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Care Process Model
JUNE
2013
GUIDELINES FOR MANAGEMENT OF
Neonatal Hypoglycemia
2013 update
These guidelines were prepared by Larry Eggert, MD, in consultation with

Intermountain Healthcares (Intermountains) Well Newborn Development Team
and NICU Development Team, under the guidance of Intermountains Women
and Newborns Clinical Program. The guidelines are derived from analysis of the
literature and expert consensus.
THE PROBLEM
Hypoglycemia in the newborn is not a medical condition in itself, but can be a
symptom of underlying disease. Prolonged or recurrent low glucose levels may lead
to long-term neurodevelopmental sequelae.
Unfortunately, the exact parameters of normal blood glucose in the neonate remain
controversial. Although neonates have a lower normal blood glucose range than
older infants, a blood glucose level that requires intervention in every newborn has
not been defined and appears to be dependent on birth weight, gestational age,
feeding method, and postnatal age in hours. Also uncertain are the level and duration
of hypoglycemia that cause damage and the vulnerability, or lack thereof, of the
brains of infants of differing gestational ages.
Because of the lack of clear definition of safe neonatal blood glucose levels, knowing
when and how to screen and intervene can be difficult. Based on analysis of the
literature, clinical experiences, and expert consensus, these guidelines promote a
pragmatic approach that provides a wide safety margin.
GENERAL RECOMMENDATIONS
The following are generally recommended principles; detailed recommendations
are given in the algorithm on page 2 of this document.
1 Initiate feeding. Feeding should be initiated for all neonates as soon as the
infant is ready, preferably within 1 hour of birth. Neonates who are not fed
will have a physiologic drop in blood glucose, with a low at 1 to 1.5 hours of
age. The feeding should be breast milk (colostrum) or infant formula NOT
dextrose-water. Colostrum, if available, is preferred to formula.
2 Assess risk factors and symptoms. All neonates with risk factors or major
symptoms should have blood glucose checked.
3 Screen and manage based on initial feeding and assessment. If the
neonate is symptomatic or blood glucose level is less than 45 mg/dL, notify a
LIP while proceeding with management steps outlined in the algorithm on page 2.
New in the 2013 update:
Based upon input from our providers and nurses, our process algorithm now
addresses multiple pre-feeding glucose results less than 45 mg/dL in the
first 24 hours of life and provides further direction to manage consecutive
or non-consecutive low glucoses in those newborns.
The problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
General recommendations . . . . . . . . . . . . . . . 1
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ALGORITHM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
R EFE R EN C ES
1. Canadian Paediatric Society. Screening guidelines
for newborns at risk for low blood glucose. Paediatr
Child Health. 2004;9(10):723-729. http://www.cps.
ca/english/statements/fn/fn04-01.htm. Accessed
March 28, 2012.
2. Chan SW. Neonatal hypoglycemia. UpToDate Online.
Waltham, MA: 2010. http://www.utdol.com/online/
content/topic.do?topicKey=neonatol/5898&select
edTitle=1%7E38&source=search_result. Accessed
March 28, 2012.
3. Cornblath M, Hawdon, JM, Williams AF, et al.
Controversies regarding definition of neonatal
hypoglycemia: suggested operational thresholds.
Pediatrics [serial online]. 2000;105(5):1141-1145.
http://pediatrics.aappublications.org/cgi/content/
full/105/5/1141?ck=nck. Accessed March 28, 2012.
4. New Zealand Ministry of Health. Auckland District
Health Board. Newborn Services Clinical Guideline.
Guidelines for the Management of Hypoglycaemia.
2004 July. http://www.adhb.govt.nz/newborn/
guidelines/nutrition/HypoglycaemiaManagement.
htm. Accessed March 28, 2012.
5. Newborn Nursery QI Committee. Neonatal
hypoglycemia: initial and follow up management.
Portland (ME): The Barbara Bush Childrens Hospital
at Maine Medical Center; 2004 Jul. http://www.
guideline.gov/summary/summary.aspx?ss=15&doc_
id=7180&nbr=4293. Accessed March 28, 2012.
6. Volpe JJ. Neurology of the Newborn. 5th ed.
Pennsylvania, PA: Saunders/Elsevier; 2008.
7. Wight N, Marinelli KA, Academy of Breastfeeding
Medicine Protocol Committee. ABM clinical protocol
#1: guidelines for glucose monitoring and treatment
of hypoglycemia in breastfed neonates. Breastfeed
Med. 2006;1(3):178-184. http://www.guideline.gov/
summary/summary.aspx?doc_id=11218&nbr=0058
65&string=neonatal+AND+hypoglycemia. Updated
January 25, 2010. Accessed March 28, 2012.
8. World Health Organization. Hypoglycaemia of
the Newborn, Review of the Literature: 1997.
http://www.who.int/maternal_child_adolescent/
documents/chd_97_1/en/index.html. Accessed
March 28, 2012.
G U I D E L I N E S F O R M A N A G E M E N T O F N E O N ATA L H Y P O G LY C E M I A
J U N E 2013
ALGORITHM: MANAGEMENT OF NEONATAL HYPOGLYCEMIA

1 Initiate feeding for all neonates as soon as infant is ready, preferably within 1 hour of birth.
Feed breast milk/colostrum or infant formulaNOT dextrose-water. Colostrum, if available, is preferred to formula.
2 Assess the neonate for presence of the following risk factors and symptoms.
Risk factors:
Symptoms:
Prematurity or LBW (<2500 gm)

SGA or IUGR
Intrapartum asphyxia
Infant of a diabetic mother (IDM)
Macrosomic infant
Discordant twin (smaller)

Erythroblastosis fetalis
Polycythemia
Cold stress or
hypothermia
Asymptomatic
WITHOUT risk factors
No further action
necessary
Respiratory distress or
suspected sepsis
Microphallus or midline defect
Maternal terbutaline, propranolol, or
oral hypoglycemic agent during L&D
Asymptomatic
WITH risk factors
Symptomatic
Check blood glucose at least 30 minutes after conclusion of feeding,

but no later than 4 hours of age. (If baby wasnt interested in feeding
right after birth, check blood glucose within 2-3 hours after birth.)
Glucose >45
Some at-risk babies may
develop late hypoglycemia,
often between 12 and 24
hours of age. Follow clinically
and recheck glucose about
every 6 hours, before feeding,
for the first 24 hours of life.
If glucose remains <45, notify

LIP to request Neonatology
consult. Discuss further therapy
and discuss transport/transfer to a
higher-level neonatal unit.
Glucose 30 - 45
Recheck glucose 30 minutes after

conclusion of feeding
Glucose 45?
Check blood glucose immediately.
Glucose <30
Breastfeed, or feed expressed

breast milk or formula (10 ml/kg)
by mouth or gavage.
yes
Continue feeding.
Monitor glucose before feeding
until stable (>45 x 2).
Follow clinically and recheck
glucose about every 6 hours,
before feeding, for the first 24
hours of life.
Major symptoms: stupor, jitteriness, irritability,

high-pitched cry, seizures, apnea, cyanosis,
irregular rapid breathing, hypotonia
May be seen: hypothermia, temperature
instability, and/or poor suck or refusal to feed
Glucose 45
Notify LIP while proceeding with algorithm.

Retest glucose at bedside using Nova StatStrip
(venipuncture) or i-STAT (heel-stick or venipuncture); send
for STAT lab glucose only if bedside retesting cant be
done as described. If glucose is >45, return to appropriate
box above. Otherwise, proceed with algorithm.
Notify LIP.
Search for
other etiology.
Give minibolus D10W @ 2 ml/kg IV push

Then start D10W @ 80 ml/kg/day
no
Recheck glucose in
no more than 30 minutes
IF in the first 24 hours

2 consecutive glucose readings
before feeding are <45
or
3 non-consecutive glucose
readings before feeding are <45,
return to box indicated above.
Continue IV and wean as

tolerated.
After stopping IV, recheck glucose
before feedings until stable
(>45 x 2).
Follow clinically and recheck
glucose before feeding, as needed,
for the first 24 hours of life.
Glucose <45
Glucose 45?
yes
Repeat minibolus D10W @ 2 ml/kg IV push

Increase rate of D10W to 100 ml/kg/day
For glucose <30, now or later, notify LIP
to request STAT Neonatology consult.
Recheck glucose in no
more than 30 minutes
no
yes
Once glucose is >45,

screen every 1-2 hours
until stable (>45 x 2)
Glucose 45?
no
Repeat minibolus D10W @ 2 ml/kg IV push
no
Symptoms?
Increase rate of D10W to 120 ml/kg/day

Recheck glucose in no
more than 30 minutes
yes
Notify LIP. Search for
other etiology.
yes
Glucose 45?
no
2010-2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. PATIENT AND PROVIDER PUBLICATIONS 801-442-2963 CPM011 - 06/13
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Care Process Model

GUIDELINES FOR MANAGEMENT OF

These guidelines were prepared by Larry Eggert, MD, in consultation with

ALGORITHM: MANAGEMENT OF NEONATAL HYPOGLYCEMIA

Prematurity or LBW (<2500 gm)

Discordant twin (smaller)

Check blood glucose at least 30 minutes after conclusion of feeding,

If glucose remains <45, notify

Recheck glucose 30 minutes after

Check blood glucose immediately.

Breastfeed, or feed expressed

Major symptoms: stupor, jitteriness, irritability,

Notify LIP while proceeding with algorithm.

Give minibolus D10W @ 2 ml/kg IV push

IF in the first 24 hours

Continue IV and wean as

Repeat minibolus D10W @ 2 ml/kg IV push

Once glucose is >45,

Increase rate of D10W to 120 ml/kg/day

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