1. Definition of terms
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Hypoglycaemia: There is a lack of consensus on a definition of neonatal hypoglycaemia. It is recommended that clinical practice be guided by operational thresholds (i.e. blood glucose levels at which clinical interventions should be considered).
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Clinical signs which suggest clinically significant hypoglycaemia are non-specific and include jitteriness, irritability, high pitched cry, cyanotic episodes, apnoea, seizures, lethargy, hypotonia or poor feeding. Many babies with hypoglycaemia will have no clinical signs.
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Operational threshold
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 | - infant with risk factors for hypoglycaemia but no clinical signs - blood sugar level < 2.0 mmol/L
- infant with clinical signs: blood sugar level < 2.6 mmol/L.
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- Newborn Intensive and Special Care:
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| - all infants - true blood glucose < 2.6 mmol/L.
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Blood Sugar Level (BSL): as measured by a blood glucose monitor and reagent strips in Birth Centre and postnatal wards. These measurements are less accurate at lower BSL. Therefore a TBG should be sent to the laboratory for any BSL < 2.0 mmol/L if no clinical signs, or BSL < 2.6 mmol/L if clinical signs present.
True Blood Glucose (TBG): as measured on a blood gas analyser in Newborn Intensive and Special Care or by laboratory measurement.
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2. Responsibility
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All medical and nursing staff caring for newborn infants, including infant of a mother who has diabetes.
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3. Process
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Do not measure blood glucose levels in well, term infants.
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Monitor infants with risk factors for hypoglycaemia, including:
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a. maternal indications:
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b. infant indications:
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- small for gestational age infants (< 10th centile), low birthweight infants (< 2,500gm) or clinically wasted regardless of birthweight
- macrosomic or large for gestational age infants (> 90th centile)
- infants admitted to Newborn Intensive and Special Care with:
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| - CNS depression at birth or encephalopathy
- rhesus isoimmunisation
- polycythaemia
- sepsis
- respiratory distress
- prematurity
- nil orally
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Infants of mothers who have diabetes
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Inform paediatric registrar of impending birth of an infant of a mother who has diabetes. After birth, paediatric registrar to decide whether the infant should be managed in the Postnatal Ward or Newborn Special Care.
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Transfer infant of a mother who has diabetes to SCN if:
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a. maternal indications:
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- poor control during pregnancy (most recent HbA1c > 7.5%)
- BSL > 8 mmol/L during labour
- IV glucose during labour.
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b. infant indications:
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- unwell (e.g. signs of respiratory distress)
- macrosomic (> 90th centile)
- small for gestational age infants (< 10th centile), low birthweight infants (< 2,500gm) or clinically wasted regardless of birthweight
- preterm (< 37 weeks gestation)
- other reason(s) for SCN admission.
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All other well infants of mothers who have diabetes (type 1, type 2 or gestational diabetes, controlled by insulin or diet) should be transferred to the postnatal ward with their mother. Refer to: Management of infants at risk for hypoglycaemia in Birth Centre and postnatal wards and Flowchart 1 (Appendices) in this procedure.
Note: Mother managed with insulin prior to or during pregnancy is not an indication alone for transfer of infant to SCN.
For management of infants transferred to Newborn Intensive and Special Care, refer to: Management of infants with risk factors for, or diagnosis of hypoglycaemia in Newborn Intensive and Special Care and Flowchart 2 (Appendices) in this procedure.
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Management of infants at risk for hypoglycaemia in Birth Centre and postnatal wards
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Commence feeding within one hour of birth and feed 3 - 4 hourly.
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Measure Blood Sugar Level (BSL):
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- at four hours of age or before the second feed (whichever comes first)
- if clinical signs of hypoglycaemia present
- before each subsequent feed until 3 consecutive readings ≥ 2.6 mmol/L, or as requested by paediatric registrar.
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Recommence glucose monitoring if change in feeding or clinical condition.
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Note: Confirm any BSL reading < 2.0 mmol/ L (infant with no clinical signs) or < 2.6 mmol/L (infant with clinical signs) with a TBG (laboratory) measurement. Do not wait for result before responding.
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If BSL is 1.5-1.9 mmol/L in infant with no clinical signs:
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- inform paediatric registrar
- complement this feed only with EBM/formula (5-10mL/kg/feed)
- feed infant 3 hourly
- continue to measure BSL before feeds.
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Notify paediatric registrar and arrange timely transfer to SCN if:
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- any BSL < 1.5 mmol/L
- any BSL < 2.6 mmol/L and clinical signs
- 2 consecutive BSL 1.5-1.9 mmol/L (no clinical signs).
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Refer to: Flowchart 1 (below):
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| Flowchart 1: Infants at Risk for Hypoglycaemia - Birth Centre and Postnatal Ward
| Click on thumbnail to view full size image of flowchart (pdf 23kb)
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Infants may be discharged from paediatric care after 3 consecutive BSL ≥ 2.6 mmol/L.
Paediatric registrar to review infants daily until discharge from paediatric care.
Infants do not require routine follow-up in the Women's Paediatric Outpatients department unless admitted to SCN for management of hypoglycaemia.
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Management of infants with risk factors for, or diagnosis of hypoglycaemia in Newborn Intensive and Special Care
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Measure TBG on blood gas analyser:
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- within one hour of arrival in nursery (or as ordered by paediatric registrar)
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- if TBG ≥ 2.6 mmol/L repeat before next feed, or 3 hourly if infant nil orally
- if TBG < 2.6 mmol/L- repeat TBG in 1 hour
- measure TBG before feeds if feed due
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- glucose monitoring may be discontinued when 3 consecutive TBG readings ≥ 2.6 mmol/L
- recommence glucose monitoring if indicated when change in feeding regime or clinical condition.
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TBG ≥ 2.6 mmol/L:
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- feed by 1 hour of age (60mL/kg/day) with EBM if available, or formula
- feed 3 hourly (if birthweight > 1.5kg)
- complement breastfeeds with EBM/formula (30-60mL/kg/day)
- if there is any contraindication to enteral feeds - insert IV and commence 10% glucose infusion at 60mL/kg/day (4mg/kg/min).
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TBG 1.5 - 2.5 mmol/L:
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- feed 2 hourly (60mL/kg/day)
- commence feeding within 1 hour of admission with EBM if available, or formula
- if repeat TBG is 1.5-2.5 mmol/L increase feeds to 90ml/kg/day
- change to 3 hourly feeds (if birthweight > 1.5kg) after 24 hours of age if at least 2 consecutive blood glucose readings ≥ 2.6mmol/L
- complement breastfeeds with EBM/formula (60-90mL/kg/day)
- if there is any contraindication to enteral feeds - insert IV and commence 10% glucose infusion:
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| - AGA infant - 70mL/kg/day (5mg/kg/min), increasing to 90mL/kg/day (6mg/kg/min) if subsequent TBG < 2.6 mmol/L
- SGA infant - 90mL/kg/day (6mg/kg/min), increasing to 120mL/kg/day (8mg/kg/min) if subsequent TBG < 2.6 mmol/L.
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TBG <1.5 mmol/L:
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- consider an intramuscular injection of glucagon for infants ≥ 34 weeks gestation with adequate glycogen stores (birthweight > 10th centile) - refer to Pharmacy Manual. This will increase blood glucose whilst IV is inserted and 10% glucose infusion commenced.
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- insert IV and commence 10% glucose infusion:
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| - AGA infant - 70mL/kg/day (5mg/kg/min), increasing to 90mL/kg/day (6mg/kg/min) if subsequent TBG < 2.6 mmol/L
- SGA infant - 90mL/kg/day (6mg/kg/min), increasing to 120mL/kg/day (8mg/kg/min) if subsequent TBG < 2.6 mmol/L.
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- administer IV bolus of 2ml/kg 10% glucose (200mg/kg) over 3-5 minutes.
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TBG 1.5-2.5 mmol/L despite feeding regime:
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- consider an intramuscular injection of glucagon for infants ≥ 34 weeks gestation with adequate glycogen stores (birthweight > 10th centile) - refer to Pharmacy Manual. The decision to insert an IV may be delayed until result of next TBG (repeated in 1 hour or as ordered by paediatric registrar).
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OR
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- insert IV and commence 10% glucose infusion at 90mL/kg/day (6mg/kg/min). (Do not administer IV bolus of 10% glucose if TBG ≥ 1.5mmol/L.
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Refer to: Flowchart 2 (below):
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| Flowchart 2: Infants admitted - Newborn Intensive and Special Care with risk factors / diagnosis hypoglycaemia
| Click on thumbnail to view full size image of flowchart 2 (pdf 23kb)
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Calculate and document IV glucose infusions in mg/kg/min.
Continue enteral feeds as tolerated and support breastfeeding (do not make nil orally unless enteral feeding contraindicated).
Increase feeds gradually and gradually reduce IV glucose infusion when TBG readings are stable (at least 2 consecutive readings ≥ 2.6mmol/L).
Infants on 3 hourly sucking feeds may be discharged to postnatal ward as soon as BSL ≥ 2.6 mmol/L on 3 consecutive occasions. If hypoglycaemia has occurred, complementary feeds after breastfeeding may be necessary for a day or two until maternal milk supply is established. Infant admitted to SCN for management of hypoglycaemia to remain under paediatric care in postnatal ward for at least 72 hours.
Arrange for the Women's Neonatal Outpatient follow-up for the following infants:
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- admitted to SCN for management of hypoglycaemia
- macrosomic
- growth restricted
- other paediatric issues.
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Persistent hypoglycaemia
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Glucagon injection may be repeated once if initial response was good (TBG ≥ 2.6 mmol/L).
Increase rate of IV 10% glucose infusion (up to 150mL/kg/day - 10mg/kg/min).
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- IV fluids must not be increased > 120mL/kg/day in the first 24 hours
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- if fluid restriction necessary, increase glucose concentration.
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Increase IV glucose concentration. Concentrations above 12.5% must be given via a central venous line. Refer to Pharmacy Manual. A glucose infusion rate >10mg/kg/min indicates hyperinsulinism.
If persistent hypoglycaemia in spite of increased glucose infusion rate/concentration, discuss with Paediatric Consultant and consider:
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- intravenous infusion of glucagon
- administration of hydrocortisone.
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Investigate for hyperinsulinism if hypoglycaemia persists after day 3 or if it is not possible to wean the glucose infusion.
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Suspected hyperinsulinism
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Diagnosis:
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- macrosomia
- glucose infusion rate >10mg/kg/min
- hypoglycaemia persists after day 3.
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Investigations:
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When TBG < 2.0mmol/L collect arterial or venous blood for:
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- glucose
- insulin
- growth hormone
- cortisol
- free fatty acids
- urine for ketones and organic acids.
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Also consider:
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- ammonia
- acyl-carnitine
- lactate.
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Management:
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- Aim for TBG > 3.0 mmol/L.
- Consider ceasing enteral feeds (as may stimulate insulin release).
- Discuss specific management with Endocrinologist.
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Appendices
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Appendix 1
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| Flowchart 1: Infants at Risk for Hypoglycaemia - Birth Centre and Postnatal Ward
| Click on thumbnail to view full size image of flowchart (pdf 23kb)
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Appendix 2
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| Flowchart 2: Infants admitted to Newborn Intensive and Special Care with risk factors / diagnosis hypoglycaemia
| Click on thumbnail to view full size image of flowchart 2 (pdf 23kb)
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5. Reference documents
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Victorian Neonatal Handbook, 2005 http://www.netsvic.org.au/nets/handbook/index.cfm
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Cornblath M. et al, Controversies regarding definition of neonatal hypoglycemia: Suggested Operational Thresholds. Pediatrics 2000; 105:1141-45
Deshpande S, Ward Platt M. The investigation and management of neonatal hypoglycaemia. Seminars in Fetal & Neonatal Medicine 2005;10:351-361
Roberton's Textbook of Neonatology, Rennie JM (Ed), 2005, 4th edition
The Royal Women's Hospital Clinician's Handbook, 2006, Intensive and Special Care Nurseries.
Williams A F. Neonatal hypoglycaemia: Clinical and legal aspects. Seminars in Fetal & Neonatal Medicine 2005;10:363-368
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Published: 21 July 2008
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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