Neonatal Hypoglycaemia Guidelines

Transcription

1 N.B. Staff should be discouraged from printing this document. This is to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the document.

2 Contents: 1 Executive Summary Scope of guideline Essential Implementation Criteria Aims Responsibilities Training Monitoring and Effectiveness Appendices... 2 Hypoglycaemia Guidelines... 3 Page 1

3 1 Executive Summary This document is a clinical guideline designed to support safe and effective practice 1.1 Scope of guideline This guideline applies to all clinicians working within Neonatal and Maternity services 1.2 Essential Implementation Criteria Auditable standards are stated where appropriate 2 Aims To provide support for clinical decision making 3 Responsibilities The Neonatal and Maternity Management team 4 Training Staff are expected to access appropriate training where provided. Training needs will be identified through appraisal and clinical supervision. 5 Monitoring and Effectiveness Local service Improvement Plan will guide monitoring and effectiveness. 6 Appendices Page 2

4 Appendix 1 Neonatal Hypoglycaemia flow charts Hypoglycaemia Hypoglycaemia is defined as blood glucose < 2.6 mmol/l when measured with Advantage machine The following are guidelines only. In individual clinical circumstances the neonatal staff may need to deviate from the guidelines in the best interests of a particular baby. Asymptomatic Healthy Term Infants who are Reluctant to Feed Newborn Babies at Risk of Hypoglycaemia Feed- Check- Review Symptomatic Hypoglycaemia Symptoms + BM < 2.6 Convulsions Apnoea Jitteriness Cyanosis Irritability Pallor Floppiness Lethargy Abnormal Cry Asymptomatic High Risk Infants Preterm <37w BW < 2.5 Kg Hypothermia Apgars <6 Maternal DM Maternal severe PET/ labetolol Rhesus disease Resp distress See Flowchart 2 This is a Medical Emergency Call Neonatologist Early feed Keep warm 3 hourly feeds Pre-feed BMs See Flowchart 1 See Flowchart 3 Page 3

5 FLOWCHART 1 SYMPTOMATIC HYPOGLYCAEMIA Symptomatic hypoglycaemia is a medical emergency. Infants with major symptoms of hypoglycaemia (convulsions, apnoea or central cyanosis) and a blood glucose <2.6 mmol/l on ward testing must be seen immediately by a paediatrician and admitted to SCBU for IV dextrose. SYMPTOMS OF HYPOGLYCAEMIA + BM < 2.6 Convulsions Apnoea Jitteriness Cyanosis Irritability Lethargy Floppiness Pallor Abnormal Cry Symptoms significant Infant in any way unwell Or BM 1.4 Airway- Breathing- Circulation. Admit to SCBU CALL NEONATOLOGIST IMMEDIATELY Thorough neonatal assessment decides: Symptoms absent/ insignificant Infant able to take enteral feed AND BM > 1.4 Send lab glucose (heelprick) Assess infant for evidence of underlying illness e.g. sepsis and treat as appropriate Feed immediately 10 ml/kg EBM/ formula top-up IV Access Send lab 2 ml/kg bolus of 10% dextrose + dextrose infusion BM < 2.6 Admit to SCBU for IV Dextrose Post-feed BM in 1 hour BM 2.6 or more At least 3 hourly breast feeds or 60 ml/kg/day of EBM or formula Monitor Pre-feed blood sugars Join high-risk flowchart 3 Jitteriness is a rapid generalised repetitive symmetrical tremor of the limbs, occurring in the absence of being handled. It can usually be stopped by handling the baby, and is not accompanied by physiological changes e.g. raised HR or apnoea, unlike a convulsion. Jitteriness in a healthy term infant is often a benign finding, but in a high-risk infant, hypoglycaemia or cerebral irritability should be considered. Page 4

6 HEALTHY TERM INFANTS. Healthy term infants who are asymptomatic, maintaining their temperature and either learning to feed (i.e. rooting) or feeding well, do not need routine blood glucose measurements, and need no supplementary foods or fluids. Healthy term newborns do not develop symptomatic hypoglycaemia as a result of simple underfeeding All mothers should be encouraged to hold babies in skin-to-skin contact after the birth and offer the first breastfeed as soon as possible in an unhurried environment. A midwife should explain to the mother how to achieve correct positioning and attachment of the baby to the breast. Mothers should be offered further help within 6 hours of the first feed. If the baby has not fed within 6 hours encourage feeding by keeping the baby in skin-to-skin contact and offering the breast. If the baby is still reluctant to feed, colostrum may be hand expressed and fed to the baby via syringe or cup. An infant who remains unwilling to feed, who does not wake for a feed or is symptomatically hypoglycaemic must be reviewed by a paediatrician to exclude an underlying illness. Blood glucose may form part of this assessment but does not replace clinical review. If there are concerns that the infant is unwell, appropriate treatment should be initiated, which may require discussion with senior neonatologists or SCBU admission. If the infant is unwilling to feed but remains well, a feed-check-review policy can be adopted: Feed: Encourage frequent attempts at feeding/ breast. Hand express colostrum. Check: Monitor vital signs, initiate skin-to-skin, observe a complete breastfeed Review: Well infant- continue. Concerns- contact neonatologist. If it is not possible to obtain expressed breast milk earlier and the infant has still not fed by 12 hours old, check observations and seek medical review by a neonatologist. In the absence of clinical symptoms continue feed-check-review policy. If there are clinical concerns, a blood glucose must be checked and treatment instigated as appropriate. Page 5

7 References: Hypoglycaemia of the Newborn: A Review of the Literature, Bulletin of the World Health Organisation. Geneva 1997 Hypoglycaemia of the Newborn- Guidelines for appropriate blood glucose screening and treatment of breastfed and bottle fed babies in the UK. National Childbirth Trust, Glasgow 1997 FLOWCHART 2: HEALTHY TERM INFANTS WHO ARE RELUCTANT TO FEED Baby reluctant to feed or observed feed is unsatisfactory ACTION: Gently stimulate baby to feed Baby feeds well and is asymptomati Baby refuses breast/ bottle but remains asymptomatic ACTION: Skin-to-skin, Express milk + give via cup/ syringe, offer feeds 2-3 hrly Baby unwell or has symptoms of hypoglycaemia Continue as normal Feed- Check- Review If despite all this, infant still not feeding adequately at 12 hrs old ACTION: Refer to neonatologist to exclude Refer to Neonatologist Immediately. Check BM No clinical concerns Continue Feed-check-review Feeds remain inadequate, and symptoms develop, then treat as highrisk infant (flowchart 3) Clinical concerns Check blood glucose. Treat as appropriate. Discuss with registrar Consider SCBU admission Page 6

8 HIGH RISK ASYMPTOMATIC INFANTS Hypoglycaemia is defined as BLOOD GLUCOSE <2.6 MMOL/L If 2 blood glucose measurements are below 2.6 mmol/l, a laboratory glucose should be measured. Sample is sent in a fluoridated tube (yellow top); a few drops from a heelprick sample should be adequate. However, treatment (i.e. feeding) should not be delayed whilst waiting for the result. These High Risk Infants need monitoring for asymptomatic hypoglycaemia -Preterm infants (<37/40) -Rhesus isoimmunisation -Birthweight <2500g -Respiratory distress/ sepsis -Hypothermia T< 36C -Maternal labetolol/ severe PET -Maternal diabetes (including gestational) -Perinatal asphyxia (Apgar <6 at 5 min) If infant becomes symptomatic: refer to neonatologist immediately Follow flowchart 1 for symptomatic hypoglycaemia For all High-Risk Babies: Prevention of Hypoglycaemia 1. Start feeds within 1 hour of birth and continue 3 hourly. 2. Keep the infant warm. Encourage skin-to-skin contact with mother. 3. Start breastfeeds/ EBM 6-8 times per day or formula milk at 60 ml/kg/day. 4. Check pre-feed BM before second feed (at about 4 hours old) and follow flowchart 3 overleaf for high-risk infants. Refer to Neonatologist Immediately if: 1. Infant is unwell (eg floppy, drowsy, possible sepsis, any other concerns) 2. Blood glucose <1.4 mmol/l at any time 3. Blood glucose <2.6 mmol/l on 2 occasions 4. Symptomatic hypoglycaemia Admit to Transitional Care: All infants of diabetic mothers (including gestational diabetes) Any other infants for whom the neonatal registrar considers it necessary Admit to SCBU: Any infant who is unwell or has symptoms of major hypoglycaemia: coma, seizures, apnoea Profound hypoglycaemia (< 1.4 mmol/l) Any infant with hypoglycaemia due to suspected inborn error of metabolism or hyperinsulinaemia e.g. Beckwith-Wiedemann Syndrome. Any hypoglycaemic infant from the postnatal ward who fails to respond to measures given above Page 7

9 FLOWCHART 3: HIGH RISK INFANTS Healthy Term Infant who continues not to feed despite medical review and prolonged access to breast, and has now developed symptoms (from flowchart 2) High- Risk Asymptomatic Infants -Identify at risk infants at birth -Start feeds within 1 hour of birth and continue 3 hourly Avoid Hypothermia -Breast feed/ EBM 6-8 times/ day -Or formula at 60 ml/kg/day - Measure pre-feed BM before 2 nd feed (approx 4 hours old) Measure Pre-feed BM BM < 1.4 BM BM 2.6 Refer to Neonatologist Feed and check BM in 1 hour BM < 2.6 Call Neonatologist. Check Urgent Lab Glucose Lab glucose Recheck 2 more pre-feed BMs Lab glucose < 2.6 Give more EBM or increase volume of substitute to 120 ml/kg/day, oral/ NGT 3 Pre-feed BMs 2.6 Recheck BM after 1 hour BM < 2.6 Refer to Neonatologist Admit to SCBU? BM 2.6 No more BMs Page 8