Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates
Publication Date: May 15, 2021
Last Updated: March 14, 2022
General Management Recommendations
Early and exclusive breastfeeding meets the nutritional and metabolic needs of healthy term newborn infants
1. All stable infants should initiate breastfeeding as soon as possible after birth, hopefully by 30–60 minutes of life. [A] Late preterm infants may need additional assistance with breastfeeding. Early breastfeeding is not precluded because the infant meets the criteria for glucose monitoring.
2. Infants should continue breastfeeding on cue [B]. Crying is a very late sign of hunger.82,83 After the initial awake period of ∼2 hours, some infants have a sleep/rest period of 6 to 8 hours with very brief periods of semiwakefulness.87 Infants at risk for hypoglycemia should be offered breastfeeding opportunities during these 6–8 hours as well.
3. Initiation and establishment of breastfeeding is facilitated by skin-to-skin contact between mother and infant. [A] This maintains normal infant body temperature and reduces energy expenditure (enabling maintenance of normal blood glucose) while stimulating suckling and milk production.
4. Routine supplementation of healthy term infants with water, glucose water, or formula is unnecessary and may interfere with normal metabolic compensatory mechanisms3 and establishing normal breastfeeding. [A]
5. Clinicians must identify and document risk factors, coexisting conditions, clinical signs/normality, and make assessments and decisions to avoid harm from hypoglycemia, but also to avoid iatrogenic harm, such as the effects of separation of mother and infant.82 [C] Clinicians need skills to distinguish between abnormal feeding behaviors, suggesting illness and mere reluctance to feed.
2. Infants should continue breastfeeding on cue [B]. Crying is a very late sign of hunger.82,83 After the initial awake period of ∼2 hours, some infants have a sleep/rest period of 6 to 8 hours with very brief periods of semiwakefulness.87 Infants at risk for hypoglycemia should be offered breastfeeding opportunities during these 6–8 hours as well.
3. Initiation and establishment of breastfeeding is facilitated by skin-to-skin contact between mother and infant. [A] This maintains normal infant body temperature and reduces energy expenditure (enabling maintenance of normal blood glucose) while stimulating suckling and milk production.
4. Routine supplementation of healthy term infants with water, glucose water, or formula is unnecessary and may interfere with normal metabolic compensatory mechanisms3 and establishing normal breastfeeding. [A]
5. Clinicians must identify and document risk factors, coexisting conditions, clinical signs/normality, and make assessments and decisions to avoid harm from hypoglycemia, but also to avoid iatrogenic harm, such as the effects of separation of mother and infant.82 [C] Clinicians need skills to distinguish between abnormal feeding behaviors, suggesting illness and mere reluctance to feed.
Glucose screening should be performed only on at-risk infants and those with clinical signs compatible with hypoglycemia
1. At-risk infants should be screened for hypoglycemia with a frequency and duration related to the specific risk factors of the individual infant. [C]
a. Monitoring should begin within 60 minutes after birth for infants with suspected significant hyperinsulinemia (e.g., poorly controlled maternal diabetes or known genetic hyperinsulinemia). [C]
b. Monitoring should commence before the second feeding, or 2–4 hours after birth, in other at-risk groups. (i.e., not so soon after birth that the physiologic fall in blood glucose level causes confusion and overtreatment). [B]
2. Monitoring should continue until acceptable preprandial levels are consistently obtained (until the infant has had at least three satisfactory measurements). A reasonable (although arbitrary) goal is to maintain plasma glucose concentrations ≥45 mg/dL (2.5 mmol/L). If energy intake falls, glucose monitoring should be recommenced. [C]
3. For hypoglycemia persisting beyond 48 hours, or for severe hypoglycemia at any time, urgent investigation is recommended. [A]
4. For severe persistent hypoglycemia, the PES recommends a “safety” fast of 6–8 hours before discharge, maintaining preprandial glucose >60 mg/dL (3.3mmol/L). [C]
5. Late preterm and small for gestational age infants and babies who have clinical features of intrauterine growth restriction should be monitored (with decreasing frequency) for 24 hours. [C]
6. Bedside nonenzymatic glucose screening tests must be confirmed by formal laboratory testing, although treatment should begin immediately in symptomatic infants. POC enzymatic glucometers (e.g., blood gas analyzers) do not need confirmation. [A]
a. Monitoring should begin within 60 minutes after birth for infants with suspected significant hyperinsulinemia (e.g., poorly controlled maternal diabetes or known genetic hyperinsulinemia). [C]
b. Monitoring should commence before the second feeding, or 2–4 hours after birth, in other at-risk groups. (i.e., not so soon after birth that the physiologic fall in blood glucose level causes confusion and overtreatment). [B]
2. Monitoring should continue until acceptable preprandial levels are consistently obtained (until the infant has had at least three satisfactory measurements). A reasonable (although arbitrary) goal is to maintain plasma glucose concentrations ≥45 mg/dL (2.5 mmol/L). If energy intake falls, glucose monitoring should be recommenced. [C]
3. For hypoglycemia persisting beyond 48 hours, or for severe hypoglycemia at any time, urgent investigation is recommended. [A]
4. For severe persistent hypoglycemia, the PES recommends a “safety” fast of 6–8 hours before discharge, maintaining preprandial glucose >60 mg/dL (3.3mmol/L). [C]
5. Late preterm and small for gestational age infants and babies who have clinical features of intrauterine growth restriction should be monitored (with decreasing frequency) for 24 hours. [C]
6. Bedside nonenzymatic glucose screening tests must be confirmed by formal laboratory testing, although treatment should begin immediately in symptomatic infants. POC enzymatic glucometers (e.g., blood gas analyzers) do not need confirmation. [A]
Management of Documented Hypoglycemia
At-risk infant with no clinical signs and blood glucose >20–25 mg/dL (1.1–1.4 mmol/L) but <35–45 mg/dL (2.0–2.5 mmol/L)
1. Continue skin-to-skin care. [A]
2. Continue breastfeeding as frequently as possible, or feed any available amount of colostrum, or 2–10 mL per feed (first 24 hours), and 5–15 mL per feed (24–48 hours of life), of substitute nutrition (pasteurized donor human milk,93,94 artificial milk). [B] Glucose water (5% or 10%) is not suitable because of insufficient energy and lack of protein.
3. Buccal 40% dextrose gel is recommended at 0.5 mL/kg (200 mg/kg) in conjunction with a feeding plan (preferably breastfeeding) when the glucose is low or borderline, and the blood glucose is checked before the next feeding. [A] A single repeat dose of buccal dextrose appears safe. [B]
4. Recheck blood glucose concentration before subsequent feedings until the value is acceptable and stable (usually >45 mg/dL or ≥2.5 mmol/L). [C] If staff is unavailable to check blood glucose, and an infant has no clinical signs, breastfeeding should not be delayed while waiting for the preprandial blood glucose to be checked.
5. If glucose remains low despite feedings, begin intravenous (IV) glucose therapy, and adjust IV rate by blood glucose concentration. [A]
6. If the neonate is unable to suck or feedings are not tolerated, avoid forced feedings and begin IV therapy. [C] Such an infant requires a careful examination and evaluation for other underlying illness, especially if the infant had been feeding well earlier. [C]
7. Breastfeeding or oral feeding should continue during IV glucose therapy when the infant is interested and will suckle. Gradually wean the IV glucose as serum glucose normalizes and feedings increase. [B] Feeding during IV therapy for hypoglycemia reduces the duration of IV therapy needed and is associated with lower maximum glucose infusion rates.
8. Carefully document physical examination, screening values, laboratory confirmation, treatment, and changes in clinical condition (i.e., response to treatment). [A]
9. Any infant with persistent hypoglycemia (>4 days) or requiring IV glucose therapy for symptomatic or asymptomatic low glucose levels should not be discharged until reasonable levels of blood glucose (>70 mg/dL; 3.9mmol/L) are maintained through several fast-feed cycles. [A]
2. Continue breastfeeding as frequently as possible, or feed any available amount of colostrum, or 2–10 mL per feed (first 24 hours), and 5–15 mL per feed (24–48 hours of life), of substitute nutrition (pasteurized donor human milk,93,94 artificial milk). [B] Glucose water (5% or 10%) is not suitable because of insufficient energy and lack of protein.
3. Buccal 40% dextrose gel is recommended at 0.5 mL/kg (200 mg/kg) in conjunction with a feeding plan (preferably breastfeeding) when the glucose is low or borderline, and the blood glucose is checked before the next feeding. [A] A single repeat dose of buccal dextrose appears safe. [B]
4. Recheck blood glucose concentration before subsequent feedings until the value is acceptable and stable (usually >45 mg/dL or ≥2.5 mmol/L). [C] If staff is unavailable to check blood glucose, and an infant has no clinical signs, breastfeeding should not be delayed while waiting for the preprandial blood glucose to be checked.
5. If glucose remains low despite feedings, begin intravenous (IV) glucose therapy, and adjust IV rate by blood glucose concentration. [A]
6. If the neonate is unable to suck or feedings are not tolerated, avoid forced feedings and begin IV therapy. [C] Such an infant requires a careful examination and evaluation for other underlying illness, especially if the infant had been feeding well earlier. [C]
7. Breastfeeding or oral feeding should continue during IV glucose therapy when the infant is interested and will suckle. Gradually wean the IV glucose as serum glucose normalizes and feedings increase. [B] Feeding during IV therapy for hypoglycemia reduces the duration of IV therapy needed and is associated with lower maximum glucose infusion rates.
8. Carefully document physical examination, screening values, laboratory confirmation, treatment, and changes in clinical condition (i.e., response to treatment). [A]
9. Any infant with persistent hypoglycemia (>4 days) or requiring IV glucose therapy for symptomatic or asymptomatic low glucose levels should not be discharged until reasonable levels of blood glucose (>70 mg/dL; 3.9mmol/L) are maintained through several fast-feed cycles. [A]
Infants with abnormal clinical signs, or infants with blood glucose levels <20–25 mg/dL (<1.1–1.4 mmol/L)2 or <1.0 mmol/L (18 mg/dL)
1. Initiate IV 10% glucose solution with a bolus of 1–2 mL/kg and continuous IV at 5–8 mg/(kg·min). [B]
2. If the neonate is unable to suck or feedings are not tolerated, avoid forced feedings and begin IV therapy. [C] Such an infant requires a careful examination and evaluation for other underlying illness, especially if the infant had been feeding well earlier. [C]
3. The glucose concentration in symptomatic infants should be maintained >45 mg/dL (>2.5 mmol/L). [C]
4. Encourage frequent breastfeeding after initiation of IV therapy. [C]
5. Monitor glucose concentrations before feedings as the IV is gradually weaned, until values are stabilized off IV fluids. [B]
6. Document physical examination, screening values, laboratory confirmation, treatment, and changes in clinical condition (i.e., response to treatment). [A]
7. Do not use glucose gel on infants with clinical signs unless there is a delay in establishing IV access. [C]
8. Infants who have had severe hypoglycemia accompanied by cerebral symptoms such as seizures, impaired consciousness, or circulatory collapse should receive magnetic resonance imaging and long-term follow-up. [C]
2. If the neonate is unable to suck or feedings are not tolerated, avoid forced feedings and begin IV therapy. [C] Such an infant requires a careful examination and evaluation for other underlying illness, especially if the infant had been feeding well earlier. [C]
3. The glucose concentration in symptomatic infants should be maintained >45 mg/dL (>2.5 mmol/L). [C]
4. Encourage frequent breastfeeding after initiation of IV therapy. [C]
5. Monitor glucose concentrations before feedings as the IV is gradually weaned, until values are stabilized off IV fluids. [B]
6. Document physical examination, screening values, laboratory confirmation, treatment, and changes in clinical condition (i.e., response to treatment). [A]
7. Do not use glucose gel on infants with clinical signs unless there is a delay in establishing IV access. [C]
8. Infants who have had severe hypoglycemia accompanied by cerebral symptoms such as seizures, impaired consciousness, or circulatory collapse should receive magnetic resonance imaging and long-term follow-up. [C]
Recommendations for Supporting the Mother and Family
1. Provide parents with verbal and written information that explains why their baby is receiving extra support and blood glucose monitoring. [C] (See Appendix A3: Parent Information)
2. Teach mothers to hand express and give the resulting colostrum to the infant. [C]
3. Consider antenatal/perinatal milk expression in mothers with gestational diabetes, as well as delayed baths to further support maintenance of normal glucose homeostasis among high-risk newborns. [B]
4. Provide manual and/or mechanical breast expression with appropriate frequency (ideally eight times in 24 hours) until the baby is latching and suckling well to protect mothers' milk supply. [A]
5. Keep the infant at breast or return the infant to the breast as soon as possible to maintain breastfeeding, as well as breast milk supply. [C]
6. Encourage continuous skin-to-skin care. [A] Skin-to-skin care may lessen the trauma of intervention, while providing physiologic thermoregulation and metabolic homeostasis. Delaying or omitting the bath (unless medically indicated) may also reduce stress and maintain thermoregulation.
7. Provide expert, consistent, and sustained breastfeeding support by trained experienced members of the health care team. [A]
2. Teach mothers to hand express and give the resulting colostrum to the infant. [C]
3. Consider antenatal/perinatal milk expression in mothers with gestational diabetes, as well as delayed baths to further support maintenance of normal glucose homeostasis among high-risk newborns. [B]
4. Provide manual and/or mechanical breast expression with appropriate frequency (ideally eight times in 24 hours) until the baby is latching and suckling well to protect mothers' milk supply. [A]
5. Keep the infant at breast or return the infant to the breast as soon as possible to maintain breastfeeding, as well as breast milk supply. [C]
6. Encourage continuous skin-to-skin care. [A] Skin-to-skin care may lessen the trauma of intervention, while providing physiologic thermoregulation and metabolic homeostasis. Delaying or omitting the bath (unless medically indicated) may also reduce stress and maintain thermoregulation.
7. Provide expert, consistent, and sustained breastfeeding support by trained experienced members of the health care team. [A]
Recommendations for Future Research
1. Well-controlled studies are needed that look at plasma glucose, alternative brain fuel concentrations, clinical symptoms, and long-term sequelae to determine what ranges of blood glucose are the minimum safe levels for term healthy and various groups of at-risk infants.
2. Blood glucose over time in exclusively breastfed babies in hospitals with baby-friendly policies (i.e., current perinatal best practices) should be compared with nonbaby-friendly designated hospitals.
3. Development of more reliable bedside testing methods would increase the efficiency of diagnosis and treatment of clinically relevant glucose abnormalities. Noninvasive glucose monitoring is needed.
4. The role of other glucose-sparing fuels and the methods to measure them in a clinically meaningful way deserve further study.
5. Research into how much enteral glucose, and in what form, is necessary to raise blood glucose is important for clinical management, considering it may vary by weight, gestational age, time after birth, and comorbidities.
6. Measures of brain function in relation to a comprehensive portfolio of neural fuels (glucose, ketone bodies, and lactate), adaptive changes in cerebral microcirculation, and local factors are needed.
7. The mechanism of the ability of breast milk to enhance ketogenesis needs elucidation.
2. Blood glucose over time in exclusively breastfed babies in hospitals with baby-friendly policies (i.e., current perinatal best practices) should be compared with nonbaby-friendly designated hospitals.
3. Development of more reliable bedside testing methods would increase the efficiency of diagnosis and treatment of clinically relevant glucose abnormalities. Noninvasive glucose monitoring is needed.
4. The role of other glucose-sparing fuels and the methods to measure them in a clinically meaningful way deserve further study.
5. Research into how much enteral glucose, and in what form, is necessary to raise blood glucose is important for clinical management, considering it may vary by weight, gestational age, time after birth, and comorbidities.
6. Measures of brain function in relation to a comprehensive portfolio of neural fuels (glucose, ketone bodies, and lactate), adaptive changes in cerebral microcirculation, and local factors are needed.
7. The mechanism of the ability of breast milk to enhance ketogenesis needs elucidation.
Recommendation Grading
Overview
Title
Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates
Authoring Organization
Academy of Breastfeeding Medicine
Publication Month/Year
May 15, 2021
Last Updated Month/Year
August 30, 2024
Document Type
Guideline
Country of Publication
US
Inclusion Criteria
Male, Female, Infant
Health Care Settings
Ambulatory, Hospital
Intended Users
Nurse, nurse midwife, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D007003 - Hypoglycemia, D015997 - Neonatal Screening, D009359 - Neonatology
Keywords
hypoglycemia, neonates
Source Citation
Wight NE; Academy of Breastfeeding Medicine. ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021. Breastfeed Med. 2021 May;16(5):353-365. doi: 10.1089/bfm.2021.29178.new. Epub 2021 Apr 7. PMID: 33835840.