In this section
Hypoglycaemia is the most common metabolic disorder of the neonate, and occurs in 5-15% of all neonates. Untreated hypoglycaemia has a high mortality rate, and prolonged or severe neonatal hypoglycaemia can result in brain injury and adverse neurological outcomes; which may impact the
neonate well into childhood.
During intrauterine life, the neonate receives a continuous supply of glucose from the placenta via the umbilical cord. After birth, the umbilical cord is cut and the glucose supply ceases. This, coupled with a transient increase in insulin production cause a drop in blood
sugar levels. Immediately after birth, the neonate must adapt and stimulate its own glucose supply with the assistance of enteral feeds (or intravenous fluids if the newborn is unable to feed).
Even with immediate commencement of breastfeeding/formula feeding/intravenous glucose, there is an expected period of less than 72 hours post-birth in which the glucose levels fluctuate in the neonate. The balance of glucose supply and glucose utilisation in the neonate is
impacted by various risk factors and/or underlying conditions.
When there is an imbalance between glucose supply and glucose utilisation, the neonate may experience hypoglycaemia – which is defined as a blood glucose measurement of below
This guideline will provide information about the risk factors, clinical signs, investigations, and treatmentof neonatal hypoglycaemia.
level (BGL): Blood glucose measurement from a bedside glucometer, which is less accurate at low readings.
gas (CBG): blood test less invasive than arterial blood gas collected from infant heel,
see here for collection instructions
Hypoglycaemia: A TBG or BGL below 2.6mmol/L
True blood glucose (TBG): Blood glucose measurement from laboratory or blood gas analyser, the most accurate reading of a blood glucose
Most neonates with hypoglycaemia are initially asymptomatic, and therefore, early detection of hypoglycaemia is based on surveillance of neonates who have risk factors for hypoglycaemia.
Risk factors should be assessed on admission, and a blood glucose level (BGL) ordered if the neonate has 1 or more risk factors.
Table one: Risk factors include, but are not limited to
Neonatal hypoglycaemia is frequently asymptomatic and only detected when BGL testing is performed due to risk factors identified. Clinical signs of neonatal hypoglycaemia may also be shared or similar to the clinical signs of other conditions such as
sepsis of asphyxia.
Therefore, if a neonate is presenting with clinical signs, it is important to get a true blood glucose (TBG) via a capillary blood gas (CBG) as soon as possible for diagnosis and treatment.
Clinical signs of
All neonatal admissions presenting with risk factors for hypoglycaemia should have a CBG or a TBG on admission or if there is any clinical signs of hypoglycaemia. Depending on the result, a plan can be discussed with the medical team.
A TBG should be taken as a capillary blood gas (CBG) for an instant result, when clinical signs are noted, so the potential hypoglycaemia can be treated as quickly as possible.
A capillary bedside
glucometer reading is unreliable at low readings; hence it is important to confirm
that the TBG is less than 2.6 mmol/L which can be done by CBG.
The Glucose Infusion Rate (GIR) is a measurement of how much glucose (as mg/kg/min) a neonate is receiving. When a neonate has hypoglycemia, their GIR should be calculated to make sure they are receiving an adequate dose of glucose.
Initially these ranges can be used as a guide, but they can be increased if hypoglycemia persists.
Term Neonates: 4-6mg/kg/min
Premature Neonates: 6-8mg/kg/min
Glucose Delivery Calculator (NICU Tools) allows you to calculate the GIR of the neonate – including IV and enteral intake.
Table two: Parenteral nutrition glucose concentrations
If a neonate requires greater than 10mg/kg/min of glucose to keep TBG greater than 2.6mmol/L, hyperinsulinism should be suspected and the priority blood tests (below) should be taken.
Further blood tests are required if it is suspected that the hypoglycaemia has an underlying cause.
BGL done via a glucometer is ordered as a POCT (point of care test) and can be done by nursing staff. The result is then entered either via the Manage Labs tab or in the Hub.
Medical Staff must order all other tests, including CBG, prior to collection. In EMR the IP Hypoglycaemia Order Set includes picture of vials and which tests to order.
The following blood tests should be done while the neonate is hypoglycaemic. Appropriate tubes and amounts indicated in brackets. Serum Gel (Brown); Fluoride Oxalate (Yellow); Lithium Heparin (Orange). These samples should be venous or arterial, capillary specimens are not suitable.
Urine – first voided urine after hypoglycaemic episode, requesting glucose, ketones, reducing substances and amino and organic acids
Support non-pharmacological interventions to minimise pain and discomfort (wrapping, comfort care, and sucrose if appropriate) should be provided during blood tests.
Table three: Testing
(Brown, 0.5mL, Ice)
(Brown 0.7mL, tested with Cortisol)
(Brown, 0.7mL tested with GH)
(Blood Glucometer, Urine Dipstick)
(on CBG) (is this Yellow 0.3mL)
(Brown, 1mL, Ice)
(Orange, 0.5mL, Ice)
Free Fatty Acids
(Orange, 1mL, Ice)
Liver Function Tests (LFT)
See also Specimen
When a neonate is hypoglycaemic – prompt treatment is the goal. The aim of the treatment is to quickly bring the neonates BGL greater than 2.6mmol/L.
A successful treatment plan should include identifying and treating causes, underlying aetiology for the hypoglycaemia.
While treating the neonate’s hypoglycaemia (as per the below flowchart) it is also important to keep them “warm”, “pink”, “sweet” and “calm”.
Refer to the
Management of the neonate and/or
Preterm infant management guideline for optimising basic care of the neonate
Fluids with glucose concentration above 12.5% should be administered through a central venous
line (either an umbilical catheter or peripherally inserted central catheter) to reduce risk of extravasation/thrombophlebitis.
As per the RCH’s Paediatric Injectable Guidelines:
Intravenous fluid additive calculations to prepare 500 mL.
The use of a
Glucose 50% concentration infusion is via neonatal consultant approval only and administered only within PICU/NICU.
In hypoglycaemia, a single bolus injection of glucagon can sometimes increase the blood glucose level enough to make further treatment unnecessary.
A glucagon continuous infusion is the next step once maximum glucose concentration has been reached and the neonate remains hypoglycaemic.
Glucose 40% Gel can be administered into the buccal space and enters the systemic circulation via the lingual and jugular veins. Administration of buccal glucose should be immediately followed by enteral feeds, has been shown to increase BGL and reduce the need for IV
fluids. Studies have shown this is most effective in babies less than 72 hours of age experiencing suspected transient hypoglycaemia.
At RCH this
treatment is appropriate for babies who have asymptomatic hypoglycaemia and
have no IV access and should be followed up with an enteral feed. Buccal
glucose should be ordered by a doctor before administration.
Medication: Oral gel, 15g glucose in 37.5g (Glucose 40%)
Dose is 200mg/kg (0.5mL/kg) massaged directly into a neonate's buccal space, followed by a feed (breastfeed, EBM or formula) orally or NGT.
Education for family members regarding hypoglycaemia is an important aspect of the neonate’s holistic care.
Education may include:
Family-centered care must always be upheld during clinical concerns of the neonate. Communication of a hypoglycaemic event, investigations taken and subsequent results should be discussed with the family when appropriate. Communication with the family can be documented within EMR progress notes.
Click here to view the evidence table.
Please remember to
read the disclaimer.
The revision of this nursing guideline was coordinated by Rose Wilson, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.