Screening guidelines for newborns at risk for low blood glucose

Question 1

What are symptoms of neonatal hypoglycemia?

Answer 1

1. Jitteriness or tremor
2. Apathy
3. Cyanosis
4. Convulsions
5. Intermittent apneic spells or tachypnea
6. Weak or high-pitched cry
7. Limpness
8. Lethargy
9. Difficulty in feeding
10. Eye rolling
11. Sweating
12. Sudden pallor
13. Hypothermia
14. Cardiac arrest
15. Cardiac failure

Question 2

What are three approaches to defining a safe range for blood glucose?

Answer 2

1. Using normative ranges
2. Using the presence or absence of sequelae
3. Using prospective clinical trials to determine whether benefit of intervention outweighs the short-term and long-term risks

Question 3

What normative ranges have been noted in breastfed, term, appropriate for GA babies?

Answer 3

1.8 @ 1h of life, then >2.0 x 72h

12-14% BA <2.6 in the 1st 72h

Question 4

When infants usually symptomatic?

Answer 4

<2.6mmol/L

but some report <1.6

Question 5

Who is at risk for neonatal hypoglycemia?

Answer 5

1. SGA (<10th percentile)
2. LGA (>90th percentile)
3. IDM
4. Preterm infants
5. Perinatal asphyxia

Question 6

Why does impaired gluconeogenesis occur, resulting in neonatal hypoglycemia?

Answer 6

1. Excess insulin production
2. Altered counter-regulatory hormone production
3. Inadequate substrate supply

Question 7

When should at-risk infants be screened?

Answer 7

1. Screening should be initiated in at-risk babies at 2h of age
2. Continue screening until the period of risk is considered over
3. LGA and IDM can stop screening if BS >2.6 x 12h
4. Preterm and SGA can stop screening if BS >2.6 x 36h
5. Symptomatic infants should have blood glucose assessment without delay

Question 8

How should screening for neonatal hypoglycemia be performed?

Answer 8

Rapid laboratory testing should be available to verify POC glucose checks

Question 9

When does symptomatic hypoglycemia require intervention?

Answer 9

BS <2.6mmol/L

Question 10

When does asymptomatic hypoglycemia require intervention?

Answer 10

1. Asymptomatic, at-risk babies should receive at least one effective feed before a blood glucose check at 2 h of age and should be encouraged to feed regularly thereafter. At-risk babies who have a blood glucose of less than 1.8 mmol/L at 2 h of age despite one feed (breastfeed or approximately 5 mL/kg to 10 mL/kg of formula or glucose water), or less than 2.0 mmol/L after subsequent feeding, should receive an intravenous dextrose infusion.
2. At-risk babies who repeatedly have blood glucose levels of less than 2.6 mmol/L despite subsequent feeding should also be considered for intravenous therapy.

Question 11

What interventions should be offered when neonatal asymptomatic hypoglycemia is suspected?

Answer 11

1. Offer feeding intervention and re-check level in 60min to ensure response
2. If increased enteral caloric intake is ineffective D10W @ TFI 80 (GIR 5.5)
3. If BS <1.8 confirm response within 30min
4. 2mL/kg IV D10W bolus at start of an infusion more rapidly achieves steady state level, benefit in asymptomatic babies is uncertain
5. Repeated mini-boluses without an increase in the infusion rate are not recommended

Question 12

What interventions should be offered when neonatal symptomatic hypoglycemia is suspected?

Answer 12

1. Immediate D10W IV @ TFI 80 (GIR 5.5) and confirm response in 30min
2. Target BS >2.6
3. Change from D10W to D12W OR TFI 80 to 100 will increase GIR 25%
4. If fails, increase from D12.5W @ TFI 100 to 120 (GIR 8.7 to 10.4)
5. If D12.5W @ TFI 120 fails to keep BS >2.6 consider further investigations, specialist referral and/or pharmacological intervention (i.e. glucagon)
6. Investigations should be aimed to identify endocrine pathology (i.e. hyperinsulinism) or IEM
7. Glucagon IV bolus (0.1-0.3mg/kg) or infusion (10-20ug/kg/h) raise BS
8. Other therapeutic options incld: hydrocortisone, diazoxide, and octreotide
9. May continue breastfeeding but oral and IV intake should not be >100mL/kg/day
10. Wean IVF when BS levels stable x 12h

Question 13

How frequently should asymptomatic, at-risk infants be screened?

Answer 13

Before feeds x 24h, then 2-3 times on day two

Question 14

What are the CPS recommendations re: neonatal hypoglycemia?

Answer 14

1. Routine screening of appropriate-for-gestational-age infants at term is not recommended. It is recommended that IDMs (gestational or otherwise), preterm infants (less than 37 weeks) and SGA infants (weighing at less than the 10th percentile) be routinely screened for neonatal hypoglycemia. Until further data are available, LGA infants (weighing at higher than the 90th percentile) should be considered at risk.
2. Blood glucose screening of asymptomatic, at-risk infants may be performed at 2 h of age and every 3 h to 6 h after this, in keeping with breastfeeding practices. Testing may be discontinued after 12 h in LGA infants and IDMs if blood glucose levels remain at 2.6 mmol/L or higher, and after 36 h in SGA and preterm infants if feeding has been established and blood glucose levels remain at 2.6 mmol/L or higher. Symptomatic and unwell babies require immediate glucose testing.
3. It is recommended that, where possible, methods should be instituted to measure blood glucose that are quality-controlled, accurate and reliable in the range of 1 mmol/L to 3 mmol/L.
4. At-risk infants with glucose levels less than 1.8 mmol/L on one occasion (assuming one effective feed), or repeatedly less than 2.6 mmol/L, require intervention. Symptomatic infants should be treated immediately for blood glucose levels less than 2.6 mmol/L; there should be concurrent investigation and management of the underlying cause.
5. Enteral supplementation may be used in asymptomatic infants with blood glucose levels of 1.8 mmol/L to 2.5 mmol/L to augment caloric intake, rechecking levels in 60 min to identify persistent hypoglycemia.
6. It is recommended that symptomatic, hypoglycemic infants (and asymptomatic infants who have failed to respond to enteral supplementation) be treated with intravenous dextrose solution. Consider investigation, consultation and pharmacological intervention if target blood glucose levels are not achieved by intravenous dextrose