Hypoglycemia In The Newborn

Hypoglycemia in newborns, as with adults, can be a medical emergency and in any case needs immediate treatment. At particular risk are newborns whose mothers had gestational diabetes (GDM) or prepregnancy type 1 or type 2 diabetes mellitus. My particular facility has standing orders to check a heelstick blood glucose on any baby whose mother had any of the above conditions at one, two, and four hours of age.

Hypoglycemia In The Newborn

While in utero, glucose from the maternal bloodstream crosses the placental barrier and into fetal circulation to be used for growth. The fetal pancreas functions much as would an adult pancreas; that is, it facilitates glucose uptake by the cells that need it.

However, in a situation in which the mother has diabetes, the risk for neonatal hypoglycemia increases, especially if the mother's blood glucose levels were not well controlled. What happens is that the fetal pancreas accomodates the extra maternal glucose; however once delivered, the baby is not receiving maternal glucose. The pancreas continues to function as though it needed to accomodate the extra maternal glucose, however. This is a set-up for hypoglycemia.

Definition of hypoglycemia varies slightly between institutions; for my facility, hypoglycemia is defined as blood glucose less than 40mg/dl in a neonate less than 24 hours old. If we find a baby with hypoglycemia, we feed them as soon as possible. If baby is breastfed, we give mom the option breastfeed. Often this works well to bring up the baby's glucose to an acceptable level.

I say 'option' not because I am against breastfeeding (quite the contrary), but on occasion the mother is ill or does not at the moment want to breastfeed, and when dealing with hypoglycemia, time is of the essence in feeding the baby.

(The human brain functions solely on glucose. If glucose is low, the brain has little fuel with which to work.)

If mom is bottle-feeding or doesn't wish to breastfeed at the moment, we feed the baby formula. Depending on the size of the baby and the blood glucose level, our goal is to get between ten and 30ml of formula in. Rarely is this ineffective, and even in breastfed babies, we have not seen so-called 'nipple confusion' when a hypoglycemic breastfed baby is fed formula in a bottle.

At any time we can check the blood glucose of other newborns as well - a newborn who is not thermoregulating, is jittery, lethargic, or in respiratory distress. Our orders also require us to check the blood sugar of any infant weighing over 8lb 13oz (on the working theory that there may be undiagnosed GDM) or under 5lb 8 oz (as they may run out of liver glycogen stores quickly). We check those newborns' glucose at one, two, and four hours of age as well.

At any point if the blood glucose is 20mg/dl or lower, the infant goes to intensive care for intravenous fluids. As well, any infant whose glucose does not improve after a feeding may go to intensive care. Fortunately, this is rare and we catch most cases of neonatal hypoglycemia before they become severe.

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Elvish

About Elvish, BSN, DNP, RN, NP

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Specializes in OB, ER, Tele-MS.

I wonder how we can do a better job educating our non-compliant gestational diabetic moms to be more strict with their prenatal care/diet in order to prevent this problem? We can do only so much teaching, but the patient still goes home and eats whatever she wants.

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Our unit checks every baby that is admitted with a heel stick Accu check. We have had several babies since I've started working here that the mother didn't have any diabetes gestational or otherwise that would not hold their sugar up and we ended up putting them on IV D10w until we could get them controlled.

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Our nursery was checking blood sugars on high risk infants: of gestational diabetic mothers, LGA, SGA, premature infants for 24 hours; and 8 hours for meconium stained fluid, regardless of the number of results within normal range. It seemed cruel when you saw the bruised heels of some of the babies. Now we're in the process of changing our policies to lesson the total amount of heel sticks routinely done for these babies. They get stuck for other routine tests too, so it gets to be too much sometmes.

I'm sure we will be able to use our discretion when needed as well.

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Regarding what and how to teach patients with gestational diabetes concerning their diet....

As a fairly newly diagnosed diabetic myself, I found the most helpful intervention concerning my diet was a referral to a diabetes educator. She sat down with me and explained in concrete terms what constituted a carbohydrate and how big my serving sizes should be. She actually had plastic serving sizes of various food groups to show me how big a serving was. It was an extremely informative and life changing meeting. Some people, especially younger teens simply may not know about portion sizes and which foods are carbohydrates.

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If the baby is delivered via section is there a time where we shouldn't feed. I had a infant yesterday that was an hour old and had a BGL of 42. The NP told me to feed the baby because are protocol states feed if 45 or lower. HOwever, another nurse was agitated and stated that the infant did not need to be fed. The infant did end of with mild abd. distention. but was okay. What are your thoughts ?

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Specializes in Community, OB, Nursery.

We encourage all moms to feed as soon as possible, whether they deliver lady partslly or c/s. A lot of moms nurse in the PACU or even in the OR. Regarding your particular situation, I wouldn't freak out over a sugar of 42, as our policy says that a 1hr of 40 or higher is ok. We no longer check sugars at 2 and 4 hrs unless symptomatic, but back when we still did, most babies whose sugars were between 40-45 at 1hr went on to be higher at 2 and 4 hours, whether fed or not. Still, a feeding won't hurt, and if your policy is to feed (or have baby nurse) under 45, you should do it unless there's a better reason not to.

If I had to hazard a guess I'd say the abdominal distention was from amniotic fluid still in baby's stomach compounded with the feeding. No biggie. They'll either spit it up or poop it out eventually.

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