THE PROBLEM

Hypoglycemia in the newborn is not a medical condition in itself, but can be a

symptom of underlying disease. Prolonged or recurrent low glucose levels may lead
to long-term neurodevelopmental sequelae.
Unfortunately, the exact parameters of normal blood glucose in the neonate remain
controversial. Although neonates have a lower normal blood glucose range than
older infants, a blood glucose level that requires intervention in every newborn has
not been defned and appears to be dependent on birth weight, gestational age,
feeding method, and postnatal age in hours. Also uncertain are the level and duration
of hypoglycemia that cause damage and the vulnerability, or lack thereof, of the
brains of infants of difering gestational ages.
Because of the lack of clear defnition of safe neonatal blood glucose levels, knowing
when and how to screen and intervene can be difcult. Based on analysis of the
literature, clinical experiences, and expert consensus, these guidelines promote a
pragmatic approach that provides a wide safety margin.
GENERAL RECOMMENDATIONS
Te following are generally recommended principles; detailed recommendations
are given in the algorithm on page 2 of this document.
1 Initiate feeding. Feeding should be initiated for all neonates as soon as the
infant is ready, preferably within 1 hour of birth. Neonates who are not fed
will have a physiologic drop in blood glucose, with a low at 1 to 1.5 hours of
age. Te feeding should be breast milk (colostrum) or infant formula NOT
dextrose-water. Colostrum, if available, is preferred to formula.
2 Assess risk factors and symptoms. All neonates with risk factors or major
symptoms should have blood glucose checked.
3 Screen and manage based on initial feeding and assessment. If the
neonate is symptomatic or blood glucose level is less than 45 mg/dL, notify a
LIP while proceeding with management steps outlined in the algorithm on page 2.
Tese guidelines were prepared by Larry Eggert, MD, in consultation with
Intermountain Healthcares (Intermountains) Well Newborn Development Team
and NICU Development Team, under the guidance of Intermountains Women
and Newborns Clinical Program. Te guidelines are derived from analysis of the
literature and expert consensus.
The problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
General recommendations . . . . . . . . . . . . . . . 1
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ALGORITHM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
REFERENCES
1. Canadian Paediatric Society. Screening guidelines
for newborns at risk for low blood glucose. Paediatr
Child Health. 2004;9(10):723-729. http://www.cps.
ca/english/statements/fn/fn04-01.htm. Accessed
March 28, 2012.
2. Chan SW. Neonatal hypoglycemia. UpToDate Online.
Waltham, MA: 2010. http://www.utdol.com/online/
content/topic.do?topicKey=neonatol/5898&select
edTitle=1%7E38&source=search_result. Accessed
March 28, 2012.
3. Cornblath M, Hawdon, JM, Williams AF, et al.
Controversies regarding denition of neonatal
hypoglycemia: suggested operational thresholds.
Pediatrics [serial online]. 2000;105(5):1141-1145.
http://pediatrics.aappublications.org/cgi/content/
full/105/5/1141?ck=nck. Accessed March 28, 2012.
4. New Zealand Ministry of Health. Auckland District
Health Board. Newborn Services Clinical Guideline.
Guidelines for the Management of Hypoglycaemia.
2004 July. http://www.adhb.govt.nz/newborn/
guidelines/nutrition/HypoglycaemiaManagement.
htm. Accessed March 28, 2012.
5. Newborn Nursery QI Committee. Neonatal
hypoglycemia: initial and follow up management.
Portland (ME): The Barbara Bush Childrens Hospital
at Maine Medical Center; 2004 Jul. http://www.
guideline.gov/summary/summary.aspx?ss=15&doc_
id=7180&nbr=4293. Accessed March 28, 2012.
6. Volpe JJ. Neurology of the Newborn. 5th ed.
Pennsylvania, PA: Saunders/Elsevier; 2008.
7. Wight N, Marinelli KA, Academy of Breastfeeding
Medicine Protocol Committee. ABM clinical protocol
#1: guidelines for glucose monitoring and treatment
of hypoglycemia in breastfed neonates. Breastfeed
Med. 2006;1(3):178-184. http://www.guideline.gov/
summary/summary.aspx?doc_id=11218&nbr=0058
65&string=neonatal+AND+hypoglycemia. Updated
January 25, 2010. Accessed March 28, 2012.
8. World Health Organization. Hypoglycaemia of
the Newborn, Review of the Literature: 1997.
http://www.who.int/maternal_child_adolescent/
documents/chd_97_1/en/index.html . Accessed
March 28, 2012.
G U I DE L I NE S F OR MA NA G E ME NT OF
Neonatal Hypoglycemia
2012 update
C a r e P r o c e s s M o d e l A P R I L 2 0 1 2
New in the 2012 update: Our process algorithm now supports the use of the
Nova StatStrip Glucose Monitoring System at the bedside for verication of initial
low glucose-screening results. This modication follows from direct comparisons of
various testing methods by Intermountain nursing, laboratory, and medical experts.
Also, consistent with current practice and science, this updated algorithm simplies
the IV infusion recommendations and suggests a lower initial IV infusion rate.
GUI DELI NES FOR MANAGEMENT OF NEONATAL HYPOGLYCEMI A APRI L 2012
yes
no
yes
yes
no
yes
yes
ALGORITHM: MANAGEMENT OF NEONATAL HYPOGLYCEMIA
1 Initiate feeding for all neonates as soon as infant is ready, preferably within 1 hour of birth.
Feed breast milk/colostrum or infant formulaNOT dextrose-water. Colostrum, if available, is preferred to formula.
2 Assess the neonate for presence of the following risk factors and symptoms.
Risk factors:
Prematurity (age <37 weeks) or LBW (<2500 gm)
SGA or IUGR (<10
th
percentile for weight)
Intrapartum depression (5 min Apgar <7)
Infant of a diabetic mother (IDM)
LGA (>90
th
percentile for weight)
Major symptoms:
Stupor, hypotonia
Jitteriness, irritability, high-pitched cry
Seizures
Apnea, cyanosis
Irregular rapid breathing
>1 hour grunting, retractions, RR >60
Hypothermia (<36.5C axillary after stabilization)
Polycythemia (central Hct >65)
Microphallus or midline defect
Maternal terbutaline, beta-blocker, or
oral hypoglycemic agent during L&D
Asymptomatic
WITHOUT risk factors
Asymptomatic
WITH risk factors
Symptomatic
No further action
necessary
Check blood glucose at least 30 minutes after conclusion of feeding,
but no later than 4 hours of age. (If baby wasnt interested in feeding
right after birth, check blood glucose within 2-3 hours after birth.)
Check blood glucose immediately.
Glucose 30 - 44 Glucose <30 Glucose <45 Glucose 45
Some at-risk babies may
develop late hypoglycemia,
often between 12 and 24
hours of age. Follow clinically
and recheck glucose about
every 6 hours, before feeding,
for the first 24 hours of life.
Breastfeed, or feed expressed
breast milk or formula (10 ml/kg)
by mouth or gavage.
Recheck glucose 30 minutes after
conclusion of feeding
Continue feeding.
Monitor glucose before feeding until stable (>45 x 2).
Some at-risk babies may develop late hypoglycemia, often
between 12 and 24 hours of age. Follow clinically and
recheck glucose about every 6 hours, before feeding, for
the first 24 hours of life.

Glucose 45?
Notify LIP. Search for
other etiology.
If glucose remains <45, notify LIP to request
Neonatology consult. Discuss further therapy and discuss
transport/transfer to a higher-level neonatal unit.
Continue IV and wean as tolerated.
Some at-risk babies may develop late hypoglycemia,
often between 12 and 24 hours of age. Follow clinically
and recheck glucose about every 6 hours, for the first 24
hours of life.
Notify LIP while proceeding with algorithm.
Retest glucose at bedside using Nova StatStrip
(venipuncture) or i-STAT (heel-stick or venipuncture); send
for STAT lab glucose only if bedside retesting cant be
done as described. If glucose is >45, return to appropriate
box above. Otherwise, proceed with algorithm.
Once glucose is >45,
screen every 1-2 hours
until stable (>45 x 2)
Give minibolus D
10
W @ 2 ml/kg IV push
Then start D
10
W @ 80 ml/kg/day
Recheck glucose in
no more than 30 minutes
Notify LIP.
Search for
other etiology.
Repeat minibolus D
10
W @ 2 ml/kg IV push
Increase rate of D
10
W to 100 ml/kg/day
For glucose <30, now or later, notify LIP
to request STAT Neonatology consult.
Recheck glucose in no
more than 30 minutes

Glucose 45?
Repeat minibolus D10W @ 2 ml/kg IV push
Increase rate of D10W to 120 ml/kg/day

Symptoms?

Glucose 45?
no

Glucose 45? no
no
Glucose >45
2010-2012 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. PATIENT AND PROVIDER PUBLICATIONS 801.442.2963 CPM011 - 4/12
page 2 of 2
Recheck glucose in no
more than 30 minutes