How to handle newborn hypoglycemia?

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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. (I also posted this in the NICU forum, btw.)

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.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
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. (I also posted this in the NICU forum, btw.)

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.

I agree with you. Treating them like healthy termers is a really huge mistake with potentially bad outcomes just around the corner. And I am sorry, but 41mg/dl at 1 hour age, especially in such a higher risk kiddo would have OUR NNP *and* us rather excited. We are quick to PC babies like this via cup (not bottle unless they are bottle babies) when sugars fall below 45 to 50 in such kids. 41 is very low and in such a case is only going to go lower. I understand the fear of NEC, but like you said, rarely is it seen.

The trick is, you can't let sugars fall too far. A 41 now can be a 28 or 29 in an hour if gone untreated in such higher risk kiddos. In tiny kids, also, bf uses up more kcal than they often need to maintain their sugars in safe range.

I wonder: What do your protocols say? If they are lacking in clarity or adequate coverage, it's time to get the heads of the NNP, peds, and nurses together to develop a very clear cut protocol for glucose checking and TX and everyone be on the exact same page, every time in such cases. Otherwise, you have situations where kids can fall through the cracks and we all know how badly it goes from there.

I can give your our Glucose protocol if you want it (we are NOT a NICU, however just a Level II nursery, so we don't see too many really early kids at all). Let me know if I can help you in any other way.

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Specializes in Community, OB, Nursery.

I can see it from both sides, but I'm thinking like you do.

Our protocol is checking BG for any kid >8+13 or

So we're supposed to have them BF or feed them formula. This was a breast & bottle baby. Only taking in 5ml doesn't seem like enough to me either, and I am in complete agreement with you on the immediacy of having to treat low BG. The NNP said she would've been ok with watching him a little longer and/or been ok with him just taking 5ml. Maybe in the NICU where you have a little more technology at your disposal than in well-baby...

I really like this NNP, and she was very nice about it even though she would've done things slightly differently. And she did say that she would bring it up @ the next neo meeting so they could work out a clear protocol to follow. I would be happy to see yours though, SBE. Thanks for your help!! :)

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I honestly wouldn't have been that worried about NEC for what you did. A sugar like that with a kid like that would probably have warranted feeding, a recheck and then, if things didn't improve, an IV start for a little D10W in my NICU.

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Specializes in Family NP, OB Nursing.

Where I am, we only have a level 1 nursery and we would have fed the kid. If he were breast feeding and fed well we would recheck the sugar 1/2 hr after the feed; if still low we would supplement with formula and if he wouldn't nurse we would just give him formula.

My only concern is that an OG tube was placed without an order...now I'm not second guessing anyones skills and I'm sure the tube was in the stomach, but IF something were to happen (even if the kid regurged then aspirated) you don't have a leg to stand on UNLESS you have a policy that supports dropping the tube without an order.

I probably would have called the NNP or doc and told them what was going on. Was he symptomatic in any other way? Feeding problems can actually be caused by a low sugar so that could have been why he wouldn't eat. I would have suggested an OG feed or maybe even a D10W bolus...but I would have wanted the order FIRST.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Rninwich brings up a good point. IF things were concerning enough to drop an OG, where I practice, we best have already involved the NNP/Pediatrician ANYhow.

Really, if you are that concerned, the NNP or ped ought be in the loop and giving you orders when you feel interventions like OG placements , IV starts, or other invasive procedures are necessary. Just my very humble opinion, as a person who is not a NICU nurse. I am quite sure the scope differs in many NICU's, but then again, they often have residents, NNPs and neonatologists in-house to cover 24/7 anyhow. We do not.

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Specializes in Community, OB, Nursery.

We are allowed to OG twice without an order, according to our P&Ps. Anything more than that, they have to go to NICU. I would surely not do that w/o an order! ;)

Edited to add that the NNP had already seen & assessed the baby prior to him coming to the nursery. Also, I did happen to find out how he did later on. While not a stellar eater, he did ok otherwise.

We all learned something, I guess!

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Different hospitals accept different accuchecks. I worked at a hospital that used 35 as where you begin treating. So, a glucose of 41 is getting low, feed what he will take and recheck.

This would NOT be the kind of kid I cup feed (I wouldnt cup feed anyway, but if I was so inclined...) These puny floppy kids are at such a higher risk for aspiration from cup/syringe feeding. Cup feeding should only be used in a kid with a coordinated suck swallow.

I think 41 is not so low that 5 ml woudnt make a difference. Now if the glucose was 25, 5m,l of formula wouldnt make a lick of a difference.

If it makes you feel any better, if this 35 weeker developed NEC, it would not be from feeding formula. Nec seen in the early postnatal stage are most likely from a hypoxic event in utero. At this gestational age, feeding has little to do with development of NEC. GBiving donal milk would not have changed the outcome if NEC did develop.

This is what I would do (have done NBN where we frequently handled hypoglycemia, ? sepsis, etc, and now am in NICU)

HTH

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