How to handle hypoglycemia??

Published

Specializes in Community, OB, Nursery.

Ok, that may sound like a stupid question but I'm asking it because I walked in on the tail end of a situation that our NNP would rather have been handled differently (and I can understand why) and I'm just curious as to how it would have been handled where you are. Also, there is not a clear policy at our facility on this situation, and probably should be, so everybody's butt is covered.

We got a baby 35 3/7 weeks (estimated due to mom's limited PNC) (this is well-baby nursery, keep in mind) born by NSVD, no substance abuse, but hx of domestic abuse & previous infant death. This baby made #6, including the one that had died. Weighed 4lb 7oz, had a 2-vessel cord. Very creased soles, lots of scrotal rugae, fairly large breast buds. So we're sorta thinking he's maybe not really 35 weeks but a little farther along, but IUGR. Very wasted & puny looking. But when the OBs have estimated 35+3, that's what you have to assume the kid is, at least where I am.

Ok, moving on. Glucose at 1 hour is 41...not technically hypoglycemic, but getting close. The charge nurse (this is at shift change, I'm just coming on to take charge report) said, gotta feed him, ok fine. So the nurse who assessing him tried to get him to take a little formula....ok, so maybe he really is a 35 weeker, as he's a poopy little eater. She gets 5ml in him. Charge nurse says that's not enough, he needs more. He is NOT sucking. She drops an OG tube & gets 15ml in.

NNP (whom I really respect and enjoy working with) comes in about 20 min later to check on him since she was at the delivery. We tell her the story (by then I've taken over charge) and she was kind of surprised that the nurse had OGed him. She says she would have been ok with 5ml intake and just watching him. She admitted to being kind of skittish about late pretermers getting formula since she'd just watched one die from NEC in the last couple weeks. Especially when the glucose is not (yet) critically low. I asked her if she would like us to call her the next time something like this happens to see if there is something else she wants us to do besides formula feed. We have a milk bank, but don't keep donor milk on hand in wellbaby nursery except w/ an order.

I can completely understand where she is coming from and she is absolutely right in being scared of NEC. I'm honestly surprised we don't see it MORE (not complaining about that), as many late pretermers as we see, and so many are bottlefeeding. And I do think we make a mistake in treating those kids like healthy termers. It just seemed that had this kid been in NICU for whatever reason, things would have been done differently regarding his glucose & feeds. It would make more sense if NICU and NBN were on the same page in treating these kiddos.

Any input on how your place would've handled this? Just trying to get ideas. Thanks a bunch.

Up Vote Up Vote ×
Specializes in Neonatal ICU (Cardiothoracic).

Would've informed the NNP/Neo of BS, asked what they wanted me to do when the next sugar is done, and is low. Usually the neos I worked with were ok with watching the kid for up to 2 hours before feeding, to allow for gut perfusion to become optimal. Personally I'd attempt to PO some 10% glucose water, then formula if babe has a good suck. If he's a poor feeder, that could be due to a dropping BS, so I'd push for IV access and 2 cc/kg of D5w. With all the funky stuff going on with ?? gestational age and all that other stuff, I'd err on the cautious side with this one.... just my 2 cents...

Stephen

Up Vote Up Vote ×
Specializes in NICU, Telephone Triage.
Ok, that may sound like a stupid question but I'm asking it because I walked in on the tail end of a situation that our NNP would rather have been handled differently (and I can understand why) and I'm just curious as to how it would have been handled where you are. Also, there is not a clear policy at our facility on this situation, and probably should be, so everybody's butt is covered.

We got a baby 35 3/7 weeks (estimated due to mom's limited PNC) (this is well-baby nursery, keep in mind) born by NSVD, no substance abuse, but hx of domestic abuse & previous infant death. This baby made #6, including the one that had died. Weighed 4lb 7oz, had a 2-vessel cord. Very creased soles, lots of scrotal rugae, fairly large breast buds. So we're sorta thinking he's maybe not really 35 weeks but a little farther along, but IUGR. Very wasted & puny looking. But when the OBs have estimated 35+3, that's what you have to assume the kid is, at least where I am.

Ok, moving on. Glucose at 1 hour is 41...not technically hypoglycemic, but getting close. The charge nurse (this is at shift change, I'm just coming on to take charge report) said, gotta feed him, ok fine. So the nurse who assessing him tried to get him to take a little formula....ok, so maybe he really is a 35 weeker, as he's a poopy little eater. She gets 5ml in him. Charge nurse says that's not enough, he needs more. He is NOT sucking. She drops an OG tube & gets 15ml in.

NNP (whom I really respect and enjoy working with) comes in about 20 min later to check on him since she was at the delivery. We tell her the story (by then I've taken over charge) and she was kind of surprised that the nurse had OGed him. She says she would have been ok with 5ml intake and just watching him. She admitted to being kind of skittish about late pretermers getting formula since she'd just watched one die from NEC in the last couple weeks. Especially when the glucose is not (yet) critically low. I asked her if she would like us to call her the next time something like this happens to see if there is something else she wants us to do besides formula feed. We have a milk bank, but don't keep donor milk on hand in wellbaby nursery except w/ an order.

I can completely understand where she is coming from and she is absolutely right in being scared of NEC. I'm honestly surprised we don't see it MORE (not complaining about that), as many late pretermers as we see, and so many are bottlefeeding. And I do think we make a mistake in treating those kids like healthy termers. It just seemed that had this kid been in NICU for whatever reason, things would have been done differently regarding his glucose & feeds. It would make more sense if NICU and NBN were on the same page in treating these kiddos.

Any input on how your place would've handled this? Just trying to get ideas. Thanks a bunch.

in our unit, a glucose less than 50 is low. i know a lot of NNP's are so worried about formula vs. breast milk...but from what i've learned about NEC there isn't a clear answer as to why it occurs...so it can't be directly linked to formula. I would have been fine with what the nurse did by OG'ing the baby.

it's less traumatic than an IV...and then you can monitor the glucose every 30 min. until above 50...but if the baby doesn't eat right and the gest. age is 35 weeks or maybe less, sounds like baby needed an IV anyway...sometimes I think we wait too long to hydrate them after birth.:o

my 2 cents.

Up Vote Up Vote ×

First, you guys don't Dubowitz?

Second, why is a nurse in the well baby nursery dropping an OG tube and gavaging a feed without an order?

Up Vote Up Vote ×
Specializes in Community, OB, Nursery.
First, you guys don't Dubowitz?

Second, why is a nurse in the well baby nursery dropping an OG tube and gavaging a feed without an order?

#1) Yes, we Dubowitz, but unofficially. For whatever reason, our PNPs (well baby uses PNPs during the day, NNPs from NICU at night) get their knickers in a bunch when we do it & document it. :( I guess they think it's making a medical diagnosis of preterm (or not). My unofficial Dub when I came on made me think the kid was a smidge more than 35 weeks.

#2) Second, we can OG twice without an order according to our P&Ps. If they still can't nipple their feeds they go to NICU. We are technically well-baby but we get and keep sicker kids than most well-baby nurseries.

I can see this from both sides, personally.

Up Vote Up Vote ×

Wow. Well in that scenario ( 35 ish weeks , No PNC) , we would do a post feed bs and if it was still low and the baby not eating, we would do a rule out sepsis on the kid, start D10 and make him NPO. Because if he was septic and we are pouring food in his gut, yes he could get NEC.

Up Vote Up Vote ×
Specializes in NICU.
Wow. Well in that scenario ( 35 ish weeks , No PNC) , we would do a post feed bs and if it was still low and the baby not eating, we would do a rule out sepsis on the kid, start D10 and make him NPO. Because if he was septic and we are pouring food in his gut, yes he could get NEC.

That sounds like what we would do too.

If it's a new kid that isn't eating, I've never seen them order to gavage the full feeds. They always start fluids, make them NPO, then gradually start feeds as tolerated. Sometimes they'll let us feed ad lib, whatever the baby tolerates .... there will be an order something like po ad lib, but NO gavage, adjust fluids accordingly.

I don't know how our well-baby nursery does it, but we don't generally gavage kids like that (late preterm/term).

Up Vote Up Vote ×
+ Join the Discussion