Management of these babies should follow the guidance below with the following amendments

• Use blood glucose threshold of >2.6 mmol/L (instead of 2.0 mmol/L)
• Continue to monitor blood sugar pre-feed until 4 consecutive values >2.6 mmol/L
• Screen all babies <37 weeks for hypoglycaemia
• Use nasogastric (NG) feeds (see Nasogastric tube administration of feed, fluid or medication guideline) in preference to IV fluids for a well baby who is unable to take sufficient milk volumes orally 
• If baby 34–36⁺⁶ weeks unable to tolerate NG feeds, admit to NNU for IV fluids

• Follow the guidance below which is based on Identification and Management of Neonatal Hypoglycaemia in the Full Term Infant – A Framework for Practice, British Association of Perinatal Medicine April 2017

• Intrauterine growth restriction
  • birth ≤2^nd centile (Table 1) or
  • clinically wasted 
• Babies of diabetic mother
• Babies of mother taking beta blockers in third trimester and/or at time of delivery

Table 1: Second centile weights for boys and girls by week of gestation

• Presence of ≥1 of the following clinical signs/diagnoses is an indication to measure blood glucose:
  • perinatal acidosis (cord arterial or baby pH <7.1 and base deficit ≥-12)
  • hypothermia (<36.5°C) not attributable to environmental factors 
  • suspected/confirmed early neonatal sepsis
  • cyanosis
  • apnoea
  • altered level of consciousness
  • seizures
  • hypotonia
  • lethargy
  • high pitched cry
• Abnormal feeding behaviour (not waking for feeds, not sucking effectively, appearing unsettled, demanding very frequent feeds) especially after a period of feeding well may be indicative of hypoglycaemia
• Jitteriness (excessive repetitive movements of ≥1 limb which are unprovoked and not in response to stimulus) is common and is not by itself an indication to measure blood glucose

• Accurate measurement of blood glucose level is essential for diagnosis and management of neonatal hypoglycaemia
• A ward-based blood gas biosensor (blood gas machine) should be considered the reference standard for measuring blood glucose
• All current cot-side devices are prone to inaccuracy, particularly in the range 0–2.0 mmol/L
• If handheld glucometer used:
  • confirm low values using an accurate method (blood gas analyser or laboratory sample)
  • use only devices conforming to ISO 15197:2013 standard
• Blood samples with high PCV can produce erroneously low results

• Provide parents with written information, e.g. https://hubble-live-assets.s3.amazonaws.com/bapm/attachment/file/53/Identification_and_Management_of_Neonatal_Hypoglycaemia_in_the__full_term_infant_-_A_Framework_for_Practice_revised_Oct_2017.pdf
• Ensure baby kept warm and commence skin-to-skin contact
• Begin care pathway in Flowchart 1 
• Ensure baby offered feed within first hour
• Offer breast in response to feeding cues as often as possible
• Do not allow >3 hr between feeds until 2 consecutive blood glucose measurements >2.0 mmol/L
• If baby not showing signs of effective feeding:
  • encourage continuous skin-to-skin contact and encourage mother to hand express
  • continue to express 8–10 times in 24 hr until baby feeding effectively
  • if no colostrum available, discuss with mother and supplement with formula milk 10–15 mL/kg until colostrum available 
• If mother chooses to formula feed: 
  • offer 10-15 mL/kg within the first hour and plan to feed 3-hrly
  • when 2 consecutive blood glucose measurements >2.0 mmol/L, demand feed
• Measure blood glucose level before second feed (2–4 hr after birth), or sooner if clinical signs suggestive of hypoglycaemia

Based on first blood glucose result, place baby on 1 of the following care pathways:

First pre-feed blood glucose ≥2.0 mmol/L

• Continue to follow Flowchart 1
• Check blood glucose before third feed (≤8 hr after birth) 
  • if ≥2.0 mmol/L no further blood glucose measurement required. Observe feeding in hospital for 24 hr and complete at least 1 breastfeeding assessment before discharge (see Breastfeeding guideline)
  • if <2.0 mmol/L follow Flowchart 2 

First pre-feed blood glucose 1.0–1.9 mmol/L and no abnormal signs

• Follow Flowchart 2
• Buccal dextrose 40% gel 200 mg/kg (0.5 mL/kg of 40% gel) may be used as part of feeding plan
  use 2.5 or 5 mL oral/enteral syringe
  • dry oral mucosa with gauze, gently squirt gel with syringe (no needle) onto inner cheek and massage gel into mucosa using latex-free gloves
  • offer a feed (preferably breast milk) immediately 
  • repeat blood glucose measurement as requested
  • if baby remains hypoglycaemic repeat buccal dextrose 40% gel (see Flowchart 2)
  • maximum 6 doses in 48 hr 
  • discuss with neonatal team before giving second dose
  • examine baby before third dose 
• Continue to support feeding as above
• After 2 consecutive values >2.0 mmol/L discontinue blood glucose measurement. Observe feeding for 24 hr and complete ≥1 breastfeeding assessment before discharge (see Breastfeeding guideline)
• If baby displays clinical signs consistent with hypoglycaemia, or >2 measurements 1.0-1.9 mmol/L, follow Flowchart 3

First pre-feed blood glucose <1.0 mmol/L, and/or clinical signs consistent with hypoglycaemia

• Follow Flowchart 3
• Seek urgent medical attention and admit to NNU
• Obtain IV access
• Collect blood samples for confirmation of blood glucose and hypoglycaemia screening tests (see Investigations)
• Review need to screen for/treat sepsis (see Infection in the first 72 hours of life guideline)
• Give glucose 10% 2.5 mL/kg IV and start infusion of glucose 10% at 60 mL/kg/day
• If unable to obtain immediate IV access, as an interim measure whilst awaiting IV access, give either: 
  • buccal dextrose 40% gel 200 mg/kg (equivalent to 0.5 mL/kg of 40% gel) as detailed above or 
  • single dose of glucagon 200 microgram/kg IM
• Recheck blood glucose after 30 min and continue to follow Flowchart 3

Indications

• Persistent hypoglycaemia (>2 measurements <2.0 mmol/L within the first 48 hr of life)
• Severe hypoglycaemia (<1.0 mmol/L) at any time
• Signs of acute neurological dysfunction and blood glucose <2.5 mmol/L at any time 

Investigations

Perform following investigations during the period of hypoglycaemia 

• Blood 
  • glucose
  • insulin
  • cortisol
  • growth hormone
  • fatty acids
  • ketone bodies
  • carnitine
  • acylcarnitine profile
  • amino acids
  • ammonia
  • lactate
• Urine
  • ketones
  • organic acids
• Review need to screen for/treat sepsis (see Infection in the first 72 hours of life guideline)
• Further investigations based on results of initial screen and following specialist advice
• Transient hypoglycaemia, defined as 1 measurement 1.0-1.9 mmol/L within the first 48 hr of life, in baby with no abnormal signs who is feeding effectively, does not require investigation 

• Defined as >2 measurements <2.0 mmol/L within the first 48 hr of life
• May be the first sign of hyperinsulinism or another metabolic disorder characterised by hypoglycaemia 
• If blood glucose concentration remains low (<2.0 mmol/L) on ≥3 occasions in the first 48 hr, despite adequate energy provision and a feeding plan, or a glucose dose >8 mg/kg/min (glucose 10% 115 mL/kg/day infusion) is required, suspect hyperinsulinism 
• Babies with suspected or confirmed hyperinsulinism may require non-standard glucose infusions to achieve target blood glucose concentration. See below for advice on making up such an infusion 
• If hyperinsulism suspected or confirmed, aim to maintain blood glucose >3.0 mmol/L until insulin levels are known 
• Hyperinsulinism confirmed if paired insulin and glucose measurements taken whilst hypoglycaemic give glucose:insulin ratio <0.3, or if insulin >10 picomole/L when glucose <2.0 mmol/L 
• If baby suspected of having hyperinsulinism discuss with the national centre for hyperinsulinism at Royal Manchester Children’s Hospital 
• Give glucose >12.5% infusion via a central line [see Umbilical venous catheter insertion and removal and Long line insertion (peripherally sited) guidelines]

Calculation of glucose infusion rate

Glucose infusion rate in mg/kg/min = % glucose x fluid volume in mL/kg/day / 144

IV glucose concentration

To make up any concentration of glucose in any volume

• Desired volume = V mL
• Desired concentration of glucose = D%
• Lower concentration of glucose = L%
• Volume of lower concentration of glucose to add = LV mL
• Higher concentration of glucose = H%
• Volume of higher concentration of glucose to add = HV mL

If >12.5% glucose required, give via a central line [see Umbilical venous catheter insertion and removal and Long line insertion (peripherally sited) guidelines]

Flowchart 1: Management of babies ≥37 weeks at risk of hypoglycaemia

Flowchart 2: Pre-feed blood glucose 1.0-1.9 mmol/L and no abnormal clinical signs

Flowchart 3: Blood glucose <1.0 mmol/L and/or clinical signs consistent with hypoglycaemia

Flowchart 4: Management of reluctant feeding in healthy breastfed babies ≥37 weeks