Which finding would the nurse expect to assess in an infant with hypoglycemia?

Note: This guideline is currently under review. 

Introduction

Aim

Definition of Terms

Assessment

Nursing Management

Education Needs

Companion documents 

Evidence Table

References

Introduction 

During intrauterine life, the neonate receives a continuous supply of glucose from maternal sources. When this supply abruptly stops at birth, the neonate must adapt and stimulate its own glucose supply with the assistance of enteral feeds. 
When there is an imbalance between glucose supply and utilisation, a low blood glucose level (BGL) may occur. There are a wide range of factors which can cause a neonate to remain hypoglycaemic. If left untreated, the neonate is at risk of brain dysfunction, brain damage and mortality.  

Aim

This guideline will provide information about the clinical signs, investigations, assessment and management strategies of neonatal hypoglycaemia. 

Definition of terms

• Neonatal Hypoglycaemia: Low blood glucose level <2.6mmol/L
  
• Normoglycaemia: Normal blood sugar level 
  
• Hyperinsulinaemia: High insulin blood level
  
• BGL: Blood glucose level
  
• GA: Gestational age
  
• LGA: Large for gestational age
  
• IUGR: Intrauterine growth restriction 
  
• GDM: Gestational diabetes mellitus
  
• Macrosomia: Above average birth weight, regardless of gestational age
  

Assessment

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

Neonates with identified risk factors must have a BGL on admission. BGL’s should then be monitored in consultation with medical teams, and as clinically indicated.

Risk factors include, but are not limited to:

• Nil by mouth patients 
  
• Preterm birth
  
• Respiratory distress
  
• LGA
  
• IUGR
  
• Macrosomia
  
• Hypoxic-ischaemic events, such as encephalopathy 
  
• Systemic conditions, such as infection
  
• Hypothermia
  
• Inborn errors of metabolism 
  
• Maternal medication use, including beta blockers
  
• Hyperinsulinaemia
  
• Maternal diabetes
  
• Congenital hyperinsulinaemic hypoglycaemia
  
• Beckwith- Wiedemann syndrome
  
• Iatrogenic hypoglycaemia
  

Other possible causes of hypoglycaemia include, but are not limited to:

• Disruption to intravenous (IV) fluid administration
  • Eg. Peripheral IV has extravasated, kinked, or is leaking
• Inadequate amount of enteral feeding
  • Poor suck
  • Vomiting 

Physical assessment 

A comprehensive nursing assessment must be conducted when hypoglycaemia is suspected and/or identified. Patients who are symptomatic may present with these clinical manifestations:

Investigations 

Nurse-initiated investigations may include:

• Bedside BGL (POCT) using capillary glucometer (blue strip)
  
  • Results of the BGL must be documented in Electronic Medical Records (EMR), discussed with ward Associate Unit Manager (AUM) and relevant medical staff for further assessment and management
    
  • Review Medical Emergency Response Procedure for escalation of care 
    

Hypoglycaemic screen of neonates

• Medical staff MUST order these tests prior to collection
  
• If requested, the tests MUST be taken at time of hypoglycaemia event (prior to management commencing)
  
• A capillary blood gas (CBG) should also be taken at time of hypoglycaemic event, which will also produce a lactate result  
  
• Consider liver function test (LFT’s) if not done on admission (serum gel vial)
  
• Additional blood tests may be required including c-peptide, ammonia, free fatty acids, amino acids and carnitine. 

• Minimum volumes have been advised by RCH Biochemistry Laboratory
  
• Refer to the RCH Specimen Collection Index on the RCH intranet for more information

Nursing management 

Basic nursing management of the neonate can influence a neonate’s blood glucose level

• Nursing care can assist in the prevention of neonatal hypolglycaemia, maintaining normoglycaemia, and when actively treating a hypoglycaemic event
  
• Four major components of basic nursing care is keeping the baby:
  
  • Warm, 
    
  • Pink, 
    
  • “Sweet”, referring to normoglycaemia 
    
  • Calm
    
• Refer to the Management of the neonate and/or Preterm infant management guideline for optimising basic care of the neonate
  

During the management phase of neonatal hypoglycaemia, careful consideration and action must be given to the cause of the hypoglycaemia

• For example, if a baby is hypothermic and hypoglycaemic, it is equally important to manage the neonate’s temperature and low BGL
  
• Management strategies within the flow chart below are subject to change dependent on individual patient factors
  
• Medical staff must order any new management strategies on EMR prior to initiation 
  
• Timing of BGL testing/re-testing must be led by medical staff, and nursing staff must relay results back after each result

Flowchart: Nursing and medical management of neonatal hypoglycaemia

Education needs 

Education for family members regarding hypoglycaemia is an important aspect of the neonate’s holistic care.

Education may include:

• Risk factors and causes of neonatal hypoglycaemia
  
• Clinical manifestations of neonatal hypoglycaemia
• Investigations of neonatal hypoglycaemia
• Basic nursing management to prevent and manage of neonatal hypoglycaemia
• Medical management of neonatal hypoglycaemia 

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.

Companion documents

• CVAD policy/procedure
  
• Neonatal Intravenous Fluid Requirements
  
• Sucrose guideline
• Temperature management
• Surgical procedures within the NICU
• Neonatal Pain Assessment
• Capillary specimen collection
• Kids Health Info: Capillary blood sampling

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 Shanai Cramer, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2019.  

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