Hypoglycaemia
Alison Neonatal Bedford Russell
First decision
Normal baby At risk baby
At risk groups
SGA (<10th centile) Low birth weight (<2.5 kg) Preterm infants (<37 completed weeks) Infants of diabetic mothers Stressed babies, e.g.:
Acutely unwell, sepsis Difficult delivery, cold baby Coma, convulsions
Dysmorphic babies
Normal babies
The rest
Glucose concentrations immediately after birth
Normal care of normal baby
DO NOT TEST EARLY FEEDING, preferably within an hour of birth Feed on demand
Feed intervals vary, newborn babies do show signs of hunger Unwilling to feed or not waking for feeds indicates a baby may be ill - examine them
Symptoms of hypoglycaemia
NOT jitteriness Reduced level of consciousness
Normal newborn
If concerned, baby should be assessed clinically - if concerns persist following assessment it might be appropriate to measure blood glucose If low (<2.6 mmol/l) then likely to be secondary to an underlying cause
Normal newborn
Treatment for low blood sugar (<2.6 mmol/l)
Treat any underlying cause (e.g. cold baby) If tolerating enteral feeds
feed baby recheck blood sugar 1 hour post low result
If not tolerating enteral feeds
will require admission to NICU IV 10% dextrose recheck blood sugar after 2 hrs on IVI
At risk groups
SGA (<10th centile) Low birth weight (<2.5 kg) Preterm infants (<37 completed weeks) Infants of diabetic mothers Stressed babies, e.g.:
Acutely unwell, sepsis Difficult delivery, cold baby Coma, convulsions
Dysmorphic babies
Why at risk?
Poor post natal adaptation Transient hyperinsulinism Low energy reserves Stress leading to deranged metabolism Endocrine and metabolic disorders
Why treat?
Persistent hypoglycaemia <2.6mmol/l leads to permanent brain damage Levels <2.6mmol/l can be normal in the first few hours after delivery
How to measure
Use glucometer Do not use reagent (BMStixTM) stick DO NOT WRITE BM = .. in the notes, this is not what has been done and implies that an inappropriate test has been done. For low readings, treat the baby but re-do the test to check result
When to measure?
NOT before 2 hours in an asymptomatic, at risk, baby. First measure before the SECOND feed (approximately 4-6 hours after delivery) If results acceptable (>3.0mmol/l) measure
before 3rd and 4th feeds then at 24, 36, 48 and 72 hours after delivery baby (if not discharged!)
Prevention of hypoglycaemia
Immediate skin to skin contact after delivery Early feeding at less than 1 hour after delivery Encourage frequent, regular feeding Keep warm Regular assessment of progress
Numbers of babies admitted 2002 with diabetic mums
45 40 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 More Length of stay, days
Frequency
Normal newborn
Skin to skin and feed in first hour
Evaluation of baby (normal routine)
Continue normal care
No
Concerns
Yes
Call NICU SHO
No
Concerns confirmed
Yes
Normal newborn contd.
Concerns confirmed
Yes
1. Management plan for underlying cause 2. Measure blood glucose
N.B. management may require NICU admission
Yes
Tolerating enteral feeds?
No
Yes
Glucose <2.6mmol/l?
No
Tolerating enteral feeds?
No
Yes
Feed baby Recheck glucose in 1 hour Treat as high risk
Feed baby
Admit NICU Review if ongoing concerns
At risk baby
Skin to skin and encourage early feeding Check blood sugar pre 2nd feed (4-6 hrs)
Yes Yes
Able to start enteral feeds?
No
Admit NICU, start IVI 10% dextrose 100ml/ kg/day
Glucose <2.6mmol/l?
No
Yes
Feed at once
Recheck glucose 1 hour after low result
Glucose <2.6mmol/l?
No
Continue monitoring until stable
Continue monitoring until stable. Blood glucose measurements at: Pre 2nd feed (4-6hrs) Pre 3rd feed (7-9hrs) Pre 4th feed (10-12hrs) Then pre feed at: 24hrs 36hrs 48hrs 72hrs* Babies can be discharged prior...