Prevention and Management of Hypoglycaemia of the Breastfed Newborn Reference Number:

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1 This is an official Northern Trust policy and should not be edited in any way Prevention and Management of Hypoglycaemia of the Breastfed Newborn Reference Number: NHSCT/10/293 Target audience: Midwifery, Neonatal, Medical and Paediatrician staff Sources of advice in relation to this document: Mrs Gillian Anderson, Breastfeeding Co-Ordinator Dr S Bali, Consultant Neonatologist Replaces (if appropriate): Previous Northern Trust Prevention and Management of Hypoglycaemia of the Breastfed Newborn NHSCT/09/175 Type of Document: Clinical Guideline Approved by: Policy, Standards and Guidelines Committee Date Approved: 18 March 2010 Date Issued by Policy Unit: 26 May 2010 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves 1

2 Prevention and Management of Hypoglycaemia of the Breastfed Newborn February

3 PREVENTION AND MANAGEMENT OF HYPOGLYCAEMIA OF THE BREASTFED NEWBORN 1.0 INTRODUCTION 1.1 Hypoglycaemia of the newborn is defined as a blood glucose of <2.6 mmol/l. 2.0 DIAGNOSIS 2.1 Blood sampling will be performed using an automatic blood letting device such as Autolet to obtain a capillary sample from the outer fleshy part of the heel. Curvette for glucose measurement with a BM meter will be used for screening hypoglycaemia trends only. Blood glucose will be estimated in the laboratory from a venous sample in a grey bullet (NaF-K Oxalate) for confirmation of hypoglycaemia. Adequate blood must be obtained to ensure accuracy. Results from an electrolyte profile blood sample are not accurate for detection of hypoglycaemia. 3.0 PHILOSOPHY OF CARE Promotion of early feeding with skin-to-skin contact as soon as possible after delivery aids thermoregulation and stability of blood glucose. Identification of the at risk infant so appropriate management is initiated. The avoidance of frequent unnecessary testing of healthy term newborn. 3.1 Skin-to-skin contact and frequent access to the breast should be used to encourage the reluctant breastfeeding baby. Giving colostrum early and regularly is an effective way of preventing or correcting hypoglycaemia. 4.0 RISK FACTORS ASSOCIATED WITH HYPOGLYCAEMIA Small for gestational age (birth weight below 9th centile) Preterm (<37 weeks) Infant of diabetic mother (maternal diabetes) Hypothermia Infection Severe rhesus disease Hypoxia / ischaemia, requiring resuscitation at birth Polycythaemia Maternal use of beta blockers e.g. labetalol. 5.0 SIGNS OF HYPOGLYCAEMIA * 3

4 i) Tremor - persistent jitteriness, unprovoked by stimulus ii) Lethargy (altered consciousness) v) Seizures (often subtle) iii) Hypothermia vi) Cyanosis / Pallor iv) Apnoea vii) Tachypnoea Altered consciousness baby should exhibit a normal level of arousal. *On the rare occasion there may be no physical signs. NB Definition of jittery persistent jitteriness which does not resolve in response to passive flexion. NOT to be confused with the normal startle response. 6.0 PREVENTION AND MANAGEMENT OF HYPOGLYCAEMIA 6.1 Maintain normal body temperature and initiate feeding as soon as possible after delivery with early skin-to-skin contact. 6.2 Feed on demand - teach mother how to recognise signs of willingness to feed. 6.3 If a healthy term baby is clinically well but has a longer than usual interval between feeds (usual breastfeeding pattern > 4 times in the first 24 hours), hand express or pump to obtain colostrum and feed by syringe or cup. Encourage skin-to-skin contact and frequent access to the breast. It is not necessary to routinely test the blood glucose level of a healthy term baby. 6.4 Continue to Feed, Check, Review until baby is breastfeeding effectively. Check: colour, tone, alertness and maintain normal body temperature. 6.5 If, however, baby is unable to feed and / or is showing signs of hypoglycaemia, check BM and follow algorithm. If baby remains reluctant to feed (non-bottle method attempted if breastfeeding), then clinical examination is required to exclude any underlying illness. 6.6 Document findings e.g. time, clinical symptoms, BM result, action and response. 7.0 MANAGEMENT OF BABIES AT RISK (See Algorithm) 7.1 Feed early (< 1 hour) to prevent hypoglycaemia. Maintain normal body temperature. If feeds well, check BM prior to next feed at three hours. If satisfactory go to Point If the baby does not feed effectively, continue hourly observation of the baby. 7.3 Within 3 hours of birth REVIEW level of consciousness, tone, temperature, respirations and colour. Do a pre-feed BM and feed, (A) If BM > 2.6 mmol/l but has not fed well review in one hour and attempt to feed again. If both feed and post feed BM are satisfactory move to Point

5 (B) If BM < 2.6 mmol/l attempt to feed. At risk breastfeeding newborns not able to suckle effectively, but well enough for enteral feeding, will be fed expressed breastmilk or, if necessary, formula by non-bottle methods. Formula is given at appropriate volume ml/kg for baby s age. Repeat BM one hour from start of the feed. If satisfactory move to Point 7.4, if not contact paediatrician and move to Point 8.0A (7.5). 7.4 Teach mother early feeding cues although these babies cannot be relied upon to exhibit these cues. Continue BM monitoring 3 hourly until 3 consecutive BM s are > 2.6 mmol/l prior to feeds. 7.5 Document management throughout. PAEDIATRICIANS / NEONATOLOGISTS GUIDELINES 8.0A MANAGEMENT OF THE AT RISK ASYMPTOMATIC INFANT WITH A PERSISTANT BLOOD GLUCOSE CONCENTRATION OF < 2.6 MMOL/L If hypoglycaemia cannot be corrected at ward level by feeding methods, baby requires admission to NNU. Venous blood glucose measurement is required and administer 10% glucose I.V. if confirmed <2.6 mmol/l. 8.0B MANAGEMENT OF THE SYMPTOMATIC INFANT WITH A BLOOD GLUCOSE OF < 2.6 MMOL/L Urgent blood glucose measurement is required. If less than 2.6mmols/L, all the above guidelines are superseded and IV glucose is required. Baby requires admission to NNU for treatment and further investigation. 9.0 ADMINISTRATION OF INTRAVENOUS GLUCOSE Give 2 ml / Kg 10% glucose by slow intravenous infusion over minutes. Follow with a continuous infusion of 10% glucose as per requirement for individual baby. Check BM one hour following the initiation of this intervention. If remains < 2.6mmol/L seek senior medical staff advice. When a baby is tolerating oral feeds, reduce IV glucose slowly to avoid rebound hypoglycaemia. Following discontinuation of glucose infusion three consecutive BM s of > 2.6 mmol/l are required before monitoring ceases. This protocol applies to all staff; any deviation from this must be justified and documented by the prescriber. 5

6 10.0 ALGORITHM FOR MANAGEMENT OF BABIES AT RISK Prevention and management of hypoglycaemia in at risk neonates Small for gestational age (BW <9 th centile) Preterm <37 weeks Infants of Diabetic mothers Hypoxia / Ischaemia Hypothermia Infection Severe Rhesus Disease Polycythaemia Maternal use of beta blockers Feeds well and clinically well Yes Dry baby, keep warm Feed early < 1hr. Feeds effectively? No Does not feed well. Ongoing observation. Give EBM (if none available continue expressing hourly). Maintain temperature. Check BM at 3hr of age or if baby symptomatic Check BM prior to feed at 3 hours If <2.6mmol/L 2.6mmol/L NOT feeding well 2.6 mmol/l <2.6 mmol/l Attempt a feed either at breast or give EBM/formula by cup or tube Review in 1 hour attempt to feed and repeat. Post feed BM at 1hr Repeat BM 1hr post feed If still poor feed or BM <2.6mmol/L Satisfactory feed continue 3hrly feeds and pre-feed BM until 3 consecutive BM are 2.6mmol/L <2.6 mmol/l Contact Paediatrician Venous blood glucose required 6

7 Appendix 1 NB It appears that breastmilk may enhance the baby s ability to counter regulate whereas large volumes of formula suppress this ability. Blood glucose measurements taken in the first 3 hours of age are not informative readings made immediately after birth are merely indicative of the mother s blood glucose concentration. Levels may drop sharply while counter-regulation is initiated. UNICEF, Hypoglycaemia Guidance, Dec

8 BIBLIOGRAPHY Cornblate M, et al (2000) Controversies regarding definition of neonatal hypoglycaemia: suggested operational thresholds. Paediatrics; 105: De Rooy L. et al. (2002) Nutritional factors that affect the postnatal metabolic adaption of full term small for gestational age infants. Paediatric 109: e42 Deshpande S, Ward Platt M. (2005) The investigation and management of neonatal hypoglycaemia. Seminars in Fetal and Neonatal Medicine ; 10, Hawdon, J.M., Ward Platt, M.P. & Aynsley Green, A. (1992). The Role of Pancreatic Insulin Secretion in Neonatal Glucoregulation in Healthy Term and Preterm Infants. Archives of Disease in Childhood, 68: Lucas, A, Morely, R. & Cole, T.J. (1988). Adverse Neurodevelopmental Outcome of Moderate Neonatal Hypoglycaemia. British Medical Journal, 297: The Confidential Enquiry into Maternal and Child Health (CEMACH). (2007) Diabetes and Pregnancy. Caring for the baby after birth. Findings of a National Enquiry : England, Wales and Northern Ireland. CEMACH, London UNICEF BF Guidance on the development of policies and guidelines for the prevention and management of hypoglycaemia of the newborn. Williams, A.F. (1997). Hypoglycaemia of the Newborn. Review of the Literature. World Health Organisation, Division of Child Health and Development, Geneva. 8