoglycaemia < 1.1 mmol follow symptomatic hypoglycaemia protocol 9.0 Symptomatic Infants 9.1 All symptomatic hypoglycemic babies on the Postnatal Ward should be reviewed immediately. 9.2 Admit to the NNU. 9.3 Check the laboratory blood glucose. 9.4 Commence an intravenous infusion of 10 % dextrose at 90ml/kg/day (6mg/kg/min) this may be increased as necessary. 9.5 Enteral feeds should be continued as tolerated (unless contraindicated) and normoglycaemia maintained with intravenous 10% dextrose. 9.6 Recheck blood glucose after 30 mins if it remains < 2mmols increase the 10% glucose to 120ml/kg/day (8.3mg/kg/min) 5

6 9.7 Due to the risk of fluid overload with large volumes of 10% dextrose if hypoglycaemia is difficult to control or the infant is volume restricted increase the concentration of glucose. If the concentration is > 12.5% a central line is required. (Refer to Appendix B) 9.8 Bolus doses of concentrated glucose should be avoided as they cause insulin release and rebound hypoglycaemia. In cases of severe hypoglycaemia persistently below 1 mmol, 1 bolus dose of 2.5ml/kg 10% dextrose infused over 5 minutes may be given. 9.9 If hypoglycaemia is persistent and central access can not obtained then consider glucagon 100 micrograms/kg intramuscularly/intravenously/subcutaneously Oral glucose gel can be used in an emergency if IV access is difficult to obtain approximately 1ml/kg is squeezed into the inside of the infants cheek and is absorbed from the buccal mucosa There are more calories in 1ml of milk than 1 ml 10% dextrose and enteral feeding will establish normal hormonal regulation of glucose and should not be discouraged. Once the blood glucose level is normal, feeds should be increased and IV fluids tailed off Failure to Respond 10.1 If > 12mg/kg/min of glucose is required to achieve normoglycaemia, hyperinsulinaemic state is likely, these infants may require up to15-20 mg/kg/min and further investigation is indicated During an episode of hypoglycaemia collect blood for: Blood glucose Plasma insulin and serum C-peptide Free fatty acids Ketones Cortisol Growth hormone Acylcarnitines Collect next passed urine for organic acid analysis 11.0 Further Investigations 11.1 Further investigations will be required in some infants such as: Persistent recurrent hypoglycaemia especially in low risk infants Unexpectedly profound hypoglycaemia in a well infant Hypoglycaemia in association with metabolic acidosis Hypoglycaemia in association with other abnormalities i. Midline defects ii. Micropenis 6

7 iii. Exomphalos iv. Erratic temperature control Family history of sudden infant death syndrome (SIDS), Reye s syndrome or developmental delay 11.2 Investigations for severe, persistent or recurrent hypoglycaemia: Glucose, Capillary Ph, Pco2 Hco3 Base Excess (BE) Acylcamitines Lactate Ketone bodies Fatty acids Insulin Cortisol Glucagons Growth hormone Amino acids (ammonia if hyperinsulinism) Galactose-1-phosphate uridyl transferase 12.0 Staff and Training 12.1 All medical, midwifery and nursing staff involved in the care of infants at risk of hypoglycaemia will be trained to identify the symptoms of hypoglycaemia and its treatment All staff will be aware of the correct equipment to use and the correct way to perform heel pricks to obtain a capillary blood sample All midwifery and obstetric staff must attend yearly mandatory training which includes skills and drills training All midwifery and obstetric staff are to ensure that their knowledge and skills are up to date in order to complete their portfolio for appraisal Supervisor of Midwives 13.1 The supervision of midwives is a statutory responsibility that provides a mechanism for support and guidance to every midwife practicing in the UK. The purpose of supervision is to protect women and babies, while supporting midwives to be fit for practice'. This role is carried out on our behalf by local supervising authorities. Advice should be sought from the supervisors of midwives are experienced practicing midwives who have undertaken further education in order to supervise midwifery services. A 24 hour on call rota operates to ensure that a Supervisor of Midwives is available to advise and support midwives and women in their care choices. 7

8 14.0 Infection Prevention 14.1 All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands before and after each procedure All staff should ensure that they follow Trust guidelines on infection prevention. All invasive devices must be inserted and cared for using High Impact Intervention guidelines to reduce the risk of infection and deliver safe care. This care should be recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork (Medical Devices) Audit and Monitoring 15.1 Audit of compliance with this guideline will be considered on an annual audit basis in accordance with the Clinical Audit Strategy and Policy and the Maternity annual audit work plan The Women s and Children s Clinical Audit Group will identify a lead for the audit As a minimum the following specific requirements will be monitored: Prevention, detection and management of hypoglycaemia in the newborn Prevention, detection and management of hypoglycaemia in the newborn of women with diabetes Prevention, detection and management of hypothermia in the newborn 15.3 A review of a suitable sample of health records of patients to include the minimum requirements as highlighted in point 15.2 will be audited. A minimum compliance 75% is required for each requirement. Where concerns ` are identified more frequent audit will be undertaken The findings of the audit will be reported to and approved by the Women s and Children s Clinical Audit Group and an action plan with named leads and timescales will be developed to address any identified deficiencies. Performance against the action plan will be monitored by this group at subsequent meetings The Women s and Children s Clinical Audit Group report will be reported to the Women s and Children s Directorate Governance Meeting on a quarterly basis and significant concerns relating to compliance will be entered on the local Risk Assurance Framework Key findings and learning points from the audit will be submitted to the Patient Safety Group within the Chief Nurse report Key findings and learning points will be disseminated to relevant staff Guideline Management 16.1 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site. 8

9 16.2 Quarterly memos are sent to line managers to disseminate to their staff the most currently approved guidelines available via the intranet and clinical guideline folders, located in each designated clinical area Guideline monitors have been nominated to each clinical area to ensure a system whereby obsolete guidelines are archived and newly approved guidelines are now downloaded from the intranet and filed appropriately in the guideline folders. Spot checks are performed on all clinical guidelines quarterly Quarterly Clinical Practices group meetings are held to discuss guidelines. During this meeting the practice development midwife can highlight any areas for further training; possibly involving workshops or to be included in future skills and drills mandatory training sessions Communication 17.1 A quarterly maternity newsletter is issued and available to all staff including an update on the latest guidelines information such as a list of newly approved guidelines for staff to acknowledge and familiarize themselves with and practice accordingly Approved guidelines are published monthly in the Trust s Focus Magazine that is sent via to all staff Approved guidelines will be disseminated to appropriate staff quarterly via Regular memos are posted on the guideline notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders References Neonatal Handbook Rosie Maternity Hospital 2013 Neonatal Guidelines (2011) Staffordshire, Shropshire and Black Country Newborn network Neonatal Hypoglycaemia Guidelines (2006) Guys and St Thomas Hospital. Neonatal Hypoglycaemia Guidelines Hammersmith Hospital NHS Trust (2007) 9

10 Appendix A Management of Glycaemic Status in at Risk Infants Check blood glucose >2.6 mmol/l No and symptomatic Admit to Neonatal Unit Send lab glucose Start IV 10% dextrose 90ml/kg/day Yes or No and asymptomatic Do not admit to Neonatal Unit unless otherwise indicated Initiate feeding as soon as possible Breastfeeding recommended but support mother s choice Check blood glucose before 2 nd feed Check blood glucose 1 hour later >2.6 mmol/l >2.0 mmol/l Yes No Symptomatic Asymptomatic No Increase volume and/or concentration of IV glucose. Investigate. Yes Continue feeding. Check blood glucose before 4 th feed >2.6 mmol/l Increase volume and frequency of feeds. Check blood glucose before 4 th feed No Yes Continue feeding. No more blood glucose monitoring necessary unless symptomatic Continue IV fluids. Increase enteral feeds as tolerated Monitor pre-feed blood glucose and decrease IV fluids gradually 10

11 Appendix B Making up Varying Concentrations of Glucose Infusion concentration Volume of 10% glucose (ml) Volume of 50% glucose (ml)

12 Carbohydrate Requirements in Hypoglycaemic Infants Conversion of rate of glucose infusion from ml/kg/hr to mg/kg/min depending on concentration of glucose Chart 1 Appendix C Infusion rate Strength of glucose solution mg/kg/min 4% 10% 15% 20% ml/kg/day mg/kg/min Glucose requirement (mg/kg/min) = Chart 2 MILK FEED ml/hr x % glucose 6 x weight (kg) mg/kg/min mls/kg/hr 1. Convert ml/kg/hr of IV to mg/kg/min. 2. Convert ml/kg/hr of milk to mg/kg/hr and add Normal requirement = 5-6 mg/kg/min Hyperinsulinism requirement = > 9-10 mg/kg/min 12

13 Appendix D 13