STATE OF THE SCIENCE

Early neonatal hypoglycemia in term and late preterm small for gestational age newborns

BACKGROUND

Neonatal hypoglycemia is a common metabolic occurrence among small for gestational age (SGA) neonates. This study aims to determine the incidence of early neonatal hypoglycemia and confirms the potential risk factors among term and late preterm SGA neonates in a well-baby newborn nursery of a tertiary medical center in Southern Taiwan.

METHODS

We performed a retrospective medical record review of term and late preterm SGA (birth weight <10 percentile) neonates, born between January 1, 2012 and December 31, 2020, in the well-baby newborn nursery, of a tertiary medical center in Southern Taiwan. Blood glucose monitoring was routinely performed at 0.5, 1, 2, and 4 h of life. Antenatal and postnatal risk factors were recorded. Mean blood glucose level, age of occurrence, symptomatic hypoglycemia, and need for intravenous glucose treatment of early hypoglycemia in SGA neonates were documented.

RESULTS

690 SGA neonates in the nursery met the criteria and were retrospectively enrolled in the study, 358 of whom (51.80%) were male and 332 (48.10%) female. Of 690 enrolled SGA neonates, 134(19.42%) SGA neonates developed hypoglycemia during a well-baby nursery stay. Among these neonates, 97% of early hypoglycemic episodes occur during the first 2 h of life. The lowest blood glucose level was 46.78 ± 11.13 mg/dL, recorded in the first hour of life. Among the hypoglycemic 134 neonates, 26 (19.40%) neonates had to be transferred from the nursery to the neonatal ward and they required intravenous glucose treatment to achieve euglycemia. 14 (10.40%) neonates had symptomatic hypoglycemia. A multivariate logistic regression analysis revealed that cesarean delivery, small head circumference, small chest circumference, and low 1-min Apgar score were significant risk factors for early hypoglycemia in these neonates.

CONCLUSION

Periodic routine blood glucose level monitoring within the first 4 h of life in term and late preterm SGA neonates is required, especially those with cesarean delivery and low Apgar score.

Nursing and midwifery management of hypoglycaemia in healthy term neonates

EXECUTIVE SUMMARY:

OBJECTIVES

The primary objective of this review was to determine the best available evidence for maintenance of euglycaemia* in healthy term neonates, and the management of asymptomatic hypoglycaemia in otherwise healthy term neonates.

INCLUSION CRITERIA

TYPES OF STUDIES: The review included any relevant published or unpublished studies undertaken between 1995 and 2004. Studies that focus on the diagnostic accuracy of point-of-care devices for blood glucose screening and/or monitoring in the neonate were initially included as a subgroup of this review. However, the technical nature and complexity of the statistical information published in diagnostic studies retrieved during the literature search stage, as well as the considerable volume of published research in this area, suggested that it would be more feasible to analyse diagnostic studies in a separate systematic review.

TYPES OF PARTICIPANTS

The review focused on studies that included healthy term (37- to 42-week gestation) appropriate size for gestational age neonates in the first 72 h after birth.

EXCLUSIONS

•  preterm or small for gestational age newborns; •  term neonates with a diagnosed medical or surgical condition, congenital or otherwise; •  babies of diabetic mothers; •  neonates with symptomatic hypoglycaemia; •  large for gestational age neonates (as significant proportion are of diabetic mothers). TYPES OF INTERVENTION: All interventions that fell within the scope of practice of a midwife/nurse were included: •  type (breast or breast milk substitutes), amount and/or timing of feeds, for example, initiation of feeding, and frequency; •  regulation of body temperature; •  monitoring (including screening) of neonates, including blood or plasma glucose levels and signs and symptoms of hypoglycaemia. Interventions that required initiation by a medical practitioner were excluded from the review.

TYPES OF OUTCOME MEASURES

Outcomes that were of interest included: •  occurrence of hypoglycaemia; •  re-establishment and maintenance of blood or plasma glucose levels at or above set threshold (as defined by the particular study); •  successful breast-feeding; •  developmental outcomes. TYPES OF RESEARCH DESIGNS: The review initially focused on randomised controlled trials reported from 1995 to 2004. Insufficient randomised controlled trials were identified and the review was expanded to include additional cohort and cross-sectional studies for possible inclusion in a narrative summary.

SEARCH STRATEGY

The major electronic databases, including MEDLINE/PubMed, CINAHL, EMBASE, LILACS, Cochrane Library, etc., were searched using accepted search techniques to identify relevant published and unpublished studies undertaken between 1995 and 2004. Efforts were made to locate any relevant unpublished materials, such as conference papers, research reports and dissertations. Printed journals were hand-searched and reference lists checked for potentially useful research. The year 1995 was selected as the starting point in order to identify any research that had not been included in the World Health Organisation review, which covered literature published up to 1996. The search was not limited to English language studies. ASSESSMENT OF QUALITY: Three primary reviewers conducted the review assisted by a review panel. The review panel was comprised of nine nurses with expertise in neonatal care drawn from senior staff in several metropolitan neonatal units and education programs. Authorship of journal articles was not concealed from the reviewers. Methodological quality of each study that met the inclusion criteria was assessed by two reviewers, using a quality assessment checklist developed for the review. Disagreements between reviewers were resolved through discussion or with the assistance of a third reviewer.

DATA EXTRACTION AND ANALYSIS

Two reviewers used a data extraction form to independently extract data relating to the study design, setting and participants; study focus and intervention(s); and measurements and outcomes. As only one relevant randomised controlled trial was found, a meta-analysis could not be conducted nor tables constructed to illustrate comparisons between studies. Instead, the findings were summarised by a narrative identifying any relevant findings that emerged from the data.

RESULTS

Seven studies met the inclusion criteria for the objective of this systematic review. The review provided information on the effectiveness of three categories of intervention - type of feeds, timing of feeds and thermoregulation on two of the outcome measures identified in the review protocol - prevention of hypoglycaemia, and re-establishment and maintenance of blood or plasma glucose levels above the set threshold (as determined by the particular study). There was no evidence available on which to base conclusions for effectiveness of monitoring or developmental outcomes, and insufficient evidence for breast-feeding success. Given that only a narrative review was possible, the findings of this review should be interpreted with caution. The findings suggest that the incidence of hypoglycaemia in healthy, breast-fed term infants of appropriate size for gestational age is uncommon and routine screening of these infants is not indicated. The method and timing of early feeding has little or no influence on the neonatal blood glucose measurement at 1 h in normal term babies. In healthy, breast-fed term infants the initiation and timing of feeds in the first 6 h of life has no significant influence on plasma glucose levels. The colostrum of primiparous mothers provides sufficient nutrition for the infant in the first 24 h after birth, and supplemental feeds or extra water is unnecessary. Skin-to-skin contact appears to provide an optimal environment for fetal to neonatal adaptation after birth and can help to maintain body temperature and adequate blood glucose levels in healthy term newborn infants, as well as providing an ideal opportunity to establish early bonding behaviours.

IMPLICATIONS FOR PRACTICE

The seven studies analysed in this review confirm the World Health Organisation's first three recommendations for prevention and management of asymptomatic hypoglycaemia, namely: 1 Early and exclusive breast-feeding is safe to meet the nutritional needs of healthy term newborns worldwide. 2 Healthy term newborns that are breast-fed on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids. 3 Healthy term newborns do not develop 'symptomatic' hypoglycaemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycaemia, look for an underlying condition. Detection and treatment of the cause are as important as correction of the blood glucose level. If there are any concerns that the newborn infant might be hypoglycaemic it should be given another feed. Given the importance of thermoregulation, skin-to-skin contact should be promoted and 'kangaroo care' encouraged in the first 24 h after birth. While it is important to main the infant's body temperature care should be taken to ensure that the child does not become overheated.

Neonatal glucose testing via prompted intervention during the pretransport phase of care

Neonatal hypoglycemia is a common metabolic problem. Critically ill neonates require effective glucose metabolism to survive and thrive. Timely and urgent transport of these neonates from a level I/II nursery to a level III NICU is often needed related to complex medical and nursing care requirements. The stabilization phase prior to transport can be chaotic, resulting in a less than optimal frequency of glucose testing. Inadequate testing may result in undetected hypoglycemia that can lead to lifelong and serious neurodevelopmental sequela. The internationally utilized S.T.A.B.L.E. curriculum, which guides postresuscitation/pretransport stabilization, has an evaluative component known as the Pretransport Stabilization Self-Assessment Tool (PSSAT). This tool allows the referral hospital staff and transport team to track glucose levels during the pretransport phase of care at 3 distinct points in time. Utilization of the PSSAT has been shown to successfully prompt glucose testing that is reflective of the S.T.A.B.L.E. curriculum.

Neurologic sequelae of neonatal hypoglycemia in Kayseri, Turkey

Contrary to belief, neonatal hypoglycemia is relatively common and can cause more severe neurological sequelae than is currently believed. Prevention of hypoglycemic brain damage by hindering prolonged and profound neonatal hypoglycemia might contribute to psychomotor development. At Erciyes University, between December 1996 and 2005, of the patients who applied to Paediatric Neurology Department, 60 cases with a history of neonatal hypoglycemia were included in the study. The magnetic resonance imaging (MRI) scans and clinical records of all patients were reviewed retrospectively. It was noted that the sequelae with glucose levels of 0 0 to 40 were more serious and intense. The same results were also observed in cranial MRI evaluation. In conclusion, intractable epilepsy, mental motor retardation, cerebral palsy, and visual disturbance were found to be the most common and severe conditions affecting sufferers of neonatal hypoglycemia. In the first 3 days of life, the close monitoring of patients at risk is critical, and hospitalization of severe cases should be considered.

Guide to capillary heelstick blood sampling in infants

Capillary blood sampling is an essential method of blood collection performed by nurses of all skill levels to obtain samples for routine laboratory tests in neonates. Accuracy of results depends on proper heelstick and sample collection technique. Recent advances including development of devices designed specifically for heelstick capillary blood sampling and research into expanded safe heel capillary sampling sites are discussed. A step-by-step guide to capillary blood sampling is outlined along with evidence-based practice incorporating neonatal-appropriate disinfection and nonpharmacological analgesia that contribute to improved infant safety and comfort during and after the procedure.

Nursing and midwifery management of hypoglycaemia in healthy term neonates

OBJECTIVES

The primary objective of this review was to determine the best available evidence for maintenance of euglycaemia in healthy term neonates, and the management of asymptomatic hypoglycaemia in otherwise healthy term neonates.

INCLUSION CRITERIA

The review included any relevant published or unpublished studies undertaken between 1995 and 2004. Studies that focus on the diagnostic accuracy of point-of-care devices for blood glucose screening and/or monitoring in the neonate were initially included as a subgroup of this review. However, the technical nature and complexity of the statistical information published in diagnostic studies retrieved during the literature search stage, as well as the considerable volume of published research in this area, suggested that it would be more feasible to analyse diagnostic studies in a separate systematic review.The review focused on studies that included healthy term (37- to 42-week gestation) appropriate size for gestational age neonates in the first 72 h after birth.All interventions that fell within the scope of practice of a midwife/nurse were included:Interventions that required initiation by a medical practitioner were excluded from the review.Outcomes that were of interest included:The review initially focused on randomised controlled trials reported from 1995 to 2004. Insufficient randomised controlled trials were identified and the review was expanded to include additional cohort and cross-sectional studies for possible inclusion in a narrative summary.

SEARCH STRATEGY

The major electronic databases, including MEDLINE/PubMed, CINAHL, EMBASE, LILACS, Cochrane Library, etc., were searched using accepted search techniques to identify relevant published and unpublished studies undertaken between 1995 and 2004. Efforts were made to locate any relevant unpublished materials, such as conference papers, research reports and dissertations. Printed journals were hand-searched and reference lists checked for potentially useful research. The year 1995 was selected as the starting point in order to identify any research that had not been included in the World Health Organisation review, which covered literature published up to 1996. The search was not limited to English language studies.

ASSESSMENT OF QUALITY

Three primary reviewers conducted the review assisted by a review panel. The review panel was comprised of nine nurses with expertise in neonatal care drawn from senior staff in several metropolitan neonatal units and education programs. Authorship of journal articles was not concealed from the reviewers. Methodological quality of each study that met the inclusion criteria was assessed by two reviewers, using a quality assessment checklist developed for the review. Disagreements between reviewers were resolved through discussion or with the assistance of a third reviewer.

DATA EXTRACTION AND ANALYSIS

Two reviewers used a data extraction form to independently extract data relating to the study design, setting and participants; study focus and intervention(s); and measurements and outcomes.As only one relevant randomised controlled trial was found, a meta-analysis could not be conducted nor tables constructed to illustrate comparisons between studies. Instead, the findings were summarised by a narrative identifying any relevant findings that emerged from the data.

RESULTS

Seven studies met the inclusion criteria for the objective of this systematic review. The review provided information on the effectiveness of three categories of intervention - type of feeds, timing of feeds and thermoregulation on two of the outcome measures identified in the review protocol - prevention of hypoglycaemia, and re-establishment and maintenance of blood or plasma glucose levels above the set threshold (as determined by the particular study). There was no evidence available on which to base conclusions for effectiveness of monitoring or developmental outcomes, and insufficient evidence for breast-feeding success.Given that only a narrative review was possible, the findings of this review should be interpreted with caution. The findings suggest that the incidence of hypoglycaemia in healthy, breast-fed term infants of appropriate size for gestational age is uncommon and routine screening of these infants is not indicated. The method and timing of early feeding has little or no influence on the neonatal blood glucose measurement at 1 h in normal term babies. In healthy, breast-fed term infants the initiation and timing of feeds in the first 6 h of life has no significant influence on plasma glucose levels. The colostrum of primiparous mothers provides sufficient nutrition for the infant in the first 24 h after birth, and supplemental feeds or extra water is unnecessary.Skin-to-skin contact appears to provide an optimal environment for fetal to neonatal adaptation after birth and can help to maintain body temperature and adequate blood glucose levels in healthy term newborn infants, as well as providing an ideal opportunity to establish early bonding behaviours.

IMPLICATIONS FOR PRACTICE

The seven studies analysed in this review confirm the World Health Organisation's first three recommendations for prevention and management of asymptomatic hypoglycaemia, namely:1 Early and exclusive breast-feeding is safe to meet the nutritional needs of healthy term newborns worldwide.2 Healthy term newborns that are breast-fed on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids.3 Healthy term newborns do not develop 'symptomatic' hypoglycaemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycaemia, look for an underlying condition. Detection and treatment of the cause are as important as correction of the blood glucose level.If there are any concerns that the newborn infant might be hypoglycaemic it should be given another feed. Given the importance of thermoregulation, skin-to-skin contact should be promoted and 'kangaroo care' encouraged in the first 24 h after birth. While it is important to main the infant's body temperature care should be taken to ensure that the child does not become overheated.

Hypoglycemia and the full-term newborn: how well does birth weight for gestational age predict risk?

OBJECTIVE

To determine whether anthropometric characteristics could be used to accurately predict risk of hypoglycemia in full-term newborns during the early post-birth period.

DESIGN

Descriptive, utilizing newborn anthropometric measurements singly and in combination to determine risk of neonatal hypoglycemia. The following measurements were obtained twice for each newborn: weight, head circumference, chest circumference, abdominal circumference, mid-arm circumference, thigh circumference, and length. The investigator was blind to all measurements except weight.

SETTING

Mothers' rooms or the newborn nursery in a community hospital.

INTERVENTIONS

All measurements were obtained twice, and a physical examination was completed on each newborn by the principal investigator. These newborns were classified as large-, average-, and small-for-gestational age, using a tool typically used in many newborn nurseries.

SAMPLE

One hundred fifty-seven full-term newborns (94 White and 63 African American).

MAIN OUTCOME MEASURES

The differences in anthropometric measurements by race and gender were calculated using two-way analysis of variance. The risk of hypoglycemia was calculated using logistic regression modeling.

RESULTS

There were significant differences in measurements by race and by gender. Additionally, there was a subset of newborns classified as average for gestational age who had an increased risk of hypoglycemia (OR = 4.17, 95% CI = 1.33-13.08). Newborns with a mid-arm circumference/head circumference ratio that varied from .26 to .29 have an odds ratio of 6.10 (95% CI = 1.89-19.66) for risk of hypoglycemia. Plotting a newborn's birth weight on a published fetal growth curve clearly did not accurately predict his or her risk of hypoglycemia.

CONCLUSIONS

These findings indicate that extremes in newborn birth weight are not always correctly defined, may vary by race and ethnic group, and may not be the best method for determining under- or overnourishment and risk of neonatal hypoglycemia.