Use with the Hypoglycaemia Care Plan for babies on Labour and Postnatal Wards.

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Diane McCoy
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1 Preventin and Management f Hypglycaemia Use with the Hypglycaemia Care Plan fr babies n Labur and Pstnatal Wards. General Principles 1) Anticipate hypglycaemia in high risk infants 1. cnsider pre-delivery breast milk harvesting 2. ensure hypglycaemia plan knwn prir t delivery 2) Initiate feeds early and three hurly feeds thereafter fr high risk babies 3) Dn t d bld sugar befre baby is 2 hurs ld unless there are clinical signs 4) Give dextrse gel t infants in crrect amunts, prmptly, accrding t bld sugar 5) Keep babies warm at all times 6) Avid separatin f mthers and infants. 7) Supprt establishing breast feeding 1. Use f dextrse gel as first line treatment fr hypglycaemia 2. Encurage expressin f breast milk fr use as feed supplement, nly use frmula supplements at 60mls/kg/d if n EBM available 3. Passing f nasgastric tube and admissin t SCU (with mther) if mre frequent feeds/larger feed vlumes required 8) The rle f the nenatal SHO/Registrar is t take a histry, lk fr risk factrs, examine the baby fr signs/symptms f hypglycaemia, review the charts, supprt the parent(s) and midwife, and ensure baby is managed accrding t the guideline. 9) If enteral feeding insufficient t maintain nrmal bld sugar levels, t cmmence IV dextrse 1. Avid IV blus f dextrse if pssible 2. Start IV glucse lad at 4--6mg/kg/min and increase in steps f 2mg/kg/min 3. Use f 5 and 50 glucse regime fr independent management f glucse lad and flw rate 10) Treat severe hypglycaemia 1.0mml/L urgently with IV glucse ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

2 Bld glucse levels in the nenate As part f the nrmal pstnatal adaptatin, newbrn infants bld glucse levels fall immediately fllwing delivery, reaching the lwest levels within 1-2 hurs after birth. After that, in healthy, nrmally grwn term babies the levels then spntaneusly recver as feeds are established. The nenatal brain uses lactate as an alternative metablic fuel whilst feeding is being established in the first hurs. Hwever recent evidence indicates that there is als a hypkettic state and s babies remain vulnerable until their bld sugar level nrmalises. There are sme grups f newbrns wh are at greater risk f symptmatic hypglycaemia and risk f neurnal damage. Preterm infants and Small fr Gestatinal Age babies (GROW prtcl) may have reduced glycgen stres, impaired glucnegenesis due t liver immaturity and additinal suppressin f ketnes prductin (as an alternative substrate). Large babies (>4.5kg) r babies with diabetic mthers are at risk f hyperinsulinism causing prfund hypglycaemia. Other at-risk grups are defined belw. Definitin f hypglycaemia We use different levels f bld sugar level (BSL) t define the actins necessary 1. BSL f 2.6mml/L r mre is nrmal 2. BSL between 1.8 and 2.5mml/L is usually transitinal 3. BSL between 1.5 and 1.8mml/L may be physilgical but may be pathlgical 4. BSL f 1.5mml/L r less, if prlnged, may put the baby at risk f neurnal damage 5. BSL f 1.0mml/L r less is severe hypglycaemia and requires urgent IV treatment Symptms and signs f hypglycaemia Neurgenic (sympathetic nervus activity): jitteriness, tachycardia, pallr, hypthermia Neurglycpenic (impaired brain functin): flppiness, sleepiness (mre than 8 hurs between feeds), irritability, pr feeding, cyansis, tachypnea, apneic episdes, weak r high-pitched cry, seizures. Measurement f bld sugar levels (BSL) D nt check a BSL in a baby less than 2 hurs ld lw BSL are nrmal befre then unless there are clear clinical signs f hypglycaemia. The quickest / mst cnvenient way t measure BSL is with a handheld bld glucse meter. These cnsistently underestimate the actual sugar level cmpared t capillary bld gas glucse (CBGS). Thus a lw/brderline reading n prtable glucse meter shuld be checked with a CBGS, althugh treatment (e.g. with dextrse gel) shuld nt be delayed Jitteriness Jitteriness is a prly defined symptm and is nt a definitive sign f hypglycaemia (UNICEF). Many babies will appear jittery n handling, therefre a definitin such as the fllwing is suggested: Excessive repetitive mvements f ne r mre limbs, which are unprvked and usually relatively fast. It is imprtant t be sure that this mvement is nt simply a respnse t stimuli. ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

3 Measures fr preventin and management f hypglycaemia Babies are at LOW r HIGH risk fr hypglycaemia which is ften preventable General measures t PREVENT hypglycaemia apply t all babies: Keep babies warm and dry Offer feeds early (high risk babies within 30 minutes f birth, lw risk within 3 hurs) The risk f hypglycaemia shuld be anticipated and assessed n Delivery Suite by the midwife caring fr the mther and newbrn infant. LOW RISK INFANTS Nrmally grwn term infants wh are well, warm and feeding prperly are at lw risk f hypglycaemia and d nt require rutine BSL testing. Infrequent feeding in a well infant is nt an indicatin fr BSL testing it is usual fr a baby t feed as little as 4 times in the first 24 hurs f life - but a baby shuld nt g fr lnger than 8 hurs between feeds. If there are clinical cncerns if baby becmes systemically unwell r there are signs f hypglycaemia, manage baby accrding t the Clinical Cncern Pathway (belw) HIGH RISK INFANTS High risk babies shuld be identified by their midwife n Delivery Suite and the Hypglycaemia Care Plan shuld be cmmenced and placed in the ntes. Babies will fllw the Infant at Risk Pathway. High risk criteria include any ne r mre f: Prematurity (<37 weeks gestatin including all babies up t and including 36+6 weeks) Small fr Gestatinal Age (GROW prtcl less than 10 th centile n EFW/BW)* Large fr dates ( 4.5kg birth weight) Diabetic mther (all types) Infants f wmen with diabetes are als at higher risk f persistent respiratry distress, cngenital heart disease, plycythaemia, and severe jaundice. If there are any clinical cncerns in these infants, the Nenatal SHO shuld be called t review the baby. Other factrs may increase the risk f nenatal hypglycaemia: Maternal drug therapy (beta blckers, sdium valprate) Infectin Plycythaemia Hypxic-ischaemic encephalpathy Respiratry distress Inbrn errrs f metablism Syndrmes such as Beckwith- Wiedemann Rebund hypglycaemia fllwing IV dextrse blus * The GROW prtcl is used antenatally t identify babies wh are SGA based n parental characteristics such as ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

4 height and ethnicity. It is administered by the Perinatal Institute. The use f GROW natinally and by regin (e.g. Suth East Cast can be fund here). Mre infrmatin abut GROW can be accessed here. ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

5 Hypglycaemia Care Pathway: Preventing and Managing Hypglycaemia in Newbrns Mst babies at risk f / with hypglycaemia will be managed by midwives n Delivery Suite/ Pstnatal Ward withut the need fr escalatin f medical interventin beynd dextrse gel administratin. This apprach supprts breastfeeding and bnding, reduces the number f heel-pricks fr the baby and shrtens the length f stay. BSL f 2.6mml/L (r mre) is the THERAPEUTIC OBJECTIVE BSL f 1.8mml/L is the OPERATIONAL THRESHOLD (nenatal medical team infrmed) There are 3 escalatins in the pathway fr calling the Nenatal SHO. Use the SBAR (Situatin- Backgrund-Assessment-Recmmendatin) framewrk t ensure clear cmmunicatin e.g. Infrm Nenatal SHO that: (S) Baby X is X hurs/days ld, has lw bld sugar (level, hw checked), temperature is X C (B) Any risk factrs, (A) Is being managed n pathway and received (X dses f gel) (X bld sugar checks) AND SHO - INFORM SHO - REVIEW SHO - URGENT (R) attendance nt expected (R) attendance required sn but nt urgently (R) attendance required urgently Dextrse Gel Dextrse gel is the immediate first-line treatment fr any lw bld sugar. 0.5mls per kg f 40% dextrse gel shuld be given t the infant (200mg/kg glucse). 0.5mls is apprximately equivalent t the same amunt f 40% dextrse gel that can be generusly applied t an adult fingertip. Therefre the dse is ne full fingertip per kg fr example a 3kg baby wuld require 3 full fingertips wrth f 40% dextrse gel. A 3.5kg baby wuld receive 4 full fingertips etc. The gel is applied tpically t the buccal mucsa. INFANT AT RISK PATHWAY fr thse infants wh have ne (r mre) risk factrs Feed within 30 minutes f birth If first feed is taken within 1 hur f birth, check first BSL prir t the secnd feed (~3 hurs) If first feed mre than 1 hur after birth (pathway failure), check BSL at 2 hurs f age Feeds shuld be ffered 3 hurly The first (pre-feed) BSL shuld be checked n the prtable bld glucse meter The baby s temperature shuld be checked at the time f the BSL If first BSL is 2.6 mml/l then recheck in 9-10 hurs (prir t the 4 th feed). Observe infant n the pstnatal ward fr 24hurs (general bs, mnitr feeding). If there are any further cncerns (such as pr feeding r clinical signs f hypglycaemia), recheck BSL immediately and start a NEW hypglycaemia care plan. If the first pre-feed BSL is <2.6 mml/l, the CBGS shuld be checked (the NICU bld gas machine has a glucse-nly prfile fr this purpse) If the first pre-feed BSL r CBGS is less than 2.6mml/L then give dextrse gel immediately THEN If CBGS between 1.5 and 1.8mml/L AND n symptms/signs SHO - REVIEW Ensure feeding plan being fllwed N frmula tp ups If CBGS between 1.5 and 1.8mml/L AND symptms/signs present SHO ATTEND If CBGS 1.5mml/L then fr immediate SHO/Registrar attendance ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

6 The infant shuld be fed (breast r frmula accrding t maternal preference.) Every step shuld be taken t aid and supprt mthers wh wish t breast feed t help with establishment f breast feeding. Ensure the infant is warm and dry BSL shuld be repeated prir t the next feed (3 hurly). There is n need t take pst-feed BSL Prvided that the bld sugars are stable r imprving and that the infant remains well, treatments with dextrse gel can be used up t three times whilst ensuring warmth and 3 hurly feeding After 3 runds f dextrse gel, if the bld sugar is still lw then ffer tp-up milk supplements (EBM if available, frmula if nt) at 10mls/kg per feed (this equates t apprximately 60mls/kg/day) If this is the baby s first lw glucse reading (i.e. it was nrmal after the first feed but n retesting prir t the furth feed is nw lw) use dextrse gel In line with the UK Baby Friendly Initiative we aim t prmte and supprt breast feeding mthers, whilst ensuring the safety f all infants at risk f hypglycaemia. Mderate hypglycaemia (i.e. BSL mml/L) in an therwise well infant is nt a cntraindicatin t breast feeding, and establishment f breast feeding shuld be supprted at all stages f the care pathway, even when supplemental frmula is required. Expressed breast milk shuld be used first as a supplement (if available), and parents shuld be infrmed as t why infant frmula is being used if this becmes necessary. These guidelines are intended fr the management f therwise well babies n the Pstnatal Ward and Delivery Suite. They are nt intended t replace clinical judgement, and if there are cncerns at any pint the Nenatal SHO r Registrar shuld be cntacted, althugh they are expected t fllw the guideline under nrmal circumstances. Supplements (EBM r frmula) may smetimes be required at day ahead vlumes: 90mls/kg/day n first day, 120mls/kg/day n secnd day, 150mls/kg/day n third day nwards. If a baby is vmiting cnsider ther causes (structural bstructin, sepsis) r cnsider a change t mre frequent smaller vlume feeds. CLINICAL CONCERN PATHWAY Nrmally grwn term infants may be started n the Hypglycaemia Care Plan if there is clinical cncern: if the baby becmes systemically unwell r there are signs f hypglycaemia such as pr tne, excessive sleepiness (>8hurs between feeds), irritability, apnea, jitteriness r seizure activity. In these cases the baby shuld have a first bld sugar level as per the abve pathway. Once the baby has had tw cnsecutive bld sugar levels at 2.6mml/L r mre, mnitring can be stpped. With these infants there is n need t cmplete a further 24 hurs bservatin as per the high risk infants. ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

7 Persistent Hypglycaemia If, despite the abve measures infants remain persistently hypglycaemic r are prfundly hypglycaemic at any stage, further measures will need t be taken. If BSL are mml/l and infants remain systematically well, the cmmencement f day ahead vlumes f EBM/frmula supplements (see abve) and/r feeding mre frequently may be adequate as the next step after dextrse gel (three runds can be used see pathway). Where pssible, it is preferable t use enteral feeding/supplementatin t IV dextrse. If an infant requires tw hurly feeding, a nasgastric tube can be passed and the baby admitted t SCU s that mthers and babies can be kept tgether where pssible. Management f persistent hypglycaemia requiring IV dextrse Any infant wh has persistent symptms, is nt tlerating enteral feeds, r is unable t maintain nrmglycaemia with apprpriate enteral feeds alne shuld be cmmenced n an intravenus infusin f 10% dextrse. This will invlve admissin. Bld tests required will depend n the clinical scenari Infants receiving IV dextrse shuld als receive enteral feeds IF there are n cntraindicatins Nrmal nenatal hepatic glucse prductin rate is 4-6 mg/kg/min start IV 10% dextrse at this rate Fr BSL mml/l despite attempts at enteral management, starting 10% dextrse at 90mls/kg/day will give 6.25mg/kg/min. A blus is nt nrmally required unless the baby is symptmatic, as bluses can prvke rebund hyperinsulinism. Fr BSL <1.5 mml/l (n CBGS) despite treatment (dextrse gel/feed) and/r with symptms (e.g. fitting), give IV blus f 3mls/kg f 10% dextrse AND increase the glucse lad being given (either increasing rate r cncentratin f IV dextrse). D nt give an IV blus withut als using glucse infusin. The aim is t rapidly increase BSL t >2.0 mml/l. Glucse lad shuld be increased in steps f 2mg/kg/min. Use the glucse infusin calculatr Check BSL 30 minutes after initiatin f treatment and then at 2 hurs. Frequency f testing can be reduced if there has been an adequate respnse. If BSL is still lw, the glucse lad needs t be increased. This can be dne by increasing either vlume f 10% dextrse given r increasing the cncentratin f the dextrse. It is imprtant nt t increase the vlume f fluid given beynd 120mls/kg/day n the first day f pstnatal life as there is a risk f hypnatraemia. T increase the cncentratin f dextrse use the 5 and 50 regime and nline calculatr If the cncentratin f dextrse required >12.5% this must be given thrugh a central line (UVC/lng line) At all stages dcument the amunt f glucse being given in mg/kg/min Further bluses can be given if there are further episdes f severe r symptmatic hypglycaemia but this shuld nt be dne in islatin: glucse lad shuld als be increased AND cause fr the drp shuld be searched fr (tissued IV line, pssible metablic cnditin etc.) The attending/n call cnsultant shuld be infrmed f all infants with persistently severely hypglycaemia and f infants requiring >12mg/kg/minute IV glucse Once BSL >2.6 mml/l fr 24 hurs, reduce IV fluids and increase enteral fluids as apprpriate every 6 hurs, checking bld sugars 4 hurly. On full enteral feeds check BSL every 6 hurs fr 24 hurs, then 12 hurly fr 24 hurs, then cease testing if BSL cnsistently >2.6mml/L ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

8 5 & 50 glucse regime By running 5% and 50% dextrse as simultaneus infusins, glucse lad (mg/kg/min) and flw rate (mls/hr) can be independently adjusted. If final glucse cncentratin is >12.5%, run infusin thrugh a central line (UVC r lng line). Electrlytes can be added t these infusins the ttal desired amunt (in mml/kg/day) added t bth infusins, calculated fr bth as if run at the full ttal daily vlume (mls/kg/day). Fr example, 4mml/kg/day NaCl desired at 120mls/kg/day wuld need 16.6mml NaCl t be added t ne 500ml bag f fluid. Therefre add 16.6mml NaCl t BOTH the 5% dextrse and 50% dextrse bag (as if each wuld run at 120mls/kg/day). 120mls/kg/day will be delivered by a cmbinatin f the 5% and 50% dextrse depending n the glucse lad required but regardless f the final glucse cncentratin 4mml/kg/day f NaCl will be delivered). Glucagn fr severe hypglycaemia Glucagn (100mcg/kg IM) may be required in the fllwing situatins: Unable t gain IV access in newly admitted infant with symptmatic hypglycaemia Lss f IV access in presence f significant/symptmatic hypglycaemia Persistence f hypglycaemia despite increasing glucse infusin rate Presence f seizures and hypglycaemia Rarely an IV blus r infusin f glucagn might be needed. Rates f mcg/kg/hr can be given IV r subcutaneusly Further Management f Persistent Hypglycaemia If infant remains hypglycaemic despite glucse lad f 12mg/kg/min take blds (preferably when baby is hypglycaemic but d NOT delay treatment) fr: FIRST LINE Labratry Glucse FBC, LFTs, TFTs Bld gas with lactate Insulin level [send t RSCH speak t bichemist, emphasise urgent sample, same day result needed] Crtisl Grwth hrmne Urine diptest fr ketnes SECOND LINE Ammnia (speak t bichemist, needs t g t lab immediately n ice) Lactate Fatty acids Ketne bdies Carnitine and acetylcarnitine (n bld spt frm) Urine rganic acids ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

9 Further testing such as lumbar puncture fr CSF glucse depends n the clinical scenari / histry. High insulin levels with hypglycaemia and n urinary ketnes indicates hyperinsulinism. In hyperinsulinism it is nt unusual t have a glucse requirement f 15-20mg/kg/min Sme babies may benefit frm Infatrini frmula fr extra glucse intake. This shuld be discussed with the attending Cnsultant and (if pssible) the Dietician first. The Nutritinal Calculatr can be used t wrk ut glucse delivery rates. Treatment with diazxide / chlrthiazide shuld be cnsidered (by the attending Cnsultant). Ttal fluids shuld be reduced t 120mls/kg/day as diazxide may cause fluid retentin. Dr Bahl will advise n management and Dr Khalid Hussein at GOSH may be cntacted if advice/transfer if required fr refractry cases. Fllw up All significantly symptmatic babies and thse wh have required mre than 12mg/kg/min f glucse infusin shuld be fllwed up as utpatients. Please discuss with the attending Cnsultant. ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

10 References Alkalay AL, Sarnat HB, Flres-Sarnat L et al.ppulatin meta-- analysis f lw plasma glucse threshlds in full- - term nrmal newbrns. Am J Perinatl 2006; 23: Aynsley-- Green A etal. Practical management f hyperinsulinism in infancy. Arch Dis Child Fetal Nenatal Ed 2000; 82: F98-F107 Burns et al. Patterns f cerebral injury and neurdevelpmental utcmes after symptmatic nenatal hypglycaemia. Pediatrics 2008; 122(1): Chantry CJ, Hward CR. Clinical Prtcls fr Management f Breastfeeding. Pediatr Clin N Am 2013;60:1, Crnblath M et al. Cntrversies regarding definitin f nenatal hypglycaemia:suggested peratinal threshlds. Paediatrics 2000 May; 105 (5): Crnblath M, Ichrd R. Hypglycemia in the nenate. Semin Perinatl 2000;24(2): Diwaker et al. Plasma glucse levels in term infants wh are apprpriate size fr gestatin and exclusively breast fed. Arch Dis Child Fetal Nenatal Ed 2002; 87: F46-48 Harris DL et al. Incidence f nenatal hypglycaemia in babies defined as at risk. J Pediatr 2012; 161: Harris DL et al. Dextrse gel fr nenatal hypglycaemia (the Sugar Babies Study): a randmised, duble-blind, placebcntrlled trial. The Lancet 2013; 302: Hawdn JM. Investigatin, preventin and management f nenatal hypglycaemia (impaired pstnatal metablic adaptatin). Paediatrics and Child Health 2012; 22:4, Hawdn JM. Definitin f nenatal hypglycaemia: time fr a rethink? Arch Dis Child Fetal Nenatal Ed 2013;98(5):F382-3 Hlmes AV. Establishing Successful Breastfeeding in the Newbrn Perid. Pediatr Clin N Am 2013; 60:1, Hussain K. Investigatins fr nenatal hypglycaemia. Clin Bichem 2011;44(7): Lucas A et al. Adverse neurdevelpmental utcme f mderate nenatal hypglycaemia. Arch Dis Child;63: Natinal Institute fr Health and Care Excellence. Diabetes in pregnancy: management f diabetes and its cmplicatins frm pre-cnceptin t the pstnatal perid. CG63. Lndn: Natinal Institute fr Health and Care Excellence; Stewart C, Sage E, Reynlds P. Supprting Baby Friendly : a quality imprvement initiative fr the management f transitinal nenatal hypglycaemia. Arch Dis Child Fetal Nenatal Ed 2015;0:F1 F4 Sundercmbe SL et al. Audit f a clinical guideline fr nenatal hypglycaemia screening. J Paediatr Child Health 2013 Sweet CB, Graysn S, Plak M. Management Strategies fr Nenatal Hypglycemia. J Pediatr Pharmacl Ther 2013;18(3): Guidance n the develpment f plicies and guidelines fr the preventin and management f Hypglycaemia f the Newbrn UNICEF UK Baby Friendly Initiative. Vannucci RC. Hypglycaemic brain injury. Semin Nenatal Apr; 6 (2): Guidelines prepared by Dr. Matthews, Dr. Sage, Dr. Reynlds March 2014 Updated by Dr. Farah, Dr. Reynlds January 2016 ASPH Nenatal Hypglycaemia Guideline 2016 v1.3

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