SDMS ID: P2010/0324-001 4.

6-08WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Postnatal Ward Management of Term Newborns at Risk of Hypoglycaemia Hypoglycaemia in the Newborn Policy 4.6 Observation and management of babies at risk of hypoglycaemia Midwives and medical staff, Queen Victoria Maternity Unit Blood glucose level, complementary feeds, hypoglycaemia P2010/0392-001 Hypoglycaemia in Healthy Term Newborns P2010/0299-003 Breastfeeding Protocol Purpose: Hypoglycaemia can lead to death if it is not recognised, and long term neurodevelopmental outcomes are still not clear. The overall incidence of hypoglycaemia in the newborn has been estimated between 1 and 5 per 1000 births, but may be as high as 30% in high risk groups of infants. Maintenance of normal body temperature is necessary to prevent hypoglycaemia. Definitions: There is no universally agreed definition of hypoglycaemia. Hypoglycaemia associated with abnormal clinical signs (symptomatic hypoglycaemia) has poor short and long term outcomes but evidence of risk in the absence of clinical signs (asymptomatic hypoglycaemia) is inconclusive (WHO, 1997). Operational thresholds have been suggested (Cornblath, 2000): Asymptomatic infants: Symptomatic infants: Unwell infants: IV therapy <2.0 mmol/L <2.5mmol/L <2.5mmol/L <1.5mmol/L

Newborns at risk of hypoglycaemia Infants of mothers who are diabetic or have gestational diabetes Newborns >4kg Newborns <2kg Infants born before 37 weeks Small for gestational age Large for gestational age Intrauterine growth restricted infants Newborns suspected of sepsis

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Newborns of Mothers with Gestation or Insulin Dependent Diabetes

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Management Plan for SGA, LGA and other at Risk Newborns

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Signs of Hypoglycaemia The clinical signs of hypoglycaemia are non-specific and associated with other disorders common in the newborn. These include: Abnormal or high pitched cry Hypothermia Poor temperature control Sweating Poor suck Refusal to feed Tremors Exaggerated Moros reflex Irritability Lethargy Hypotonia Seizures Cyanosis Pallor Tachypnoea Apnoea Abnormal eye movement Tachycardia Congestive heart failure Respiratory distress Maternal Management If the baby is unable to suckle, mothers should express their breastmilk as soon as possible after delivery and continue to express at least 3-4 hourly, even at night. All expressed breastmilk should be given to the baby. Expressing should also be encouraged after feeds where the baby can suckle to provide EBM if top ups are required. In an effort to support breastfeeding for at risk babies, mothers attending the endocrine clinic are being encouraged to commence antenatal expression of colostrum from 35 -37 weeks gestation. The EBM should be given to their newborns to assist in maintaining their blood glucose level. Complementary Feeding When expressed breast milk can not be obtained, artificial milk may be indicated for newborns requiring additional calories to maintain their blood glucose level. Adequate explanation should be provided to the mother and the Information Sheet for when Comp Feeds are Indicated or Requested (form 12G) discussed and signed. After the introduction of complementary feeding blood glucose levels should be checked before feeds until two consecutive levels above 2.6mmol/L. While complementary feeds continue blood glucose level should be done before alternate feeds. When complementary feeds are discontinued two blood glucose levels above 2.6mmol/L should be obtained before blood glucose monitoring is discontinued.

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Attachments
Attachment 1 Attachment 2 Attachment 3 Background Information Collection of Blood Samples for Haemocue References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr C Bailey (Paediatrician), Dr A Dennis Co-Director (Medical) & Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

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APPENDIX 1 BACKGROUND INFORMATION Glucose is an essential source of energy for brain metabolism and prolonged or recurrent hypoglycaemia in the newborn infant may cause mental and/or psychomotor disability. Until a decade ago hypoglycaemia was defined as a blood glucose <1.7 mmol/L in a term infant and <1.1 mmol/L in a preterm infant during the first three days, and <2.2 mmol/L in all infants thereafter. The demonstration of neurophysiological (but not neuropathological) evidence of hypoglycaemia at blood glucose levels higher than those encompassed by this definition has led to ongoing attempts to determine the most appropriate definition of neonatal hypoglycaemia with a blood glucose <2.6 mmol/L being a recently favoured lower limit. An inherent difficulty in discussing this issue relates to the problem of using a set, precise blood sugar level to define a complex metabolic disturbance. Indeed it has been said that a rational definition of hypoglycaemia is not possible since the severity and duration of hypoglycaemia, the availability and usability of alternative energy sources such as ketones (premature babies have an impaired response), and the presence of other disorders, such as hypoxaemia, are all likely to be important in the aetiopathogenesis of neurological damage and not as readily measurable as a BGL. As a result of this difficulty in developing precise and applicable guidelines, the definitions for hypoglycaemia have seemed somewhat arbitrary. Changing infant feeding practices, clinical and biochemical measurement quality improvements, and more recently, potential litigation issues, have led to a progressive shift in the acceptable lower BGL, viz. <1.5 mmol/L (1959-69), <2.2 mmol/L (1970-87), <2.6 mmol/L (1988-98), and in the USA <3.2 mmol/L (since 1999) Cornblath (2000) has recommended that hypoglycaemia should not be defined by a blood glucose level, as hypoglycaemia implies disease. Rather, neonatal practice should be guided by an operational threshold for an appropriate clinical response. There is evidence that in infants with a potentially impaired counter regulatory response to hypoglycaemia (premature <37 weeks gestation, SGA, IDM, sick infants) it is desirable to maintain BGL > 2.6mmol/L. There is little evidence that transient mild hypoglycaemia that may occur in well, term, AGA and LGA infants is detrimental to outcome (World Health Organisation 1997). Transient hypoglycaemia Transient hypoglycaemia usually lasts for <23 days. The hypoglycaemia is usually secondary to either decreased production of glucose because glycogen stores have not been accumulated (preterm or small for dates infants) or depleted glycogen stores (perinatal asphyxia, hypothermia, starvation, sepsis and congenital heart disease). The hypoglycaemia secondary to the decreased production of glucose is usually mild and easily corrected. Transient hypoglycaemia may be secondary to increased glucose utilisation from hyperinsulinism (infants of mothers with diabetes, or infants with Beckwith-Wiedemann syndrome, rhesus isoimmunisation or transient idiopathic hyperinsulinism). The hyperinsulinism in these infants is usually short lived and not difficult to control, though initial glucose infusions at high rates and treatment with glucagon may be required. Persistent Hypoglycaemia In infants with persistent hypoglycaemia the problem generally lasts for longer than 23 days. These infants either have hyperinsulinism, an inborn error of metabolism, or a hormone deficiency.

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ATTACHMENT 2

Collection of Blood Samples

Hemocue Glucose and Haemoglobin
Point of care testing equipment provides reliable results PROVIDED the sample is of the highest quality.

Essential Steps in collection of Capillary Glucose/Hb Samples (HemoCue)

1 Ensure a Good Blood-flow A good and rapid blood-flow is the most critical step. Wipe away the first drop The first drop of blood will contain tissue fluids which may distort the final result Allow a large drop to form The drop of blood must be large enough to fill the cuvette in one action. DO NOT milk for sample; this will add tissue fluids which will distort the result. Fill the Cuvette Fill in a single action from a large blood drop. Avoid bubbles. DO NOT top up the cuvette if not completely filled. Discard the cuvette and try again if not completely filled. Wipe the Cuvette Carefully wipe any excess blood from the outside of the cuvette with a tissue. Be careful not to wick any blood out from the inside of the cuvette. Be equally carefully not to smear excess blood over the outside of the cuvette. Analyse Sample Insert sample into analyser as soon as possible after filling (maximum time delay 40 seconds). You CANNOT remeasure a cuvette to check the result.

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ATTACHMENT 3 References:
Cornblath M, Hawdon JM, Williams AF, Aynsley-Green A, Ward-Platt MP, Schwartz & Kalhan SC 2000 Controversies regarding definition of neonatal hypoglycaemia: suggested operational thresholds Pediatrics, vol:105, no:5. Despande S & Ward Platt M 2005 The investigation and management of neonatal hypoglycaemia Seminars in Fetal & Neonatal Medicine Vol:10. Hewitt V, Watts R, Robertson J & Haddow G 2005 Nursing and midwifery management of hypoglycaemia in healthy term neonates, International Journal of Evidence Based Healthcare, vol: 3: pp169-205. Moore AM & Perlman M 1999 Symptomatic hypoglycaemia in otherwise healthy, breastfed term newborns Pediatrics 1999, vol:103, no: 4. NETS Victoria Neonatal Handbook 2006 Hypoglycaemia Online: http://www.rwh.org.au/nets/handbook/index.cfm?doc_id=631 Royal Prince Alfred Hospital Department of Neonatal Medicine Protocol Book 1998 Hypoglycaemia Online: http://www.cs.nsw.gov.au/rpa/neonatal/html/newprot/hypogly.htm

World Health Organisation 1997 Hypoglycaemia of the newborn review of the literature. Viewed online: http://www.who.int/reproductive-health/docs/hypoglycaemia_newborn.htm

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