Running head: NEONATAL HYPOGLYCEMIA 1

Neonatal Hypoglycemia
Allison Chulada, Alyssa Breda, Henry Chouinard, Katelyn Bouchard
University of New Hampshire
NURS 621 Maternal and Newborn Nursing







Neonatal Hypoglycemia 2

Abstract
The purpose of this paper was to gather the policies of neonatal hypoglycemia from four
different hospitals nursing students studied at for their clinical rotation, compare and contrast the
policies, and create their own refined policy based upon the most up to date literature and
national guideline. This paper defines neonatal hypoglycemia, as well as presents the risk factors
and the clinical signs and symptoms. The new ideal policy outlines these signs and symptoms, as
well as describes the screening, management, and weaning processes of newborns that have
hypoglycemia.











Neonatal Hypoglycemia 3

Neonatal Hypoglycemia
Infant hypoglycemia is the most common metabolic problem in newborns (Cranmer).
Infants require blood sugar or glucose for energy, with the majority being used by the brain.
While in the womb the baby receives glucose from the mother through the placenta and after
birth through formula, breast milk and also production of glucose from the liver (Lee). The
normal plasma glucose level for an infant is 50-80 mg/dL. Glucose levels in infants after meals
can increase to 120-140 mg/dL. An infant is considered hypoglycemic if they have a plasma
glucose level of less than 30 mg/dL in the first 24 hours of life and 45 mg/dL after 24 hours of
life. When an infant suffers from hypoglycemia or low blood sugar they may present as
symptomatic or asymptomatic (Cranmer).
The incidence of symptomatic hypoglycemia in newborns varies from 1.3 to 3 per 1000
live births in the United States. The occurrence of hypoglycemia is greater in high-risk neonatal
groups such as pre term infants, infants of diabetic mothers, low thyroid hormone levels, rare
genetic disorders, poor growth in womb, and smaller than normal infants for their gestational age
(Lee).
An infants glucose level may drop if the baby is not able to eat enough to maintain
glucose levels, there is too much insulin in the bloodstream, the baby is not producing enough
glucose or the baby is using more glucose than is being produced. If the infant is hypoglycemic
and symptomatic, they may present with bluish or pale colored skin, loose or floppy muscles,
poor feeding or vomiting, problems with body warmth, tremors, shakiness, sweating, seizures,
irritability, or breathing problems such as rapid breaths, grunting or pauses in breathing (Lee).
When infant hypoglycemia is suspected the newborn will have their blood sugar tested
every few hours after birth. The health care provider will continue taking blood tests until the
Neonatal Hypoglycemia 4

glucose levels stay normal. (Lee) Treatment for hypoglycemia is based on facility policy and
clinical guidelines but usually includes extra formula or breast milk feedings, a sugar solution
given intravenously and in severe cases removal of part of the pancreas (Cranmer).
The prognosis for infants with hypoglycemia looks good if the newborn presents with no
symptoms and responds well to treatment. In some cases low blood sugars may return after
treatment. The level of hypoglycemia that is harmful to an infants brain in unknown. Some
long-term complications that may result from hypoglycemia include mental retardation, seizure
activity, developmental delay, and personality disorders. Infants with severe cases of
hypoglycemia may also develop problems with learning, especially infants who are at a lower
than average weight or whose mothers have diabetes (Lee). Cardiovascular function may also be
impaired in cases of severe hypoglycemia that is left untreated (Cranmer).
The policies on neonatal hypoglycemia being compared to one another came from
Wentworth-Douglass Hospital, Catholic Medical Center, Southern New Hampshire Medical
Center, and Exeter Hospital. Although the organization of each policy was set up differently, all
the policies incorporated a lot of the same information. Each policy had a section stating which
newborns were at risk for developing neonatal hypoglycemia and a section listing signs and
symptoms of hypoglycemia in newborns. At Wentworth-Douglass Hospital, newborns were
screened if they appeared symptomatic or if they had the following risk factors of small for
gestational age (SGA), large for gestational age (LGA), infants of diabetic mothers, late-preterm
infants 34-36 and 6/7 weeks. Even if a newborn that had one of the previously stated risk factors
was asymptomatic, the infant would still be screened due to the increased risk of developing
hypoglycemia. According to Wentworth-Douglass Hospital signs and symptoms of neonatal
hypoglycemia include jitteriness, cyanosis, apnea episodes, tachypnea, weak or high pitched cry,
Neonatal Hypoglycemia 5

floppiness or lethargy, poor feeding, and eye rolling; in neonates that are exposed to prolonged
hypoglycemia, for example a blood sugar less than 10mg/dL, they are at an increased risk of
having a seizure or going into a coma. The policy at Catholic Medical Center states that
newborns are at an increased risk of developing hypoglycemia if they are an infant of diabetic
mother, SGA, LGA, preterm or post-term (less than 37 weeks or greater than 42 weeks), sick or
stressed. Catholic Medical Center describes symptoms of jitteriness, tremors, seizures, lethargy,
and apnea to correspond with neonatal hypoglycemia. At Southern New Hampshire Medical
Center, the policy states that risk factors for neonatal hypoglycemia include late preterm and
term SGA infants, infant of diabetic mother, LGA. Signs and symptoms consist of irritability,
tremors, jitteriness, exaggerated Moro reflex, high-pitched cry, seizures, lethargy, floppiness,
cyanosis, and poor feeding. The last policy, from Exeter Hospital, has risk factors and signs and
symptoms of neonatal hypoglycemia very similar to the other three policies. Risk factors from
Exeter hospital included infants with diabetic mothers; LGA; SGA; intra uterine growth
restrictions; gestation age of less than 37 weeks or greater than 42 weeks; sick or distressed
infants, examples being cold stressed, APGAR score less than 6 at 5 minutes, history of perinatal
stress, respiratory distress,; hypoxia, shock, sepsis, or cardiac disease; infant with hematocrit less
than 65%; inadequate oral intake, temp instability; and maternal drug treatment using drugs such
as terbutaline, propranolol, or oral hyperglycemic agent 72 hours prior to delivery. Exeter
Hospital states that the most common sign and symptom of neonatal hypoglycemia was that the
newborn would be asymptomatic; however, the policy also lists jitteriness, tremors, lethargy,
seizures, poor feeding, irritability, hypotonia, hypothermia, tachypnea, respiratory distress,
pallor, cyanosis, and apnea greater than 15 seconds as other signs and symptoms.
The next large section that was incorporated into each policy was the screening and
management of neonatal hypoglycemia. At Wentworth-Douglass Hospital, in newborns with
Neonatal Hypoglycemia 6

signs and symptoms that also have a blood glucose level less than 40mg/dL, a plasma sample is
sent to the lab to verify. However, treatment must be started before confirmation from lab. In
newborns with exhibiting jitteriness or poor feeding, as well as a blood glucose level less 40,
feeding the infant is the first intervention. The infant must have a SAIB score of 4 (alignment,
areolar grasp, areolar compression, audible swallowing) to begin breastfeeding or the newborn
should receive between 15-30mL of formula. Blood glucose should be rechecked within 30 min
of feeding, and if the blood glucose is still less than 40mg/dL the physician should be notified
and IV glucose should be started. For newborns displaying any other sign or symptom that also
has a blood glucose level less than 40mg/dL, IV glucose therapy is initiated. The first step is
administering a bolus dose of 200 mg/kg of D10W. The second step is administering an IV
infusion of D10W at 5-8mg/kg/min (80-100mL/kg/24hr). The goal of this therapy is to maintain
a glucose level between 40 and 50mg/dL. Blood glucose levels are checked at every shift in a
newborn receiving an IV infusion. In newborns who present as asymptomatic at birth, during the
first four hours of life, the policy states to feed infant within the first hour after birth. The
pediatrician should be consulted if the newborn is unable to feed; therefore, gavage feeding may
be considered. Screening of blood glucose levels should occur after first 30 minutes the newborn
is fed. If blood glucose levels are greater than 25mg/dL, scheduled feedings every 2 to 3 hours
should be initiated. Blood glucose levels are assessed before each feed and if these levels are
greater than 35mg/dL, a routine feeding schedule is followed. However, if blood glucose levels
remain less than 25mg/dL after the initial feed the physician is notified and the newborn should
be fed again. Once glucose levels are assessed after an hour of feeding, if the levels are between
25 and 40mg/dL, the physician should be notified and IV glucose therapy should be considered.
If blood glucose levels are greater than 40mg/dL the newborn should be progressed to scheduled
feedings every two to three hours. Yet, if the blood sugar level remains less than 25mg/dL the
Neonatal Hypoglycemia 7

physician should be notified and IV glucose therapy should be started immediately with a bolus
dose followed by a continuous IV infusion, as stated previously. After the first four hours of life,
the Wentworth-Douglass policy has a separate list of interventions for the first 4-24 hours. If the
newborn is still asymptomatic after the first 4 hours of life and has blood glucose levels greater
than or equal to 35mg/dL, newborn should continue feedings every 2-3 hours, and have blood
glucose screened before each feeding. If blood glucose is less than 35mg/dL, the physician needs
to be notified and the newborn should receive a feeding with blood glucose screened within 1
hour. If the newborn has a blood glucose that remains below 35mg/dL the physician should be
notified before starting IV glucose therapy. The goal of this therapy is to have the newborn
maintain a blood glucose level between 40 and 50mg/dL or a target glucose screen of greater
than or equal to 45mg/dL after 24 hours of receiving IV glucose therapy. If the newborn is fed
and after the 1 hour recheck of blood glucose, the level is between 35-45mg/dL, the newborn
should be fed again and screened in 1 hour after feeding. For newborns who are receiving IV
glucose therapy, if the newborn has a blood glucose level less than 45mg/dL after the first 24
hours of receiving therapy, the possibility of hyperinsulinemic hypoglycemia should be
considered. For newborns who are receiving IV glucose therapy without IV bolus or an increase
in the IV glucose infusion rate, the newborn can be considered to be weaned from IV glucose
therapy. The infant must maintain a blood glucose level of 40-50mg/dL and target glucose screen
of greater than or equal to 45mg/dL after 24 hours of infusion and prior to feeds. The infant must
also be able to maintain thermoregulation, have a respiratory rate less than 60 breaths/min, is
breastfeeding well or feeding at least 10mL/kg of formula every 3 hours. The weaning process
indicates that D10W is decreased by 25% of original rate every 3-6 hours as ordered. If the
newborn is unable to tolerate the weaning process, the physician should be notified. When it
becomes time to discontinue newborns from glucose screening, the Wentworth-Douglass
Neonatal Hypoglycemia 8

Hospital policy states that infants of diabetic mothers and infants and LGA should continue
blood glucose screening until 12 hours of age if they have a blood glucose level greater than
40mg/dL. For late-preterm and SGA newborns, blood glucose screening should be continued for
at least 24 hours after birth. Discontinuation of screening can be finalized when the infant can
maintain normal a normal blood glucose concentration on a routine diet for at least 3 consecutive
feedings before discharge.
The policy at Catholic Medical Center states that newborns that are at risk for
hypoglycemia should initiate feedings within first hour of life and screen blood glucose at 1
st

hour and 2
nd
hour of life. For newborns that present with signs and symptoms of hypoglycemia,
blood glucose levels should be checked immediately. If the initial blood glucose is below
25mg/dL, the special care nursery (SCN) should be notified. The newborn should also be fed
immediately with a 10-20mL supplement of formula with blood glucose screened 1 hour after
feeding. If the blood glucose level is still less than 25mg/dL, the SCN provider should be called
and the newborn will be admitted to the SCN for further treatment. If the initial blood glucose is
between 25 and 45mg/d, the newborn should be fed immediately with a supplement with 10-
20mL of formula if the newborn received a SAIB score less than 4 indicating breastfeeding
would not be possible. Blood glucose should be screened within 1 hour of feeding, and if blood
glucose level is less than 35mg/dL the SCN provider should be called and the newborn will be
admitted to the SCN for further treatment. However, if the blood glucose level is between 35 and
45mg/dL, the SCN provider should be notified; yet, the newborn should receive a feeding and
screened within 1 hour. If the initial glucose is greater than 45mg/dL the newborn should be
started on early, frequent feedings. Blood glucose screening should continue to be monitors for
newborns at risk of developing hypoglycemia until feedings are well established. The newborn
should receive an SAIB of 4 for 2 consecutive feedings or should easily tolerate 15-30 mL for
Neonatal Hypoglycemia 9

two consecutive feedings. Newborns will have blood glucose screens prior to feedings until they
are able to maintain a blood glucose level greater than 45mg/dL for 2-3 consecutive feedings.
At Southern New Hampshire Medical Center, the policy states that the provider should be
notified for any infant that is symptomatic. If the newborn presents as symptomatic with a blood
glucose level less than 40mg/dL, the provider should be notified and the newborn should be
transferred to the NICU for IV glucose therapy. If a newborn who has risk factors for
hypoglycemia, yet presents asymptomatic at birth through the first 4 hours of life, feeding should
be initiated within 1 hour, and blood glucose should be screened within 30 minutes of first feed.
If the blood glucose is less than 25mg/dL after the initial feedings, the newborn should be fed
with formula immediately and blood glucose should be checked in 1 hour after feeding. If the
blood glucose level still remains less than 25 the provider should be notified, serum glucose
should be sent to the lab, and the newborn should be transferred to the NICU for IV glucose
therapy. However, if the initial blood glucose after the first feeding is greater than 25, the
newborn should be fed in 2-3 hours and blood glucose should be screened within an hour of
eating. If this blood glucose level is between 25 and 40mg/dL, the provider should be notified to
make the decision if the newborn should be fed again with formula or if the newborn should be
transferred to the NICU to receive IV glucose as needed. In the SNHMC policy, a new algorithm
is used for newborns who have risk factors for hypoglycemia, yet that appear asymptomatic in
the first 4 to 24 hours of life. These newborns should continue with scheduled feedings every 2-3
hours and should be screened before each feed. If the screen is less than 35mg/dL, the newborn
should be fed immediately and blood glucose levels should be rechecked in 1 hour. After 1 hour,
if the blood glucose level is less than 35mg/dL, the policy states that the provider should be
notified and the newborn should be transferred to the NICU for IV glucose therapy. However, if
after the 1 hour recheck of blood glucose, the level is between 35-45mg/dL, the provider should
Neonatal Hypoglycemia 10

be notified to make the decision if the newborn should be fed immediately with formula or if the
newborn should be transferred to the NICU for IV glucose as needed. Once the newborn is able
to tolerate routine feedings, the policy also states that the target glucose screen should be greater
than or equal to 45mg/dL prior to feedings.
Before describing the procedure in screening and managing neonatal hypoglycemia the
Exeter Hospital Policy includes that patient teaching of the procedure be done, including the
importance of wrapping infant in blankets to avoid cold stress and to encourage frequent
feedings. The policy also lists the equipment that will be utilized during the management of
hypoglycemia including a blood glucose monitor with controlled solution, a heel-stick device,
gauze, alcohol pad, band aids, and gloves. The policy states that management of hypoglycemia
begins with the initiation skin-to-skin contact and feedings within the first hour of life. A heel
stick glucose test should be obtained on all babies at risk for hypoglycemia. This should be done
within the 1
st
hour of life for newborns at risk for hypoglycemia or immediately of a newborn
who presents with signs and symptoms of hypoglycemia. For a blood glucose level that is greater
than or equal to 40mg/dL, feedings should be initiated within 1 hour of birth. Blood glucose
should be checked before meals until feedings are well established and glucose levels remain
greater than or equal to 40mg/dL. Screening should continue for 12 hours of age for infants born
to mothers with diabetes and infants LGA. Late-term and SGA should continue glucose screen
for the first 24 hour of life. However, according to the Exeter policy, if the initial blood glucose
level is less than 40mg/dL, a heel stick glucose test should be repeated immediately. If the results
still yield less than 40mg/dL serum blood glucose should be to send to lab. Feeding should be
initiated if the infant is stable and vital signs within normal limits. If newborn is breast feeding,
obtain blood glucose level 1 hour after feeding. However, if the newborn is unable to breastfeed
the initiation of feeding of formula PO or gavage should be done. If infant becomes unstable
Neonatal Hypoglycemia 11

notify provider to initiate IV fluids per physician order. IV glucose therapy is started when a
newborn has a blood glucose level below 20mg/dL, where the newborn would receive the bolus
and maintenance dose. IV glucose therapy is also initiated if the newborn has a blood glucose
level less than 40mg/dL and is also not tolerating by mouth. This newborn would receive only
the maintenance dose of IV therapy. The Exeter Hospital policy states that IV glucose therapy
consists of a D10W bolus of 2-3mL/kg over 5 minutes, and then maintenance of D10W at
80ml/kg/day. If the newborn is feeding well physician will start to decrease fluids and blood
glucose levels should be within normal limits for two consecutive screenings after discontinuing
IV glucose therapy.
It is clear that the policies from especially Wentworth-Douglass Hospital, but also Exeter
Hospital, go into much more depth than the policies from SNHMC and Catholic Medical Center.
The policies provided by SNHMC and Catholic Medical Center were algorithms. These policies
were in a chart format that also excluded information on IV glucose therapy that was present in
both the policies from Wentworth-Douglass Hospital and Exeter Hospital. Another major
difference between the policies is that the Wentworth-Douglass Hospital policy and the SNHMC
policies separate the management of hypoglycemia into a birth to 4 hours timeframe and a 4
hours to 24 hours timeframe, while the management in the other two policies are based on blood
glucose values at any time after birth. There were slight variations in the blood glucose levels
between each policy that prompted for an intervention of either feedings or IV glucose therapy;
yet, these values never ranged more than 5mg/dL above or below each other. Another interesting
point to consider is the publication of the policies. The SNHMC and Catholic medical Center
policies were both published in 2011, and the Wentworth-Douglass Hospital and Exeter Hospital
policies were published in 2013. This could represent the lack of information present in both the
CMC and SNHMC policies regarding IV glucose therapy since both policies simply state to send
Neonatal Hypoglycemia 12

the newborn to the Special Care Nursery or the NICU. Both the Wentworth-Douglass Hospital
and the Exeter Hospital policies have information about the weaning process. Although the
policy from Wentworth-Douglass goes much more in depth regarding the rate at which the
D10W is reduced, this information is still important when considering the discharge process for
the newborn.
When comparing the policies of neonatal hypoglycemia received from the four different
hospitals to the National Guideline, there were multiple sections from the National Guideline that
were unavailable to view or were not stated. The National Guideline stated that the steps in
treatment and management of hypoglycemia were early feeding, supplementation (oral, NG, IV),
rechecking blood glucose after interventions, weaning from the supplementation, and referral to
specialists as needed. However, these interventions were not described in depth at all. The
National Guideline included risk factors and signs and symptoms that were consistent with the
policies received from the 4 different hospitals; yet, the guideline included newborns that
weighed more than 4 kg or less than 2 kg as a risk factor, which was not included in any of the
policies reviewed from the different hospitals. The guideline was also last revised in 2009, which
could be an explanation as to the lack of information available (National Guideline
Clearinghouse).
This literature review uses an article titled Neonatal hypoglycemia found on the
UpToDate database. The article was last updated on March 12, 2013; however, the literature is
current through February of 2014. The most up to date research is analyzed and presented in this
article, which references a total of 37 sources whose publication dates range from 1975 to 2013.
As stated previously, newborn hypoglycemia is a common complication that can
occur after birth. In utero, the newborn relies on the placenta for glucose supply. After birth, the
Neonatal Hypoglycemia 13

newborn must maintain plasma glucose levels by glycogenolysis, or the breakdown of glycogen
by the liver, which releases glucose into the bloodstream. This occurs for the first 8 to 12 hours
after birth until the glycogen stores are used up. The infant then uses gluconeogenesis, or the
generation of glucose from lactate, glycerol, and amino acids, to maintain plasma glucose levels.
This occurs until a routine feeding schedule is established with adequate supply of carbohydrates
for energy. The normal, healthy term infant experiences a decrease in plasma glucose
concentrations within two hours after birth, which usually does not drop below 40 mg/dL. This
usually rises and stabilizes at a therapeutic level between 45 and 80 mg/dL by 6 hours of age
(Chan).
Hypoglycemia occurs in infants who are utilizing more glucose than they are
producing. Infants who are at risk or showing signs and symptoms of hypoglycemia must be
evaluated and require observation as well as screening and management, if indicated. Those at
risk for neonatal hypoglycemia are premature infants, infants who are large for gestational age,
infants who are small for gestational age, infants of diabetic mothers, infants with polycythemia,
infants of mothers who take beta adrenergic or hypoglycemic medications, and infants who are
sick or require intensive care. The signs and symptoms of infants who present with
hypoglycemia are jitteriness, tremors, hypotonia, change in level of consciousness, lethargy,
irritability, stupor, apnea, bradycardia, cyanosis, tachypnea, poor sucking reflex, poor feedings,
weak or high-pitched cry, hypothermia, and seizures. It is important to note that the symptoms
are nonspecific, and may indicate other health problems as well. Thus, if the hypoglycemia
persists through treatment, or 8 to 10 mg/kg/min of glucose infusion is needed to maintain blood
glucose levels above 50 mg/dL for more than 7 days, other causes should be considered. It is not
necessary to routinely monitor blood glucose levels in healthy term infants who are not at risk for
hypoglycemia and who are asymptomatic (Chan).
Neonatal Hypoglycemia 14

Some infants who have hypoglycemia may be asymptomatic. It is important to screen
at risk infants who appear asymptomatic within one to two hours of birth. However, if an infant
that does present with any signs or symptoms, screening and treatment should begin
immediately. Blood samples for glucose screening should be tested with a glucometer, and sent
to the lab for verification in any case that an infant presents with signs and symptoms, or if a
reading below 40 mg/dL is obtained for asymptomatic infants at risk. This laboratory
measurement is necessary since the glucose concentration in whole blood is about 15% less than
the plasma concentration. This value may also be lower if the infant has a high hematocrit. The
blood samples should be sent promptly to the lab for accurate analysis since the glucose levels
begin to decrease by 15 to 20 mg/dL per hour if left at room temperature. Treatment should
commence as soon as possible, however. Do not wait for confirmation by the laboratory to begin
treatment. These blood samples should be taken before feedings to ensure an accurate serum
glucose level. Evaluation and screening should continue for 12-24 hours after birth, and longer
for those who are 24 hours of age and maintain plasma glucose concentrations less than 45
mg/dL. Screening can be discontinued once the infant maintains glucose levels above 45 mg/dL,
and feedings are established on a routine schedule (Chan).
Management of hypoglycemia in infants begins once symptoms are present, or when
an asymptomatic infant presents with glucose levels of less than 40 mg/dL in the first 24 hours or
age and less than 50 mg/dL after 24 hours of age. This is the practice that UpToDate uses, but
they also note the American Academy of Pediatrics (AAP) uses more age specific guidelines in
their 2011 clinical report regarding neonatal hypoglycemia. According to AAP, management and
treatment should begin for symptomatic infants whose blood glucose is less than 40 mg/dL. In
asymptomatic infants at risk, they suggest an initial feeding within 1 hour of birth, and a glucose
check 1 hour after. If the infant is less than 4 hours old, and the reading is less than 25 mg/dL,
Neonatal Hypoglycemia 15

parenteral glucose should be initiated. If the level is between 25 and 40 mg/dL, oral feedings or
parenteral glucose can be used for management. If the infant is greater than 4 hours old, and the
blood glucose is less than 35 mg/dL, parenteral glucose should be initiated for treatment. If the
reading is between 35 and 45, either oral feedings or parenteral glucose can be used (Chan).
Interventions vary depending upon the symptoms as well as the infants tolerance of
the treatment. Oral feedings within an hour of life for asymptomatic infants is a preventative
measure, and may help raise glucose levels if they are low. Blood samples should be taken for
glucose testing 30 minutes after the feeding. Feeding schedule should also be every two to three
hours to provide adequate nutrition and energy (Chan).
Parenteral glucose infusions are another way to treat infants who are both
symptomatic and asymptomatic. To start, a bolus dose is infused over one minute using 200
mg/kg of glucose in 10% dextrose in water. This small bolus is beneficial in that is minimizes the
risk of causing hyperglycemia, which would stimulate insulin production and make the
hypoglycemia worse. It is necessary to check the blood glucose level 20 minutes after the bolus
to determine the effect of the intervention. Next, an infusion of 6 to 8 mg/kg/minute has shown
to be effective for infants who are symptomatic with blood glucose levels less than 40 mg/dL,
infants who have plasma glucose levels less than 25 mg/dL, infants who are unable to feed, or
infants who remain hypoglycemic after feedings. These infusions can be titrated per doctors
orders to maintain blood glucose levels at or above 50 mg/dL, and if the hypoglycemia is
persistent, then rates may exceed 12 mg/kg/minute. IV glucose therapy can begin to be tapered
slowly if the infants glucose levels are stable. This is a slow process that occurs over two to four
days. Blood glucose levels should continue to be checked during the weaning process before
feedings every three to four hours (Chan).
Neonatal Hypoglycemia 16

Glucocorticoids may be used if hypoglycemia persists for two to three days despite IV
glucose therapy. Administration of glucocorticoids helps the body of the infant to stimulate
gluconeogenesis, and thus increase blood sugar levels. Hydrocortisone 5 mg/kg per day divided
into two doses can be used as well as prednisone 2 mg/kg per day. This will usually help to
stabilize the glucose levels over several days. Serum cortisol and insulin levels are tested at the
beginning of glucocorticoid therapy as well. Glucocorticoid therapy can be tapered rapidly once
glucose levels have stabilized. Glucagon can also be used in severe case in which infants fail to
maintain therapeutic glucose levels despite IV glucose therapy. The dosage can range from 20 to
200 mcg/kg, with a maximum of 1 mg per dose. This is only used for severe hypoglycemia. This
is supported by case studies that gave newborns suffering from acute severe hypoglycemia doses
of glucagon ranging from 10 to 200 mcg/kg, and each case study validated the effectiveness of
the intervention. UpToDates policy uses an initial dose of 20 to 30 mcg/kg to treat infants with
persistent hypoglycemia despite both IV glucose and glucocorticoid therapy. It may be given
intravenously over one minute, or injected intramuscularly or subcutaneously. It should take 15
to 30 minutes for the infants blood glucose levels to begin to rise, and should last for about two
hours. It is important to monitor blood glucose levels throughout treatment, since rebound
hypoglycemia may occur. Another dose should be given if the infants serum glucose does not
rise within 20 minutes of the first dosing administration. Further evaluation of the infant is
needed if glucagon therapy is unsuccessful. Glucagon should not be used in infants who are
small for gestational age. In severe cases of hyperinsulinemic hypoglycemia, drug therapy may
be used followed by a pancreatectomy if treatment proves to be futile (Chan).
Based on this literature review, more research is needed to determine the effectiveness
of screening infants from birth to four hours of age and from four hours of age to 24 hours of
age as opposed to less than 24 hours of age.
Neonatal Hypoglycemia 17

The Wildcat Hospital Neonatal Hypoglycemia Policy provides standardized
guidelines for screening and management of newborns at risk or showing signs and symptoms of
hypoglycemia. Infants that may be screened for hypoglycemia include preterm or post term,
small for gestational age, large for gestational age, infant of diabetic mother, infant of mother
treated with oral hypoglycemic agents or beta adrenergic medications, sick or stressed infants or
intrauterine growth restriction infants. An infant may be symptomatic or asymptomatic; some
symptoms may include jitteriness, tremors, hypotonia, changes in LOC, weak or high pitched
cry, poor sucking or feeding, apnea, hypothermia, tachypnea, and/or cyanosis.
For all infants showing any symptom of hypoglycemia blood glucose levels will be
obtained, if less than 40 mg/dL a blood sample will be sent to the lab for confirmation.
Treatment will be started immediately and will include a bolus infusion of dextrose 10% and
then a blood glucose check 20 minutes after bolus infusion, as well as a continuous infusion of
D10W. For infants who are asymptomatic and are birth to four hours of age a feeding should be
initiated and blood glucose level should be obtained within 30 minutes after the feeding. For
infants who are 4 24 hours of age and asymptomatic feeding should occur every 2-3 hours and
screen glucose before each feed.
When weaning a newborn of IV glucose therapy the infant must maintain a blood glucose
level between 40 50 mg/dL and a target glucose screen greater than 45 mg/dL after first 24
hours of infusion and prior to feeds. The newborn must be able to maintain thermoregulation,
respiratory rate less than 60 breaths/minute, and breastfeed well or feed at least 10ml/kg of
formula every 3 hours. Blood glucose screenings should be the first 12 hours of life for infants
of diabetic mothers and infants that are large for gestational age and the first 24 hours of life for
infants that are small for gestational age and are late preterm. To discontinue testing newborn
Neonatal Hypoglycemia 18

blood glucose levels the infant must maintain normal glucose concentrations during three
consecutive routine feedings. For the full Wildcat Hospital policy, please refer to the end of the
paper for the attachment.















Neonatal Hypoglycemia 19

Wildcat Hospital Neonatal Hypoglycemia Policy
Purpose: provide standardized guidelines for screening and management of newborns at risk or
showing signs and symptoms of hypoglycemia.
Applications:
Babies at risk for hypoglycemia
Preterm or post-term infant (less than 37 weeks or greater than 42 weeks)
Small for gestational age
Large for gestational age
Infant of diabetic mother
Infant of mother treated with oral hypoglycemic agents or beta adrenergic medications
Sick or stressed infants
Intrauterine Growth Restriction

Signs and Symptoms of Hypoglycemia: these signs are nonspecific, it is important to note an
infant may be asymptomatic with hypoglycemia.
Jitteriness
Tremors
Hypotonia
Changes in LOC [irritability, lethargy, stupor, seizure]
Weak or high pitched cry
Poor sucking or feeding
Apnea
Hypothermia
Tachypnea
Cyanosis

Screening and Management
1. For all infants showing signs and symptoms of hypoglycemia (see above)
a. Obtain blood glucose (BG) immediately via heel stick.
b. If BG is less than 40 mg/dL, send blood sample to lab for confirmation. Start
treatment immediately; do not wait for laboratory confirmation.
c. Initiate IV glucose therapy
i. Bolus infusion: D10W at 200mg/kg (dextrose 10%) over 1 minute. Check
BG 20 minutes after bolus infusion, adjust IV infusion rate as needed
ii. IV infusion: D10W at 6-8mg/kg/min. Check BG every shift while infant is
receiving continuous infusion.
d. In infants with persistent hypoglycemia seek further evaluation to determine the
cause.
2. For all infants at risk (see above) who are asymptomatic
Birth to 4 hours of age
a. Initiate feeding within 1
st
hour of life
i. If newborn is unable to feed, notify the physician for possibly of gavage
feedings.
b. Screen for blood glucose within the first 30 minutes after the feeding.
Neonatal Hypoglycemia 20

i. If BG is less than 40 mg/dL, send blood sample to lab for confirmation.
Start treatment immediately; do not wait for laboratory confirmation.
ii. If BG is greater than 25mg/dL begin scheduled feedings every 2-3 hours.
Check blood glucose after 1 hour of feeding.
1. If BG is between 25-40mg/dL notify the provider to either repeat
feeding with formula or initiate IV glucose therapy.
iii. If BG is less than 25mg/dL notify the physician and repeat feeding.
1. Recheck BG in 1 hour.
a. If BG remains less than 25mg/dL notify the physician prior
to initiating IV glucose therapy
i. Bolus infusion: D10W at 200mg/kg (dextrose 10%)
over 1 minute. Check BG 20 minutes after bolus
infusion, adjust IV infusion rate as needed
ii. IV infusion: D10W at 6-8mg/kg/min. Check BG
every shift while infant is receiving continuous
infusion.
iii. Goal: target range of BG 40-50mg/dL. At 1
st
24
hour of IV therapy, target glucose screen greater
than 45mg/dL.
b. If BG is between 25-40mg/dL, repeat feeding and recheck
blood glucose in 1 hour.
i. Notify the physician to consider IV glucose therapy
c. If BG is greater than 40 mg/dL begin scheduled feedings
every 2-3 hours. Check blood glucose prior to each feed.
c. When infant if 4 hours old, refer to 4-24 hour guidelines
4-24 hours of age
d. Continue feeds every 2-3 hours, screen glucose before each feed.
i. If BG is less than 35mg/dL
1. Repeat feeding immediately and recheck BG in 1 hour.
a. If BG is less than 35mg/dL, notify the provider before
initiating IV glucose therapy
i. Bolus infusion: D10W at 200mg/kg (dextrose 10%)
over 1 minute. Check BG 20 minutes after bolus
infusion, adjust IV infusion rate as needed
ii. IV infusion: D10W at 6-8mg/kg/min. Check BG
every shift while infant is receiving continuous
infusion.
iii. Goal: target range of BG 40-50mg/dL. At 1st 24
hour of IV therapy, target glucose screen greater
than 45mg/dL.
Neonatal Hypoglycemia 21

b. If BG is between 35-45mg/dL, notify physician to repeat
feeding or consider initiating IV glucose therapy.
c. If BG is greater than 45mg/dL continue feedings every 2-3
hours and screen prior to feedings.
Weaning of IV glucose
e. Determine if newborn is a candidate for weaning.
i. If newborn is being managed on continuous IV glucose therapy without
bolus dose or increasing of IV infusion rate can maintain a blood glucose
between 40-50mg/dL and a target glucose screen greater than 45mg/dL
after 1
st
24 hours of infusion and prior to feeds
ii. Newborn is able to maintain thermoregulation
iii. Newborn is able to maintain respiratory rate less than 60 breaths/minute
iv. Newborn is breastfeeding well or feeding at least 10mL/kg of formula
every 3 hours
f. Decrease IV glucose therapy rate of D10W by 25% of original rate every 3-6
hours PRN
g. Continue with feedings after 2-3 hours and assess blood glucose prior to feeds.
i. Notify physician if infant is not tolerating weaning process or begins to
decline in status.
h. Convert IV to saline lock when weaning is complete. Refer below to
discontinuation of blood glucose screening.
Discontinuation of blood glucose screening
i. Continue screening through 1
st
12 hours of infants of diabetic mothers and infants
LGA.
j. Continue screening through 1
st
24 hours of infants SGA and late-preterm.
k. To discontinue testing newborn must maintain normal glucose concentrations
(greater than 50mg/dL) during three consecutive routine feedings.
*If blood glucose is less than 50mg/dL after 24 hours, notify physician to consider alternative
causes of hypoglycemia. Possible Endocrinologist consult.





Neonatal Hypoglycemia 22

References
Chan, W. (n.d.). Neonatal hypoglycemia. UpToDate. Retrieved March 20, 2014, from
http://www.uptodate.com/contents/neonatal-
hypoglycemia?source=search_result&search=neonatal+hypoglycemia&selectedTitle=1~
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Cranmer, H. (2014, October 7). Neonatal Hypoglycemia. Medscape. Retrieved March 24, 2014,
from http://emedicine.medscape.com/article802334-overview
Lee, K. G. (2011, November 14). Low blood sugar newborns: MedlinePlus Medical
Encyclopedia. U.S National Library of Medicine. Retrieved March 24, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article
National Guideline Clearinghouse | Neonatal hypoglycemia: initial and follow up management..
(n.d). National Guideline Clearinghouse | Neonatal hypoglycemia: initial and follow up
management.. Retrieved March 23, 2014, from
http://www.guideline.gov/content.aspx?id=7180