• There is no established definition of hyperglycaemia. However, treat if: 
  • 2 blood sugars ≥14 on 2 occasions measured ≥2 hr apart or 
  • blood sugars ≥12 on 2 occasions measured ≥2 hr apart with evidence of significant glycosuria (2+ on urine dipstick)

• Osmotic diuresis leading to dehydration
• Poor weight gain

Risk factors

• Immaturity of pancreatic function (e.g. extremely premature infants and small-for-gestational-age)
• Insulin resistance
• Glucose overload (e.g. equipment failure, administrator error) 
• Stress (e.g. infection, pain)
• Side effects of a medication (e.g. glucocorticoid treatment)

• Most blood gas machines provide glucose measurements
• Check blood glucose at least 6–8 hrly in:
  • unstable or acutely ill babies [respiratory distress syndrome, septicaemia, necrotising enterocolitis (NEC)]
• Check blood glucose at least once a day in stable babies: 
  • <32 weeks’ gestation for first week
  • receiving parenteral nutrition (PN)
    
    • with severe unexpected dehydration or metabolic acidosis
    • with poor weight gain while receiving >120 kcal/kg/day

Babies treated with corticosteroids

• Check urine for glycosuria daily 
• Check blood glucose if ≥2+ glucose in urine

• If possible, discontinue or decrease medications that worsen hyperglycaemia
• Lipid component of PN may contribute to worsening hyperglycaemia. If on PN discuss stopping lipid with consultant/pharmacist

Suspected infection/NEC

• Hyperglycaemia in baby with previously stable blood glucose may be an early indicator of infection or NEC
• Assess baby clinically
• After taking appropriate cultures, treat empirically

Fluids

• If blood glucose ≥12 mmol/L, check urine for glycosuria (of ≥2+) and assess clinical hydration and fluid input/output. Check for fluid administration errors
• Calculate amount of glucose baby is receiving (as mg/kg/min) using the formula:

• If glucose delivery rate >10 mg/kg/min, decrease glucose in decrements to 
  6–10 mg/kg/min. If on PN, 8–10 mg/kg/min is acceptable
• If glycosuria and hyperglycaemia >12 mmol/L persists despite an appropriate glucose infusion rate, consider treating with insulin 

Insulin

• Commence insulin therapy at 0.05 units/kg/hr and titrate according to response – see Administration of Actrapid^® insulin (soluble insulin)
• Check blood glucose 1 hr from starting and hourly until target reached
• Increase the insulin by increments of 0.05–0.1 units/kg/hr. Target blood glucose while on insulin is 6–8 mmol/L
• Once blood glucose stable, continue to monitor blood glucose 4-hrly 
• When a baby is on insulin it is very important to prevent hypoglycaemia – see below

Preventing hypoglycaemia

• Recheck blood glucose 1 hr after reducing dose, then 1–2 hrly until stable, then 4-hrly when stable
• If unable to wean off insulin after 1 week, transient neonatal diabetes is possible; consult paediatric endocrinologist
• Early introduction of PN and early trophic enteral feeding will help reduce incidence of hyperglycaemia requiring insulin

• Follow instructions in Neonatal Formulary for making up insulin infusion 
• Administer Actrapid^® insulin infusion via a central line or dedicated peripheral cannula
• Before starting infusion, prime all IV connecting and extension sets and T-connectors with insulin infusion fluid. Check manufacturer’s guide on lumen capacity for priming volumes (insulin can adhere to the plastic of the syringe)

Summary of neonatal hyperglycaemia management