Aim

The aim of this guideline is to guide the initial treatment of hypoglycaemia in the newborn infant including the early management of refractory hypoglycaemia

Definition of terms

• Hypoglycaemia: Within the neonatal period, hypoglycaemia is defined as a blood glucose less than 2.6mmol/L.
  
• BSL: blood sugar level
  
• Macrosomic: literally means “of large body”. Babies weighing more than 4.5kg at birth are considered much larger than normal or macrosomic

Assessment

Neonates at risk of developing hypoglycaemia include:

• Premature infants
• Small for gestational age infants
• Macrosomic infants
• Infants with CNS depression at birth or encephalopathy
• Infants with sepsis
• Infants with respiratory distress
• Infants with Rhesus isoimmunisation
• Infants of mothers with gestational diabetes or insulin dependent diabetes
• Infants who are nil orally
• Infants with genetic predisposition to hyperinsulinaemia

Most neonates with hypoglycaemia are initially asymptomatic and detection is based on surveillance of at-risk infants.

Those who are symptomatic may present with the following:

• Apnoea
• Cyanosis
• Jitteriness
• Hypotonia
• Poor feeding
• Seizures
• Irritability
• High pitched cry
• Lethargy

Management 

BSL <2.6mmol/L:

• Asymptomatic hypoglycaemia should be treated with an immediate enteral feed (at usual type e.g. EBM or formula, amount and frequency) and BSL tested one hour later.
• If BSL remains <2.6mmol/L despite an enteral feed and the patient does not have IV access, administer 0.5mL/kg of buccal glucose gel (15g glucose in 37.5g oral gel) Can use up to a maximum 6 doses in a 48 hour period.
• If hypoglycaemia recurs after an initial response to an enteral feed, give a further feed increased by 20mL/kg/day or alter feeds to two hourly (if originally ordered less frequently than two hourly). Re-test BSL prior to each feed until 3 normal levels occur.If BSL remains <2.6mmol/L or enteral feeds are contra-indicated, give an IV bolus of 10% Dextrose 2ml/kg. Re-test BSL after one hour.
• If hypoglycaemia continues, commence an IV infusion of 10% Dextrose at recommended daily intake for the infants age (refer to Neonatal Intravenous Fluid Requirements guideline).
• If BSL remains <2.6mmol/L, increase the total amount of IV fluid by 20ml/kg/day if safe to to so relative to other patient factors. Monitor serum sodium levels as patient may become hyponatraemic. If hypoglycaemia continues, increase the dextrose concentration in increments of 2.5% (e.g. 12.5% then 15%). If treating with >12.5% Dextrose, a central line is required due to risk of extravasation injury (see CVAD policy/procedure).
• If BSL remains <2.6mmol/L, treat with glucagon bolus (IV or IM) 0.02mg/kg. Commence glucagon infusion if hypoglycaemia continues.

BSL <1.0mmol/L or unrecordable:

• Give IV bolus of 10% Dextrose 2ml/kg and commence infusion. If the patient does not have IV access and there is no contraindication for enteral administration, administer 0.5mL/kg of buccal glucose gel whilst obtaining IV access.

Note:

• For all BSL results under 2.6mmol/L recorded on bedside dextrometer, send a true blood glucose specimen to the laboratory for testing and concomitant samples for insulin, cortisol and growth hormone levels. 
• Consideration must be given to the cause for hypoglycaemia in a neonate. Treating the cause is as important as correcting the low glucose level.
• Healthy term breastfed babies will not develop hypoglycaemia from underfeeding.
• Maintaining a normothermic environment for neonates is necessary to prevent hypoglycaemia.
• Further treatments for persistent hypoglycaemia may include hydrocortisone, diazoxide and octreotide. An endocrine consult should be considered before prescribing these medications.
• Further investigations such as genetic testing and pancreatic imaging may be considered, after consultation with endocrinology, for prolonged hyperinsulinaemic hypoglycaemia.

Flowchart: Management of neonatal hypoglycaemia

Companion documents

• RCH hypoglycaemia guideline (non- neonates)
• CVAD policy/procedure (RCH access only)

Links

• Neonatal ehanbook (hypoglycaemia) www.health.vic.gov.au/neoantalhandbook/
  
  

Evidence table

Click here to view the evidence table.

References

• Hawdon J.M, Definition of neonatal hypoglycemia: time for a rethink? Published online first: May 3 2013, Arch Dis Child Fetal Neonatal Ed, doi: 10.1136/archdischild-2012-303422 
• Adamkin D.H and Committee on Fetus and Newborn( March 2011) Clinical report – Postnatal Glucose Homeostasis in late-preterm and term infants, Pediatrics, Volume 127, Number 3. 
• Deshpande S, Ward Platt M, (2005) The investigation and management of neonatal hypoglycemia, , Seminars in Fetal and Neonatal Medicine 10, 351-361 
• Hawdon J.M, (2011) Investigation, prevention and management of Neonatal Hypoglycemia (impaired postnatal metabolic adaption), Paediatrics and Child Health 22:4
• Faustino E.V.S, Hirshberg E.L, Bogue C.W, (January 2012) Hypoglycemia in Critically ill children, Journal of Diabetes Science and Technology, Volume 6, Issue 1 
• Harris DL, Weston PJ, Signal M, Chase G, Harding JE. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial. Lancet 2013;382(9910):2077-83. Epub 2013 Sep 25

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Trudy Holton, Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2015.