Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates

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.

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]