CHHS17/144

Canberra Hospital and Health ServicesClinical Guideline Neonatal Hypoglycaemia Contents

Contents....................................................................................................................................1

Guideline Statement.................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Neonates at Risk.....................................................................................................3

Section 2 – Procedure for specimen collection.........................................................................3

Section 3 – Buccal glucose gel 40% administration...................................................................4

Section 4 – Early Hypoglcaemia BGL <2.6 mmol/L....................................................................4

Section 5 – Treatment failure and recurrent Hypoglycaemia...................................................5

Section 6 – Severe/persistent Hypoglycaemia BGL <1.5mmol/L...............................................5

Section 7 – Neonatal Intensive Care (NICU)/ Special Care Nursery (SCN) inpatients..............6

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 7

Definition of Terms...................................................................................................................8

Search Terms............................................................................................................................ 8

Attachments..............................................................................................................................8

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Guideline Statement

BackgroundGlucose is an essential nutrient for the brain. Abnormally low blood glucose levels can cause an encephalopathy and has the potential to result in long term neurological injury.

Key ObjectiveThe purpose of this document is to provide a clinical pathway to detect, prevent and treat hypoglycaemia in the neonate. This guideline refers to neonates born in, transferred to, or admitted to the Canberra Hospital and Health Services (CHHS)

Alerts Any BGL <2.6mmol/L is considered abnormal If a neonate has a BGL of < 2.6mmol/L treatment as per the flow chart (Attachment 1)

should be initiated first, then the neonatal Registrar must be notified. All babies at risk of hypoglycaemia need a feeding plan. Neonates with hypoglycaemia

need feeding support and their mother’s need lactation support For administration of Buccal Glucose Gel 40% please refer to the NICU Drug Manual,

which can be found on the policy register (http://inhealth/PPR/default.aspx) Any neonate with BGL <1 mmol/L must receive intravenous dextrose 10% bolus and

infusion in NICU. To be ordered by medical officer.

Refer to individual sections for additional information and alerts.

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Scope

This document applies to neonates (infants aged less than 28 days) cared for in CHHS.

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice: Medical Officers and medical students Registered Nurses and Midwives Student Nurses and Midwives working under supervision

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Section 1 – Neonates at Risk

Neonates Requiring a Blood Glucose Screen All at risk neonates at 1-2 hours of age and then before the next feed (see flow chart

Attachment 1) All at risk neonates require a feeding plan with 3 hourly feeds as per flow chart All symptomatic neonates at any time

At Risk Neonates Large for Gestation Age (LGA)- Weight > 90th percentile or weight greater than length or

head circumference by 30 percentile points Small for Gestation Age (SGA)- Weight <10th percentile or weight less than length or

head circumference by 30 percentile points Prematurity born at <37 weeks gestation Weight <2.5kg Infant of a diabetic mother with either pre-existing Insulin Requiring Diabetes Mellitus

(type 1) or Insulin Requiring Gestational Diabetes (IRGDM) Perinatal stress/hypoxia – apgar score <7 at any time or an umbilical cord Ph <7.1 or an

umbilical cord BGL <2.6mmol/L Cold stress – temperature <36.0ᵒC which doesn’t improve after 30 minutes of warming Symptomatic neonates-jittery, apnoea, hypotonia, lethargy, irritability, seizures Poor feeding and or more than 10% weight loss (BGL to be measured as a part of their

blood investigations)

Note: Infants of diet controlled GDM mothers’ do not need screening unless there are maternal risk factors (e.g. high HbA1c) or neonatal risk factors (e.g. macrosomia or perinatal stress)

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Section 2 – Procedure for specimen collection

Alerts: Staff must have completed the certified venepuncture education to perform

venepuncture. Enrolment is via Capabiliti Neonates with a BGL< 2.6 mmol/L on a Haemocue require a BGL to be performed on a

blood gas machine in NICU or Pathology. Treatment must be initiated whilst waiting for the result

Equipment Alcohol Based Hand Rub (ABHR) Heel Lance Capillary tube or yellow top pathology container

And /or

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Haemocue blood sugar testing device and testing strip Gauze squares

Procedure1. Inform parents of procedure and give an explanation of hypoglycaemia2. Attend hand hygiene before touching the patient by either hand washing or using ABHR.3. Administer Sucrose for pain relief (as per NICu drug manual) and/or breastfeed 4. Blood specimen may be obtained from the neonate via a heel lance or venepuncture

(see alert)5. If using haemocue and BGL < 2.6mmol/L collect blood for formal BGL.6. Follow Neonatal Hypoglycaemia Management Pathway (Attachment 1)

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Section 3 – Buccal glucose gel 40% administration

Note:For administration of Buccal Glucose Gel 40% please refer to the NICU Drug Manual, which can be found on the policy register (http://inhealth/PPR/default.aspx)

Buccal glucose gel 40% is composed of 15g glucose in 37.5g oral gel. Dose - 0.5ml/kg Route - buccal Administration - dry neonate’s mouth with gauze and massage gel into buccal mucosa Max dose - 4 doses in a 48 hours period Up to 2 doses may be given as nurse initiated on the medication chart as per neonatal hypoglycaemia management flow chart. This must be counter signed by the neonatal registrar within 24 hours.

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Section 4 – Early Hypoglcaemia BGL <2.6 mmol/L

All neonates with hypoglycaemia (BGL <2.6mmol/L) need treatment as per the flowchart (Attachment 1). The neonatal registrar must be notified if a neonate has a BGL of <2.6mmol/L.

The first episode of hypoglycaemia (BGL 1.5 - < 2.6mmol/L) will require the neonate to be treated with buccal glucose gel 40% and a feed (Box 2; Attachment 1 flowchart). For any glucose <1.5 mmol/L refer to Section 6-Severe Hypoglycaemia.

If the neonate has an adequate breast feed- feeding code 3 as per newborn feeding record (good attachment, effective suck and signs of adequate milk transfer) then a top up is not required.

If the neonate does not breast feed well a top up should be given (EBM or formula) (Attachment 1 flowchart).

For formula fed neonates a feed of approximately 30ml/kg/day should be given.

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After the second low blood sugar the baby needs to have a breast feed AND a top up feed of at least 60ml/kg/day in addition to the second dose of buccal glucose gel 40%(Box 4; Attachment 1 flowchart)

After any episode of hypoglycaemia the BGL needs to be repeated ½ hour after treatment to document a response.

Blood glucose monitoring needs to be continued until there have been 2 normal pre-feed BGLs (≥2.6mmol/L)

Continue 3 hourly feeds/top-ups

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Section 5 – Treatment failure and recurrent Hypoglycaemia

Treatment failure - is defined as hypoglycaemia (BGL < 2.6mmol/L) despite 2 doses of buccal glucose gel 40% or <1.5mmol/L after one dose of buccal glucose gel 40%. The neonate must be reviewed by the neonatal registrar to develop an individual plan and consideration of admission to NICU/SCN

Recurrent hypoglycaemia – is defined as pre feed BGL of <2.6mmol/L after previous successful treatment with buccal glucose gel 40%. Two further doses of buccal glucose gel 40% can be used for treatment in addition to a change in the feeding plan. Any buccal glucose gel 40% after the first two doses must be prescribed by the neonatal registrar.

For recurrent hypoglycaemia the feeding plan needs the total fluid intake (TFI) to be increased incrementally to prevent further episodes of hypoglycaemia. Include top up feeds at 60 ml/kg/day, then increase to 80ml/kg/day. Further volume increases or second hourly feeds may be required.

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Section 6 – Severe/persistent Hypoglycaemia BGL <1.5mmol/L

BGL <1.5mmol/L: all neonates with a BGL<1.5mmol/L need urgent review by a neonatal registrar and consideration of admission to NICU/SCN. A trial of buccal glucose gel 40% AND a top up feed of at least 60ml/kg/day can be considered prior to intravenous (IV) fluids. Check BGL 30 minutes post treatment if BGL remains <1.5mmol/L, intravenous (IV) dextrose 10% should be commenced (Attachment 1 Box 3 on flowchart).

BGL <1mmol/L: all neonates with a BGL <1mmol/L need urgent review by a neonatal registrar and admission to NICU. A BGL of <1.0mmol/L at any point requires a bolus of 2ml/kg of IV dextrose 10% and IV dextrose 10% infusion. If already on IV fluids a further bolus can be given and the infusion rate increased by 20ml/kg/day. A feed or buccal glucose gel 40% can be given while attempts to gain IV access are made.

For ongoing hypoglycaemia in a neonate in the NICU increase the concentration of the IV dextrose solution to achieve stable BGLs.

Persistent or unexplained hypoglycaemia needs further investigations to establish aetiology and an individual approach to management.

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Refer to recommendations from the Pediatric Endocrine Society for evaluation and management of persistent hypoglycemia in neonates, infants, and children.

First line investigations for unexplained or persistent hypoglycaemia during a hypoglycaemic episode include insulin, pH, lactate and blood cortisol levels.

Second line investigations include growth hormones, free fatty acids, ammonia, acylcaritinine, urine ketones and organic acids.

In hypoglycaemia persisting beyond 48 hrs, goal of treatment should be to maintain a blood glucose level of ≥3.3mmol/L. Glucagon or Diazoxide treatment can be considered after consultant review

Paediatric endocrinology consultation is advised.

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Section 7 – Neonatal Intensive Care (NICU)/ Special Care Nursery (SCN) inpatients

All neonates at risk of hypoglycaemia need screening, even if already receiving 10% Dextrose or TPN intravenously.

Neonates with a BGL 1.5-2.5mmol/L who are ≥35 weeks corrected gestation age (CGA) and tolerating enteral feeds can be managed with buccal glucose gel 40% and a feeding plan as per the flow chart.

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Implementation

Implementation will be via: Inservice education to staff caring for neonates in CHWC and at CHHS. Staff will receive emails with updated information. All staff will have access to SharePoint to view the current policy.

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Related Policies, Procedures, Guidelines and Legislation

Manual Neonatal Intensive Care Drug Manual, Sucrose Neonatal Intensive Care Drug Manual, Buccal glucose gel 40%

Procedures Blood Collection using Heel Lance Device Procedure, Venepuncture Blood Specimen Collection Procedure Blood Borne Virus: Occupational Risk Exposure Management Procedure Hand Hygiene Procedure

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References

1. Hypoglycaemia- Infant Management, Guideline. The Royal Women’s Hospital, Brisbane. 2013.

2. Incidence of neonatal hypoglycaemia in babies identified as being at risk, Harris D, Weston P, Harding J; Journal of Paediatrics 2012:787-91

3. Dextrose Gel for treating neonatal hypoglycaemia: a Randomised Placebo-Controlled Trial (The Sugar Babies Study), Harris D, Weston P, Harding JE; Lancet 2013, published September 25

4. Academy of Breastfeeding Medicine Protocol#1, Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycaemia in Term and Late Pre- Term Neonates, Nancy Wright, Kathleen A Marinelli and the Academy of Breastfeeding Medicine. 2014.

5. Hypoglycaemia Incidence of neonatal hypoglycaemia in babies identified as being at risk, Harris D, Weston P, Harding J; Journal of Paediatrics 2012:787-91

6. Joint Formulary Committee. 2010-2011 ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2010. British National Formulary

7. Neofax online, accessed 21/10/158. Recommendations from the pediatric endocrine society for evaluation and management

of persistent hypoglycemia in neonates, infants, and children. Thornton PS, Stanley CA, De Leon DD, Harris D, Haymond MW, Hussain K, Levitsky LL, Murad MH, Rozance PJ, Simmons RA, Sperling MA, Weinstein DA, White NH, Wolfsdorf JI; Pediatric Endocrine Society. Pediatr. 2015 Aug;167(2):238-45.

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Definition of Terms

BGL – blood glucose level Hypoglycaemia - a BGL of less than 2.6mmol/L. Treatment Failure - a BGL of <2.6mmol/L after 2 doses of buccal glucose gel 40% or a

BGL of <1.5mmol/L after 1 dose of buccal glucose gel 40% Recurrent Hypoglycaemia – a pre feed BGL of <2.6mmol/L after previous successful

treatment with buccal glucose gel 40% Buccal- relating to the cheeks or the oral cavity Neonate – an infant to 28 days of life GDM – Gestational Diabetes Mellitus EBM – Expressed Breast Milk

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Search Terms

Neonate, Hypoglycaemia, Blood Glucose, Buccal Glucose Gel 40%, Heel Lance, Venepuncture, Haemocue, Blood sugar

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Attachments

Attachment 1: Neonatal Hypoglycaemia management flow chart

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment 1: Neonatal Hypoglycaemia management flow chart

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AT RISK NEONATES1) Large for Gestation Age (LGA)- Weight > 90th percentile or weight greater than length or

head circumference by 30 percentile points2) Small for Gestation Age (SGA)- Weight <10th percentile or weight less than length or head

circumference by 30 percentile points3) Prematurity born at <37 weeks gestation4) Weight<2.5kg5) Neonate of a diabetic mother with either pre-existing Insulin Requiring Diabetes Mellitus

(type 1) or Insulin Requiring Gestational Diabetes (IRGDM) 6) Perinatal stress/hypoxia- Apgar <7 at anytime/ Umbilical Cord gas ph<7.1/ Umbilical Cord

BGL<2.6mmol/L7) Cold stress –temperature <36.0ᵒC which does not improve after 30 minutes of warming8) Symptomatic neonates (jittery, apnoea, hypotonia, lethargy, irritability, seizures)9) Poor Feeding and/or weight loss >10% as part of their blood workup

Note: Neonates of diet controlled GDM mothers’ do not need screening unless there are maternal risk factors (e.g. high HbA1c) or neonatal risk factors (e.g. macrosomia or peri natal stress)

Alert: BGL <1.0mmol/L needs urgent registrar review and urgent iv access/bolus 10% Dextrose

2ml/kg and infusion BGL 1.0- <1.5mmol/L needs urgent registrar review and unless rapid response after

glucose gel needs intravenous 10% Dextrose infusion.

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