Guidelines for the Management of Hypoglycaemia

 

Reviewed by Clinical Practice Committee
September 2016
Clinical Guidelines Back Newborn Services Home Page
Definition Diagnosis Treatment
Continuing Therapy References

Also see guideline on investigation of severe hypoglycaemia

Click here for the Glucose calculator

Hypoglycaemia is important because:

  1. It is a common, readily diagnosed and readily treated problem.
  2. If untreated, it may cause permanent brain damage.

Definition

Serum glucose <2.6mM.  This is based on the following:

  1. Glucose levels within the ‘normal’ range are not necessarily optimal.
  2. There is no physiological reason why brain glucose requirements should differ between term and preterm infants, or between the first and subsequent days of life.
  3. The aim is to define a level which is safe for all babies, rather than is adequate for most.
  4. Altered electrophysiological measurements and poor long-term neurological outcome have been reported in infants with recurrent serum glucose levels <2.6mM.

Diagnosis

  1. Monitor at-risk infants
  1. When to monitor
  1. How to monitor
  1. How long to monitor
    If feeding well At least 12 hours
    Any recorded hypoglycaemia At least 12 hours after last low level

Click here to link to the flowchart for management of infants at risk of hypoglycaemia

Treatment

Delivery Suite, Post Natal Ward or PACU

  1. All at risk infants (see above) should receive milk feedings (either breastfeed or formula - maternal preference) or intravenous dextrose as soon as feasible, and always within the first 2 hours of life.
  2. If glucose between 1.2-2.5mM on first testing (1-2 hours)
  1. If glucose between 1.2-2.5mM on subsequent testing
  2. If glucose between 2.0-2.5mM on subsequent testing
  3. If glucose below 1.2mM at any stage; below 2.0mM despite two doses of oral dextrose gel; below 2.6mM despite two doses of oral dextrose gel and a bottle of formula/EBM; or if feeds not tolerated, admit the baby to NICU.
     
  4. If the glucose is <2.0mM at any stage notify the neonatal paediatric service.
     
  5. Dextrose gel must be prescribed on a medication chart either by a midwife, nurse specialist – neonatal advanced practice, or medical practitioner.

NICU

  1. Start IV Dextrose 10% at 60ml/kg/day (=4.2mg/kg/min glucose)
  2. Consider a bolus of 1-2ml/kg 10% Dextrose IV
  3. Recheck glucose within 1 hour

Recurrent or persistent hypoglycaemia not responding to above measures - increase IV dextrose concentration or volume e.g. 12.5 or 15% dextrose and continue feeding if tolerated.

Continuing Therapy

Continue to monitor glucoses while IV dextrose is being gradually reduced. Rapid reductions in glucose infusion are likely to cause rebound hypoglycaemia.

Persistent or severe hypoglycaemia (requiring more than 10mg/kg/min of glucose or lasting longer than 1 week) may require further investigation and management, e.g. with glucagon, diazoxide, steroids or surgery.
Click here for the Glucose calculator

In an emergency, particularly if there is difficulty in starting intravenous glucose infusion, glucagon 100 to 300ug/kg intramuscularly will stabilise blood glucose in most babies for one to two hours. The dose can be repeated, but subsequent doses are much less likely to be effective. (Glucagon mobilises glycogen stores. After the first dose, stores will probably be depleted).

References

1 Harris D, Weston P, Harding J. Incidence of neonatal hypoglycaemia in babies identified as being at risk. J Pediatr. 2012;161:787-91.
2 Hay Jr W, Faju T, Higgins RD, Kalhan SC, Devaskar SU. Knowledge gaps and research needs for understanding and treating neonatal hypoglycemia: workshop report from Eunice Kennedy Shriver National Institute of Child Health and Human Development. J Pediatr. 2009;155(5):612-7.
3 Koh THHG, Aynsley-Green A, Tarbit M, Eyre JA. Nerual dysfunction during hypoglycemia. Arch Dis Child. 1988;63:1353-8.
4 Lucas A, Morley R, Cole TJ. Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia. BMJ. 1988;297(6659):1304-8.
5 Harris D, Weston P, Battin M, Harding JE. Dextrose Gel for Treating Neonatal Hypoglycemia:
A Randomized Placebo-Controlled Trial (The Sugar Babies Study). Lancet, 2013, published online 25 September.
6 Alsweiler, J. M., Harding, J. E., Crowther, C., & Woodall, S. M. (2015). Oral dextrose gel to treat neonatal hypoglycaemia: Clinical Practice Guidelines. Prepared by the "The Oral Dextrose Gel to Treat Neonatal Hypoglycaemia Clinical Practice Guidelines” Panel (pp. 73 pages). http://hdl.handle.net/2292/26266.