NHCP ACTION PLAN GOALS

• Support the development and implementation of a protocol for management and

care of symptomatic newborns with signs and symptoms of hypoglycemia and
asymptomatic newborns at risk for hypoglycemia in 100% of participating hospitals
• Decrease the number of newborn transfers to a higher level of care by 25% solely
for the diagnosis of hypoglycemia
• Decrease non-breastmilk supplementation for hypoglycemia by 20 %
• Decrease the number of IV infusions for hypoglycemia by 25%
• Monitor use of weaning protocol to decrease duration of IV infusion
• Systematize clinical care processes of symptomatic newborns with signs and
symptoms of hypoglycemia and asymptomatic newborns at-risk for hypoglycemia to
promote sustainability
 IS THERE A NURSE DRIVEN STANDARDIZED ALGORITHM TO
GUIDE CLINIC AL MANAGEMENT OF ASYMPTOMATIC
NEWBORNS AT-RISK FOR HYPOGLYCEMIA AT YOUR FACILITY?

NBN NICU
100 100

90 90

80 80
81%
70 70 76%
60 60

Percentage
Percentage

50 50

40 40

30 30

20 20 24%
19%
10 10

0 0
NO YES NO YES
 DO YOU CURRENTLY USE GLUCOSE GEL AS A TREATMENT
METHOD FOR THE ASYMPTOMATIC NEWBORNS WITH
HYPOGLYCEMIA?

NBN NICU
100
100
90
90
80
80
70
70

60
60
64%

Percentage
Percentage

50
50 52%
40 48% 40

30 30 36%
20 20

10 10

0 0
NO YES NO YES
 DO ALL PROVIDERS USE THE SAME GLUCOSE LEVEL TO DEFINE
A NEWBORN AS HYPOGLYCEMIC?

NBN NICU
100 100

90 90

80
84% 80

70 70

60 60
68%
Percentage

Percentage
50 50

40 40

30 30
32%
20 20

10 16% 10

0 0
NO YES NO YES
 IS YOUR TEAM CURRENTLY PROVIDING PARENT’S/FAMILIES
EDUC ATIONAL RESOURCES REGARDING HYPOGLYCEMIA?

NBN NICU
100 100

90 90
92%
80 80

70 70

60
64% 60
Percentage

Percentage
50 50

40 40

30 36% 30

20 20

10 10

8%
0 0
NO YES NO YES
IF INFANT REQUIRES IV THERAPY FOR HYPOGLYCEMIA, DOES
THE INFANT REQUIRE TRANSFER TO A HIGHER LEVEL OF
C ARE?

NBN
100

90

80

70

60
67%
Percentage

50

40

30
33%
20

10

0
NO YES
 IS THERE AN IV WEANING PROTOCOL IN YOUR UNIT FOR
INFANTS WHO RECEIVE CONTINUOUS IV THERAPY SOLELY
FOR THE TREATMENT OF HYPOGLYCEMIA?

NICU
100

90
92%
80

70

60
Percentage

50

40

30

20

10

8%
0
NO YES
 LEVEL 1 NURSERIES (WITH NO HIGHER ACUITY
SCN/NICU IN HOUSE) WITH A NURSE DRIVEN
STANDARDIZED ALGORITHM TO GUIDE CLINIC AL
MANAGEMENT

NBN
100

90

80

70
75%
60
Percentage

50

40

30

20
25%
10

0
NO YES
LEVEL 1 NURSERIES (WITH LEVEL 2,3 OR 4 SCN/NICU
IN HOUSE), WITH A NURSE DRIVEN STANDARDIZED
ALGORITHM TO GUIDE CLINIC AL MANAGEMENT

NBN
100

90

80
83%
70

60
Percentage

50

40

30

20

10 17%
0
NO YES
 WHO SHOULD BE ON YOUR TEAM AND
WHY?

Title Name
Hospital Executive Champion Mrs. CEO or Mr. CNO

Project Team Lead QI staff or engaged staff member

Labor and Delivery Champion MD or Nurse leader from Labor unit
Postpartum Champion MD or Nurse leader from PP unit

SCN/NICU Champion MD or Nurse leader from SCN/NICU

Patient/Family Member Parents of hypoglycemic newborn

IT Support EMR Guru
 Management of At Risk Newborns for Hypoglycemia (First 24 Hrs of life) Insert your
logo here if
“At-risk” defined as: Late Preterm (35-36 6/7 weeks), LGA (>4000gms) , SGA (<2500gms), applicable
IDM and/or GDM, Apgar <6 at 1 minute, Maternal Beta Blocker

STOP Symptomatic and BS <40mg/dL àNotify Provider STOP

SYMPTOMS OF HYPOGLYCEMIA: Irritability, tremors, jitteriness, exaggerated Moro reflex, high-pitched cry, seizures, lethargy, floppiness, cyanosis,
apnea and poor feeding, tachypnea

ASYMPTOMATIC
Provide uninterrupted skin to skin care and initiate first feed WITHIN 1 hour of life
Birth to 4 hours of age 4 to 24 hours of age
Target glucose > 40mg/dL Target glucose > 45mg/dL
Screen glucose 30 minutes after 1st feeding, Feed newborn every 2-3 hours
between 90-120 minutes of life Check blood glucose before each feed
Initial Screen <25mg/dL Initial Screen 25-40mg/dL 1st Screen after 4 hours of 1st Screen after 4 hours of
age < 35mg/dL age 35-45mg/dL
• Glucose Gel immediately • Continue feeds q 2-3 hours • Glucose Gel immediately • Continue feeds q 2-3 hours
• Place skin-to-skin and feed • Screen glucose level prior to each feed • Place skin-to-skin and feed • Screen glucose level prior to each feed
• Repeat BG 1 hr after Gel dose • Repeat BG 1 hr after Gel dose

2nd screen <25mg/dL 2nd screen 25-40mg/dL 2nd screen >40mg/dL 2nd screen <35mg/dL 2nd screen 35-44mg/dL 2nd screen >45mg/dL

• Notify Provider
• Administer Gel
• Continue skin-to-skin
• Glucose Gel immediately
• Place skin-to-skin and
feed
• Repeat glucose 1 hr after
Gel dose
• Continue feeds q2-3hrs • Glucose Gel
• Screen glucose level prior • Place skin-to-skin and
to each feed feed
• Repeat glucose 1 hr after
Gel dose
• Notify Provider
• Glucose Gel • Continue feeds q 2-3
• Place skin-to-skin and hours
feed • Screen glucose level
• Repeat glucose 1 hr after prior to each feed
Gel dose

Goal: To obtain 3 consecutive glucose values in target range for age in hours : Birth to 4 hours of age > 40 and 4 to 24 hours of age >45

Adapted from AAP, 2011

 40% ORAL GLUCOSE GEL
DOSING CHART
Recommended dose = 0.5mL/kg
(200 mg glucose / kg / dose)

Birth Weight mL to administer

< 2 kg 1 mL
> 2 – 2.5 kg 1.25 mL
> 2.5 – 3 kg 1.5 mL
> 3 – 3.5 kg 1.75 mL
> 3.5 – 4 kg 2 mL
> 4 – 4.5 kg 2.25 mL
> 4.5 – 5 kg 2.5 mL

L IMITS:
1 dose per hour
3 total doses per infant
 Insert your
IV Weaning Protocol for Newborns with Hypoglycemia logo here
if
(for infants <48 hours of age and failed PO algorithm) applicable

Blood Glucose <30 MG/DL and Symptomatic Blood Glucose <30 MG/DL and Asymptomatic

Bolus of 2mL/kg of D10W

Begin D10W @ 60-80 mL/kg/d (GIR 4-6 mg/kg/min)

Recheck BG 30 minutes after initiation of D10W

Recheck BG 60 minutes after any Recheck BG in 2-3 hours after any

increase in GIR until target BG decrease in GIR CONSIDERATIONS:
achieved (AC if PO feeding) 1. Infants with multiple risk factors or inability
TARGET BG ≥ 46 MG/DL to adequately feed will likely require higher
For infants <48 hours of age GIR
2. At 100mL/kg/d of D10W consider D12.5, if
ADJUST RATE AS FOLLOWS: GIR requirements continue to increase,
BG<30 Bolus & increase GIR by 1-2 consider central line
mg/kg/min 3. Titration guidelines should not be used if GIR
BG 30-44 Increase GIR by 1-2 mg/kg/min requirements exceed 10-12 mg/kg/min
4. If hypoglycemia recurs with decreasing GIR,
BG 45-60 No change
consider holding at previous GIR for 6-12
BG>60 Decrease GIR by 0.5-1 mg/kg/min hours before next attempt to decrease
BG>75 Decrease GIR by 2 mg/kg/min
Utilizing Glucose Gel
to Reverse Neonatal
Hypoglycemia

Catherine Bennett APN/CNS

Perinatal Clinical Nurse Specialist
Extent of Problem

Neonatal hypoglycemia occurs in up

to 20% of newborns.

There is no agreement among experts

as to the absolute threshold for normal
and safe blood glucose levels during
the first 24 hours of life.
Standard Treatments
Dextrose Gel for Neonatal
Hypoglycemia (the Sugar Babies Study):
A randomized, double-
blind,
• Conducted at a tertiary trial
placebo-controlled center in New Zealand
in 2010
• Dextrose gel reduced frequency of
hypoglycemia
• Neonates receiving dextrose gel were less likely
to:
a. Be admitted to NICU for hypoglycemia
b. Receive IV dextrose
c. Have episodes of recurrent
hypoglycemia
d. Require supplementation
* No adverse effects noted
(Harris, Weston, Signal, Chase, & Harding, 2013)
Implementing a Protocol: Using
Glucose Gel to Treat Neonatal
Hypoglycemia

´Quality Improvement Project:

Development and adoption of a nurse-
driven protocol.
´Asymptomatic were given glucose gel
(200 mg/kg of 40% dextrose) along with
feeds.

(Bennett, Fagan, Chaharbakshi, Zamfirova, &

Flicker, 2016)
´Results:
• NICU transfers from newborn
nursery to NICU decreased by 73%
• 50% of women intending to
exclusively breastfeed
accomplished this
• Mother infant contact increased
• Greatly decreased costs
associated with NICU admission
• No adverse events noted

(Bennett, Fagan, Chaharbakshi, Zamfirova, &

Flicker, 2016)
Gel Administration

Squeeze weight based Dry the buccal cavities

dose into syringe with a sterile 2 x 2

Place partial dose on latex Massage into buccal mucosa

free gloved finger alternating sides until
dose is complete.
 Percentage of Transfers to NICU
Implementation
12 of glucose gel

10

0
2013 2014 2015 2016 2017 2018
Advocate System-Wide
Success

More of this

Less of this
The Critical Assessment
Question

Is the infant symptomatic?

Infants with clinical signs should

be screened immediately.
 Survey Results

Since the implementation of glucose gel, has your

hospital had a decrease in the number of infants
(with the primary diagnosis of hypoglycemia)
admitted to NICU, SCN or needing IV dextrose?

Yes: 72 No: 17
Implemented Use of Gel
in 2014

Women’s and
Children’s Hospital
of Buffalo
Advocate Lutheran
General Hospital
 Implemented Use of Gel
by 2018
Elmendorf AFB
Alaska
Keep the new
family
together
whenever
possible.
 References
Adamkin, D. Committee on Fetus and Newborn (2011). Clinical Report: Postnatal glucose homeostasis in late-preterm and term infants.
Pediatrics 127(3) 575

American Academy of Pediatrics. (2012). Policy Statement: Breastfeeding and the use of human milk. Pediatrics 129 (3).

Association of Women’s Health, Obstetric and Neonatal Nurses. (2015). Breastfeeding: AWHONN Position Statement. Nursing for Women’s
Health, 19(1), 83-88.

Bennett, C., Fagan, E., Chaharbakhshi, E., Zamfirova, I., Flicker, J. Implementing a protocol using glucose gel to treat neonatal hypoglycemia.
Nursing for Women’s Health, 2016; 20 (1): 64-74.

Cornblath, M., Ichord, R. (2000). Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics,
105(5) 1141-1145.

Crenshaw, J. (2007). Care practice #6: No separation of mother and baby, with unlimited opportunities for breastfeeding. Journal of Perinatal
Education, 16(3).

Eidelman, A., Schanler, R. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), 827-841.

Frattarelli DA, Galinkin JL, Green TP, Johnson TD, Neville KA, Paul IM, Van Den Anker JN, American Academy of Pediatrics Committee on D.
Off-label use of drugs in children. Pediatrics. 2014;133(3):563-7.

Harris, D., Weston, P., Signal, M., Chase, J., Harding, J. (2013). Dextrose gel for neonatal hypoglycemia (the Sugar Babies Study): a
Randomized, double-blind, placebo-controlled trial. The Lancet 382, 2077-2083.

Hsieh EM, Hornik CP, Clark RH, Laughon MM, Benjamin DK, Jr., Smith PB. Medication use in the neonatal intensive care unit. Am J Perinatol.
2014;31(9):811-21.
Hay, W., Raju, T., Higgins, R., Kalhan, S., & Devaskar, S. (2009). Knowledge gaps and research needs for understanding and treating
neonatal hypoglycemia: workshop report from Eunice Kennedy Shriver National Institute of Child Health and Human
Development. Journal ofPediatrics 155(5), 612.

Moore, E., Anderson, G., Bergman, N., & Dowswell, T. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants.
Cochrane Database of Systematic Reviews, 2012(5), 1-108. doi: 10.1002/14651858.CD003519.pub3

Perrine, C., Scanlon, K., Li, R., Odom, E., Grummer-Strawn, L. (2012). Baby friendly hospital practices and meeting exclusive
breastfeeding intention. Pediatrics,130 (1) 54-60.

Walker, Marsha. (2014). Just one bottle won’t hurt or will it? Mass Breastfeeding Coalition. Retrieved from
http://massbreastfeeding.org/wp-content/uploads/2013/05/Just-One-Bottle-2014.pdf

Yoshioka, H., Iseki, K., Fujita, K. (1983). Development and differences of intestinal flora in the neonatal period in breast-fed and bottle-fed
infants. Pediatrics, 72(3), 317-321.
 BREAK!
PICK UP PACKET
 PQCNC NHPC RESOURCES

www.pqcnc.org
 TRACKING PROGRESS

• Must be able to identify those infants at-risk

• Must be able to identify those infants receiving

supplementation

• Must be able to determine if protocol is being

followed
 NHPC Goals
Goal 1 Goal 3 Goal 5

Develop and implement

a nurse-driven Decrease the number Systematize clinical
standardized algorithm of newborn transfers processes of symptomatic
to guide clinical to a higher level of and asymptomatic
management of care by 25% solely newborns at-risk for
asymptomatic and for the diagnosis of July – hypoglycemia to promote
symptomatic newborns hypoglycemia December sustainability
at-risk for hypoglycemia
April- July 1, 2019
2019

January- July – January-

April 1, 2019 December December
Decrease non- Decrease the
breastmilk
2019 number of IV 2019
supplementation infusions for
for hypoglycemia hypoglycemia by
by 20 % 25%

Goal 2 Goal 4
 NHPC Success Plan
January – April 1, 2019

Completed Complete by Interventions

Goal 1
Meet with multidisciplinary team to adopt criteria to identify newborns at-risk for

Develop and implement

□ February 21, 2019 hypoglycemia

a nurse-driven Establish a treatment algorithm that guides staff to screen and manage
standardized algorithm □ February 21, 2019 symptomatic and asymptomatic, at-risk hypoglycemic newborns. Use PQCNC
to guide clinical Statewide Hypoglycemia algorithm as a guide
management of Complete staff training outlining the implementation plan for the algorithm,
asymptomatic and □ March 21, 2019
including the PQCNC Hypoglycemia Tracking Tool
symptomatic newborns
at-risk for hypoglycemia Standardize the technique of blood glucose sampling to ensure accurate results
by conducting mandatory training for all staff on proper heel stick procedure and
location using internal resources if available or utilize the following PQCNC
□ March 21, 2019
resources. (video titled, Proper Heel stick Demonstration and PQCNC
illustration titled, Proper Puncture Site for Newborn Heel stick located on
PQCNC website)

Collaborate with 1 or more patient and/or family members to obtain feedback on

□ Ongoing algorithm and determine necessary education they desire to partner with staff in
caring for their at-risk and/or hypoglycemic newborn

□ Ongoing Meet with IT and develop plan to integrate hypoglycemia algorithm into EMR for
successful sustainability
 NHPC Success Plan
April – July 1, 2019

Complet Completed Interventions

ed by
Standardize care for all newborns to be placed skin-to-skin immediately following
□ July 1, 2019 delivery

Promote early breastfeeding of newborns at- risk for hypoglycemia within 60 minutes
of birth for mothers who desire to breastfeed
□ July 1, 2019

Provide breastfeeding support with International Board-Certified Lactation Consultants

□ July 1, 2019
(IBCLC’s) or trained staff early after delivery
Standardize a process to promote early feeding of colostrum, donor breastmilk, or
Decrease non- □ July 1, 2019 glucose gel treatment in asymptomatic newborns with hypoglycemia before
accelerating care. Formula should be last choice for early feeding supplementation.
breastmilk
supplementation Complete training of all staff using internal resources if available or utilize the following
PQCNC presentation titled, Use of Glucose gel to treat newborn hypoglycemia so
for hypoglycemia □ July 1, 2019
staff understand why this clinical decision is vital to supporting breastfeeding.
by 20 %
Standardize the technique of glucose gel administration by conducting mandatory
training for all staff using internal resources if available or utilize the following PQCNC

Goal 2
□ July 1, 2019 resources. (video titled, Administering Glucose Gel and PQCNC illustration titled,
Gel Administration located on PQCNC website)

Partner with mothers to determine best early feeding supplementation option based on
□ July 1, 2019 desire to breastfeed
 NHPC Success Plan
On-going

Goal 3 Goal 5 Completed Complete by

Decrease the number
of newborn transfers
to a higher level of
care by 25% solely
for the diagnosis of
hypoglycemia
Interventions
Systematize clinical
processes of □ December
Develop system to audit success of treatment algorithm that will track the number of
newborn transfers to a higher level of care and the number of IV infusions needed for
symptomatic and 2019 hypoglycemia
asymptomatic
newborns at-risk for
hypoglycemia to □ December
Establish an IV weaning protocol that reduces variability and standardizes care of the
hypoglycemic newborn receiving intravenous therapy. Use PQCNC resource titled,
promote sustainability 2019 IV Weaning Protocol as a guide

□ December
Determine monthly method of report out for the number of newborn transfers to a
higher level of care and the number of IV infusions needed for hypoglycemia to all
2019
disciplines
□ December
Develop clinical decision supports that empower nursing staff to wean infusion rates
of infants with resolving glucose levels to expedite decision making and limit
2019 continuous dextrose infusions
Decrease the number
of IV infusions for □ December
Integrate EMR functions to support clinical decision making such as alerts when
dose adjustments might be indicated
hypoglycemia by 25% 2019
and utilize weaning
protocol to decrease □ December
Complete training of all staff of the Use of Glucose gel to treat newborn
hypoglycemia so staff understand why this clinical decision is vital to supporting
duration of IV infusion 2019
when necessary breastfeeding.

Goal 4
/education