Next Newborn / Neonatal

Initiative
General Meeting
March 7, 2017
Reducing Asymptomatic
Hypoglycemia NICU
Transfers
Sherry LeBlanc NNP-BC
Department of Pediatrics
University of North Carolina at Chapel Hill
Neonatal Hypoglycemia Background

30% of infants at risk

10% requiring intensive care
Estimated to cost $2.1 billion
annually
Mother/infant separation and usually
decreased breastfeeding/lactogenisis
Highly variable practice from cut-off
values for treatment and method of
treatment
Insert
your
logo Neonatal Hypoglycemia Best Practice
here if
applicab
le

Prevention!! Hypoglycemia Bundle

Universal, uninterrupted skin-to-skin care (SSC)
Early feeding (in the first hour, preferably breast)
Multiple studies have shown benefit of SSC &
Early feeding
Delay initial serum glucose check until after first
feed, to avoid physiologic nadir (60-120 minutes)
Evaluation by Licensed Independent Provider of
any concerning values or symptoms
QI Initiative at UNC decreased NICU admissions
by 10%
 Initiative Aim

Reduce NICU transfers for asymptomatic

hypoglycemia
Maintain mother/infant dyad
Support breastfeeding
Reduce healthcare costs
Key Measures to track
NICU transfers for hypoglycemia
Received IVF yes/no
SSC rates
Early feeding rates
Time to 1st glucose measure
 Initiative Reach

All newborns delivered in NC with risk

factor for hypoglycemia
Maternal Diabetes (all types)
Late Preterm Infant
Large for Gestational Age
Small for Gestational Age
All Delivery Hospitals in NC
 Initiative Impact

Utilizes free and most natural resource MOM

Goal is to maintain family unit
Decreases family stress
Involves family in newborns care
Ideally educate and empower families
prenatally to care for their at-risk infants
Promotes best practice per AAP and focuses
on prevention
Low cost initiative, utilizes existing staff &
family
 Initiative Challenges / Barriers

Unknown definition of hypoglycemia,

disagreement between AAP and PES
Initiative focuses on prevention of this common
problem while ongoing research determines
optimal definition/treatment
Availability of Licensed Independent Provider
for evaluation
Often requires a culture shift for staff
Delay of initial therapies (erythromycin/Vit K,
footprints, etc).
Transition to assessment and care while SSC
 Supporting Materials

Feeding term infants in 1st 30

minutes decreased borderline
hypoglycemia by 18% (Chertok)
SSC is proven to stabilize glucose,
facilitate initiation of breast feeding
and prolong breastfeeding duration
(Vila-Candel, Moore)
Supporting Materials
 Neonatal Hypoglycemia Newborn/NCCC 3.6.15
Symptomatic Hypoglycemia (BG<40mg/dL) Notify LIP STAT

Asymptomatic Infant with Risk Factors*

Birth through 4 hours of life: After 4 hours of life:

First hour: Uninterrupted skin to skin. Feed at least every 2-3 hrs
Initiate first feed by 1 hour of life. Check BG prior to each feeding
Obtain BG at 90 minutes of life.
<35mg/dL feed measureable amount+
<25mg/dL: 40mg/dL: 41mg/dL: & call NBN LIP
Continue 35-45mg/dL feed and re-check after 1hr.
Continue skin to Routine care
skin to skin & If no improvement Notify Newborn LIP
skin. See box to
feed 46mg/dL feed on demand min q2-3hr
Feed right
measurable measureable
amount + Three normal consecutive pre-prandial
amt.+ & recheck
Notify NBN BGs = PASS ^
BG in 1 hour.
LIP Call NBN LIP if infant has not
If after 2nd feeding the blood glucose is
<25mg/dL, notify NBN LIP to facilitate passed protocol by 12 hours of life.
transfer to NCCC. Continue skin to
skin.

Hypoglycemia | Key Learning Points:

*Risk Factors- IDM/GDM, <37 weeks, SGA(<2500gm), LGA(>4000gm)
+ Measurable supplementation: 3-5mL/kg expressed colostrum/donor milk/formula

Symptoms- poor feeding, irritability, tremors, jitteriness, exaggerated Moro, lethargy, seizure, poor tone, persistent
hypothermia
Interventions to minimize hypoglycemia: skin-to-skin; avoid cold stress; warm heel before obtaining BG; help with
latch/feeding. ^If BG values during birth-4hrs of life are 41 they may be included in the 3 consecutive passing
values.
 References
Adamkin DH. Neonatal Hypoglycemia. Semin Neonatal Fetal Med. 2017;22, 1:36-41.
Adamkin DH, Polin RA. Imperfect advice: Neonatal hypoglycemia. J Pediatr. 2016;176:195- 196
Chertok IR, Raz I, Shoham I, Haddad H, Wiznitzer A. Effects of early breastfeeding on neonatal glucose levels of
term infants born to women with gestational diabetes. J Hum Nutr Diet. 2009;22(2):166-169
Committee on Fetus and Newborn, Adamkin DH. Postnatal glucose homeostasis in late-preterm and term
infants. Pediatrics. 2011;127(3):575-579.
Harding JE, Harris DL, Hegarty JE, Alsweiler JM, McKinlay CJ. An emerging evidence base for the management of
neonatal hypoglycaemia. Early Hum Devel. 2017;104:51-56.
McKinlay CJ, Alsweiler JM, Ansell JM, et al. Neonatal glycemia and neurodevelopmental outcomes at 2 years. N
Engl J Med. 2015;373(16):1507-1518
Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn
infants. Cochrane Database Syst Rev. 2016;11:CD003519
Stanley CA, Rozance PJ, Thornton PS, De Leon DD, Harris D, Haymond MW, Hussain K, Levitsky LL, Murad MH,
Simmons RA, Sperling MA, Weinstein DA, White NH, Wolfsdorf JI. Re-evaluating "transitional neonatal
hypoglycemia": mechanism and implications for management. J.Pediatr., 2015;166, 6, 1520-5.e1,
Vila-Candel R, Duke K, Soriano-Vidal FJ, Castro-Sanchez E. Effect of early skin-to-skin mother-infant contact in
the maintenance of exclusive breastfeeding. J Hum Lact. 2017:890334416676469.
Wight N, Marinelli KA, Academy of Breastfeeding Medicine. ABM clinical protocol #1: Guidelines for blood
glucose monitoring and treatment of hypoglycemia in term and late-preterm neonates, revised 2014. Breastfeed
Med. 2014;9(4):173-179.