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Amplified by AACE. For Patients. Breadcrumb Home Diabetes Guidelines. Stenninger et al [35] followed-up 28 IDMs at eight years of age and matched, healthy control subjects and discovered evidence of minimal neurological dysfunction in the whole group, most significant with blood glucose levels of less than 1. It is worth noting that most of these babies had asymptomatic hypoglycemia. Williams [26] supports the cut-off of less than 2. Cornblath et al [36] proposed the concept of operational thresholds, the range of blood glucose concentrations at which clinicians should consider intervention.

They distinguished between the threshold glucose value that requires action 2. It seems that, in at-risk infants, blood glucose levels below 2. There is a strong case for randomized clinical trials comparing interventions, intervention thresholds and their long-term outcomes.

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The following recommendations are outlined in the algorithm, see Figure 1. There are, essentially, two approaches. The first supports increased energy intake orally or intravenously , while the second supports increased mobilization of energy stores using counter-regulatory hormones, such as glucagon or corticosteroids [37] [38].

Pragmatically, the urgency and nature of interventions depend on the presence of symptoms and the severity of the hypoglycemia. Common clinical practices in both the prevention and treatment of asymptomatic hypoglycemia include increased breastfeeding frequency, supplementation with breastmilk or a breastmilk substitute, or intravenous glucose therapy [39]. No clinical trials have been performed to demonstrate the benefit of one supplement over another or, indeed, over breastfeeding on demand [40] on long-term outcome.

Neonatal Advanced Practice Nursing

Frequent breastfeeding on demand should be encouraged in at-risk babies, and, if formula fed or supplemented, the volume of enteral intake should be adjusted according to the size, age and gestation of the infant [41]. There is some evidence that increased carbohydrate intake prevents low blood glucose levels in healthy term breastfed infants.

Martin-Calama et al [42] found in a randomized trial that routine supplementation with dextrose water reduced the likelihood of hypoglycemia. Randomized clinical trials in SGA [43] and appropriate-for-gestational-age [44] infants found that augmented glucose formulas raise blood glucose and prevent hypoglycemia Level 1b. When feeding interventions are offered for low blood glucose, levels should be rechecked in 60 min to ensure that there has been a response.

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If increased enteral caloric intake is not effective, current practice is to provide intravenous glucose. Infants with very low glucose levels, particularly those with levels less than 1. Due to the short duration of action of glucose, repeated miniboluses without an increase in the infusion rate are not recommended. There is both observational evidence and clinical consensus that sick, hypoglycemic infants, particularly those with neurological signs, should be treated immediately with an intravenous infusion of glucose.

The effect of intravenous interventions may be rechecked after 30 min. The target level should be 2. An initial failure to respond to intravenous glucose requires a stepwise increase in glucose supply, with a review of blood glucose 30 min after each increment. If this infusion rate fails to keep blood glucose levels at 2. Investigations should be aimed at identifying endocrine pathology particularly hyperinsulinism and inborn errors of metabolism.

Glucagon by intravenous bolus 0. Alternative therapies include hydrocortisone, diazoxide and octreotide, but data are limited in their use for the initial management of hypoglycemia. Breastfeeding may be continued without risk of overhydration because the volume of colostrum is small. Blood glucose levels should be checked frequently until interventions result in stable glucose levels of 2. Intravenous dextrose can be weaned when levels have been stable for 12 h.

Given the paucity of evidence on the adverse effect of glucose levels between 1. Because feeding raises blood glucose [55] and stimulates ketosis [12] , it seems rational to feed at-risk infants at regular intervals, while screening before feeds.

Neonatal Advanced Practice Nursing

Holtrop [22] showed that IDMs and, by inference, LGA infants were most likely to develop hypoglycemia in the first few hours of life — as a consequence, screening is not required in this population after 12 h of age if levels remain at 2. SGA and preterm infants may become hypoglycemic as late as the second day although this may be prevented by establishing intake. It would be reasonable to screen once or twice on the second day of life, to ensure levels remain at 2.

If there are no feeding concerns and the infant is well, screening may be discontinued at 36 h of age Level 2b. Both parents and health care providers require education regarding screening. Parents should be aware that their child is symptomatic or at risk, and therefore, requires blood testing at regular intervals.


An algorithm Figure 1 is provided to assist health care providers in the use of this statement. Although blood glucose levels as low as 1. Screening and intervention is therefore aimed at the detection and treatment of infants who are at risk. Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed.

Neonatology A Practical Approach to Neonatal Management

Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication. Focus Issues. Skip to Content. Home Clinical practice Position statements and… Current: Screening guidelines for… Position statement. Posted: Dec 1 Reaffirmed: Feb 28